Priya Abhyankar, MD, Ivana Deyl, MD, Samuel Mardini, MD, MBA, MPH, FACG University of Kentucky, Lexington, KY
Introduction: Bariatric surgeries, such as Roux-en-Y gastric bypass, provide a long-term weight loss option for patients. Many studies report a reduced risk of obesity-related cancer after bariatric surgery. However, there are roughly 15 case reports of gastric cancer of the excluded stomach following Roux-en-Y gastric bypass. Of note, cancer of the excluded stomach is difficult to diagnose as this structure is endoscopically challenging to access and symptoms are often nonspecific. Most cases are diagnosed at advanced stages. We present a case in which gastric adenocarcinoma of the excluded stomach was successfully diagnosed through endoscopic ultrasound (EUS)-guided creation of a jejuno-gastric anastomosis.
Case Description/Methods: A 77-year-old woman with history of remote Roux-en-Y gastric bypass, atrial fibrillation, and diabetes presented with two days of left sided abdominal pain, nausea, and vomiting. CT imaging showed distended excluded stomach and gastric pouch with concern for gastric outlet obstruction at the level of the pylorus. A jejuno-gastric anastomosis was created under EUS guidance between the proximal jejunum and the excluded stomach using a 15 mm x 10 mm lumen apposing metal stent (AXIOS) with plans to repeat endoscopy in two weeks. A week later, she presented to the emergency department with abdominal pain and one episode of hematemesis. Repeat CT scan showed worsened dilatation of the bypassed excluded stomach after stent placement. Repeat esophagogastroduodenoscopy (EGD) with exploration of the excluded stomach revealedsevere pyloric stenosis (4-5mm in diameter) and friable, nodular, and scarred mucosa in the antrum (Figure 1). Pathology revealed invasive intestinal type gastric adenocarcinoma. The patient is undergoing evaluation by radiation oncology as she is a poor surgical candidate due to multiple comorbidities.
Discussion: Cancer of the excluded stomach is rare and there are few case reports of this phenomenon. Due to this, the risk of developing cancer of the excluded stomach remains unknown. Malignancy can affect the excluded stomach as it does the gastric remnant. Practitioners should thus have a high index of suspicion for malignancy of the excluded stomach for Roux-en-Y patients who present with symptoms of gastric outlet obstruction or upper GI bleeding. Early EUS-guided creation of a jejuno-gastric anastomosis to visualize and examine the excluded stomach should be considered.
Figure: Figure 1: Friable, nodular, and scarred mucosa in the antrum, found to be gastric adenocarcinoma.
Disclosures:
Priya Abhyankar indicated no relevant financial relationships.
Ivana Deyl indicated no relevant financial relationships.
Samuel Mardini indicated no relevant financial relationships.
Priya Abhyankar, MD, Ivana Deyl, MD, Samuel Mardini, MD, MBA, MPH, FACG. D0470 - Gastric Cancer in the Excluded Stomach Following Roux-en-Y Gastric Bypass, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.
