We report a rare case of adenocarcinoma in the excluded gastric pouch of a morbidly obese woman who underwent Roux-en-Y gastric bypass (RYGB). A gastrointestinal tumor in the excluded, postsurgical gastric pouch, has a reported incidence of 0.8%.1 According to the World Health Organization, gastric cancer is the third most common cause of cancer-related death and the fifth most common malignancy in the world today,2 and can arise from any viable gastric mucosa. We present a case of gastric adenocarcinoma in the excluded gastric pouch from a prior RYGB presenting with nonspecific symptoms.
Case Presentation
A 70-year-old woman with a past medical history of RYGB 15 years prior and subsequent gastroesophageal reflux disease presented to the Emergency Department with 2 months of intermittent epigastric pain. She had associated nausea, vomiting, and an inability to tolerate solids or liquids orally. Endoscopy demonstrated normal gastric cardia, anastomosis, and efferent jejunum with an irregular Z-line. The pathology report was negative for malignancy. Extenuating symptoms prompted a computed tomography (CT) scan of the abdomen with oral and IV contrast. The CT demonstrated a relatively pronounced dilatation of the excluded stomach pouch with oral contrast material, suggestive of a gastrogastric fistula, or at least a partial obstruction of a portion of the stomach. (Figure). Failure of conservative management prompted an exploratory laparotomy that revealed a severely distended stomach pouch, with intraoperative drainage of 800 ccs of fluid. A tight duodenal stenosis with complete obstruction of the gastric outlet was noted. Partial gastrectomy and gastrojejunostomy was performed, with placement of a feeding jejunostomy. Surgical pathology showed high-grade adenocarcinoma involving the resected stomach and proximal duodenum with clear proximal and distal margins; Helicobacter pylori was not found. The tumor itself was positive for CK7 and CA 19-9, and negative for CK20. The tumor cells were negative for estrogen receptor, progesterone receptor, and cdx-2. Repeat CT 2 weeks after surgery showed postsurgical changes without evidence of fluid collections or bowel obstruction.
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–Midhat Lakhani, MD, Daniel Stenberg, DO, Megha Shalavadi, MD, Indraneel Chakrabarty, MD
