Gastric Adenocarcinoma in patients with Roux-en-Y Gastric bypass: A case series

Abstract

The incidence of gastric cancer is approximately 24,000 cases per year with a mortality of 14,000 cases per year. There has been an increasing incidence of proximal gastric cancer and gastroesophageal junction cancer in the United States over the past 5–10 years [[1]Wanebo H.J. Kennedy B.J. Chmiel J. Steele Jr, G. Winchester D. Osteen R. Cancer of the stomach: a patient care study by the American College of Surgeons.Ann Surg. 1993; 218: 583-592Crossref PubMed Scopus (623) Google Scholar]. Gastric cancer in patients who had previously undergone gastric restrictive surgery and gastric bypass has been reported but is rare. Seventeen case reports and series have been performed describing patients with gastric cancer after undergoing gastric bypass surgery [[2]Sundbom M. Nyman R. Hedenström H. Investigation of the excluded stomach after Roux-en-Y gastric bypass.Obes Surg. 2001; 11: 25-27Crossref PubMed Scopus (93) Google Scholar]. In the majority of patients who had undergone previous Roux-en-Y gastric bypass surgery, gastric cancer developed in the excluded stomach, leading to delayed diagnosis. Unfortunately, management for these patients is difficult, given their often late diagnoses, which results in the advanced nature of their cancers when symptoms eventually develop [[2]Sundbom M. Nyman R. Hedenström H. Investigation of the excluded stomach after Roux-en-Y gastric bypass.Obes Surg. 2001; 11: 25-27Crossref PubMed Scopus (93) Google Scholar].Two cases of gastric adenocarcinoma in patients after Roux-en-Y gastric bypass will be described.Case #1Our first patient is a 69-year-old male who had undergone a Roux-en-Y gastric bypass in 1986 as well as an open cholecystectomy in 1988. As a result of his gastric bypass, he initially lost approximately 50 kg but eventually regained the weight over the proceeding years. In February 2014, he presented to the hospital after having a syncopal event, reporting a 7-day history of abdominal discomfort with associated nausea and complete loss of appetite without vomiting. He experienced a 10-pound weight loss over a 2-week period; at the time of admission, he was also found to have significant anemia. He subsequently underwent a CT of the abdomen and pelvis, which revealed a mass associated with the patient’s excluded stomach versus proximal duodenum with significant dilation (Fig. 1). This imaging also revealed a thickened omentum and significantly enlarged perigastric lymph nodes. He underwent a mini-laparotomy and push enteroscopy, which confirmed the mass in the distal excluded stomach/antrum, biopsies of which were taken and revealed adenocarcinoma. During this operation, a G-tube was placed in the excluded stomach for decompression. Subsequently, the patient was seen in our Multidisciplinary GI Oncology Clinic and was evaluated by Surgical and Medical Oncology. The plan was to proceed with neoadjuvant chemotherapy followed by surgical resection.The patient underwent 6 cycles of 5-FU, Leucovorin, Oxaliplatin (FOLFOX) and was then scheduled to be taken to the operating room for definitive surgery. A repeat staging positron emission tomography (PET) and computed tomography (CT) scan of the patient’s chest, abdomen, and pelvis was performed after completion of his chemotherapy and before his operative intervention, which revealed persistent thickening of his omentum as well as perigastric lymphadenopathy and confirmed stable disease. Our surgical oncology service proceeded with surgery, and in the OR, he was found to have significant tumor involving the excluded stomach and adherent to the undersurface of the liver as well as the anterior border of the pancreas and porta hepatis. Thickening of the omentum was discovered without any other evidence of peritoneal-based disease.The patient underwent a radical intraperitoneal tumor debulking with complete omentectomy, peritonectomies, subtotal gastrectomy, and administration of hyperthermic chemotherapy to the peritoneal cavity. Magge et al. showed a 6-month survival advantage in patients with peritoneal carcinomatosis secondary to gastric cancer who underwent hyperthermic intraperitoneal chemotherapy [[3]Magge D. Zenati M. Winer J. et al.Aggressive locoregional surgical therapy for gastric peritoneal carcinomatosis.Ann Surg Oncol. 2014; 21: 448-455Crossref Scopus (49) Google Scholar]. Final pathology in our patient revealed moderately differentiated mucinous adenocarcinoma of the stomach involving the proximal duodenum with invasion through the muscularis propria, negative margins, perigastric fat implants, and 1 of 10 lymph nodes positive for tumor. There was no involvement of the omentum by metastatic carcinoma. The patient had an uneventful postoperative course. After discharge, he underwent 6 further cycles of adjuvant FOLFOX therapy and was noted to have no evidence of disease on his 6 month CT/PET.Case #2Our second patient presented to our institution during the summer of 2011. She had undergone a Roux-en-Y gastric bypass 25 years before her visit and complained of several months of abdominal distention and progressive weight loss. According to the patient, she had lost approximately 100 kg after her Roux-en-Y gastric bypass but gained back approximately half of this loss over the ensuing years. She first presented to an outside hospital, where she underwent a CT of the abdomen and pelvis, which revealed a mass involving the excluded stomach/proximal duodenum. She underwent an upper gastrointestinal (GI) series with small bowel follow-through which showed no evidence of a mass in her gastric pouch but revealed a mass involving the biliopancreatic limb of her Roux-en-Y anatomic configuration. She then underwent an upper endoscopy and was found to have a normal esophagus with an ulcerative mass involving the excluded stomach and proximal duodenum (Fig. 2). Pathology of the biopsied mass revealed poorly differentiated adenocarcinoma with signet ring cells. The patient underwent staging CT of the chest, abdomen, and pelvis before undergoing operative intervention.Fig. 2Endoscopic images of Patient #2 revealing normal GJ anastamosis with presence of ulcerated mass in the excluded stomach/proximal duodenum.View Large Image Figure ViewerDownload Hi-res image Download (PPT)The patient was taken to the operating room and underwent an exploratory laparotomy, subtotal gastrectomy, and proximal duodenectomy without need for revision of the pre-existing gastrojejunal anastomosis or roux limb. She tolerated the procedure well with an uneventful postoperative recovery. She subsequently completed the Macdonald adjuvant therapy protocol with 5-FU/Leucovorin and radiation approximately 1 year after surgery. She had no evidence of disease recurrence on surveillance computed tomography of abdomen/pelvis (CTAP) at her 3-year follow-up visit.DiscussionThough the incidence of gastric malignancies in patients who have previously undergone bariatric surgery is rare, approximately 25–30 cases have been described between 2007 and 2014. The majority of these cancers are noted to be present in the excluded stomach, often leading to a delayed diagnosis. Both of our patients were diagnosed with gastric cancer relatively early, after recognition of their vague symptoms led to a definitive and thorough workup by our institution as well as an outside hospital. Unfortunately, this is often not the case, and patients’ symptoms either go unrecognized or are acknowledged relatively late. The etiology of gastric malignancy after gastric bypass has not been clearly demonstrated, but possible factors could be chronic reflux, bile reflux, undiagnosed Heliobacter pylori infection, and stasis of undigested food and acid in the remnant causing chronic mucosal irritation and neoplastic changes [[4]Raijman I. Strother S.V. Donegan W.L. Gastric cancer after gastric bypass for obesity: case report.J Clin Gastroenterol. 1991; 13: 191-194Crossref PubMed Scopus (76) Google Scholar].Patients with developing adenocarcinomas may present with vague symptoms, including abdominal discomfort, bloating, and nausea. Weight loss experienced with malignancy may be confused with weight loss secondary to the bypass itself. It is important for surgeons to fully assess patients presenting with these equivocal symptoms, including bloodwork, imaging, and endoscopic evaluation. Endoscopy with biopsy is the primary means of diagnosis [[5]Lord R.V. Edwards P.D. Coleman M.J. Gastric cancer in the bypassed segment after operation for morbid obesity.Aust N Z J Surg. 1997; 67: 580-582Crossref PubMed Scopus (95) Google Scholar]. Unfortunately, many centers are incapable of performing endoscopy after Roux-en-Y gastric bypass, making surveillance somewhat challenging. Studies described by Ziraik et al., Papakonstantinou et al., and Belhaj et al. have shown that patients with vertical-banded gastroplasties have been diagnosed more frequently with gastric adenocarcinomas given the ease of endoscopic evaluation [6Zirak C. Lemaitre J. Lebrun E. Journé S. Carlier P. Adenocarcinoma of the pouch after silastic ring vertical gastroplasty.Obes Surg. 2004; 12: 693-694Crossref Scopus (23) Google Scholar, 7Papakonstantinou A. Moustafellos P. Terzis I. Stratopoulos C. Hadjiyannakis E.I. Gastric cancer occurring after vertical banded gastroplasty.Obes Surg. 2002; 12: 118-120Crossref PubMed Scopus (27) Google Scholar, 8Belhaj A. Memmo L. Mehdi A. Mboti F. Closset J. Gastric adenocarcinoma following “silastic vertical ring gastroplasty”: case report.Rev Med Brux. 2010; 31: 459-462PubMed Google Scholar].An endoscopic evaluation of the remnant in an experienced center when a patient with Roux-en-Y gastric bypass presents with symptoms such as progressive weight loss, early satiety, anemia, or abdominal distention may aid in earlier diagnosis of gastric cancers after gastric bypass. In Western countries, routine surveillance for gastric cancer is not recommended universally. However, patients with significant risk factors or those who present with symptoms consistent with gastric cancer typically undergo upper endoscopy for further evaluation. This algorithm should be used for patients who have undergone previous gastric bypass as well, but given that the gastrointestinal tract is not in continuity and the fact that the tumor may involve the excluded stomach, a lower index of suspicion must be held to provide a patient with a timely diagnosis. If the patient is seen at a small volume center or is in the hands of less experienced endoscopists, accessing the excluded stomach may be difficult, making imaging modalities such as CT the primary means of diagnosis. If a small or large lesion is identified on imaging, the patient should be referred to a more experienced center for upper endoscopy. Additionally, H. pylori status may also be a preventable risk factor with routine screening and treatment for patients who have undergone gastric bypass surgery. Once a patient has been diagnosed with a gastric lesion, proper staging must be performed, including a contrasted CT scan of the chest/abdomen/pelvis, to reveal absence or presence of metastatic disease. Once a diagnosis is made of gastric adenocarcinoma, if it is deemed resectable, the patient may proceed to the operating room for surgical resection of the excluded stomach.ConclusionsThough gastric cancer is rare in patients who have previously undergone a gastric restrictive procedure, it is important to monitor these patients for development of malignancy and to complete a full and thorough evaluation of these patients if they develop vague symptoms. Thorough endoscopic evaluation as well as CT imaging play important roles in the diagnosis, and treatment of H. pylori is a potential preventative tool.DisclosuresThere are no conflicts of interest to be disclosed. The incidence of gastric cancer is approximately 24,000 cases per year with a mortality of 14,000 cases per year. There has been an increasing incidence of proximal gastric cancer and gastroesophageal junction cancer in the United States over the past 5–10 years [[1]Wanebo H.J. Kennedy B.J. Chmiel J. Steele Jr, G. Winchester D. Osteen R. Cancer of the stomach: a patient care study by the American College of Surgeons.Ann Surg. 1993; 218: 583-592Crossref PubMed Scopus (623) Google Scholar]. Gastric cancer in patients who had previously undergone gastric restrictive surgery and gastric bypass has been reported but is rare. Seventeen case reports and series have been performed describing patients with gastric cancer after undergoing gastric bypass surgery [[2]Sundbom M. Nyman R. Hedenström H. Investigation of the excluded stomach after Roux-en-Y gastric bypass.Obes Surg. 2001; 11: 25-27Crossref PubMed Scopus (93) Google Scholar]. In the majority of patients who had undergone previous Roux-en-Y gastric bypass surgery, gastric cancer developed in the excluded stomach, leading to delayed diagnosis. Unfortunately, management for these patients is difficult, given their often late diagnoses, which results in the advanced nature of their cancers when symptoms eventually develop [[2]Sundbom M. Nyman R. Hedenström H. Investigation of the excluded stomach after Roux-en-Y gastric bypass.Obes Surg. 2001; 11: 25-27Crossref PubMed Scopus (93) Google Scholar]. Two cases of gastric adenocarcinoma in patients after Roux-en-Y gastric bypass will be described. Case #1Our first patient is a 69-year-old male who had undergone a Roux-en-Y gastric bypass in 1986 as well as an open cholecystectomy in 1988. As a result of his gastric bypass, he initially lost approximately 50 kg but eventually regained the weight over the proceeding years. In February 2014, he presented to the hospital after having a syncopal event, reporting a 7-day history of abdominal discomfort with associated nausea and complete loss of appetite without vomiting. He experienced a 10-pound weight loss over a 2-week period; at the time of admission, he was also found to have significant anemia. He subsequently underwent a CT of the abdomen and pelvis, which revealed a mass associated with the patient’s excluded stomach versus proximal duodenum with significant dilation (Fig. 1). This imaging also revealed a thickened omentum and significantly enlarged perigastric lymph nodes. He underwent a mini-laparotomy and push enteroscopy, which confirmed the mass in the distal excluded stomach/antrum, biopsies of which were taken and revealed adenocarcinoma. During this operation, a G-tube was placed in the excluded stomach for decompression. Subsequently, the patient was seen in our Multidisciplinary GI Oncology Clinic and was evaluated by Surgical and Medical Oncology. The plan was to proceed with neoadjuvant chemotherapy followed by surgical resection.The patient underwent 6 cycles of 5-FU, Leucovorin, Oxaliplatin (FOLFOX) and was then scheduled to be taken to the operating room for definitive surgery. A repeat staging positron emission tomography (PET) and computed tomography (CT) scan of the patient’s chest, abdomen, and pelvis was performed after completion of his chemotherapy and before his operative intervention, which revealed persistent thickening of his omentum as well as perigastric lymphadenopathy and confirmed stable disease. Our surgical oncology service proceeded with surgery, and in the OR, he was found to have significant tumor involving the excluded stomach and adherent to the undersurface of the liver as well as the anterior border of the pancreas and porta hepatis. Thickening of the omentum was discovered without any other evidence of peritoneal-based disease.The patient underwent a radical intraperitoneal tumor debulking with complete omentectomy, peritonectomies, subtotal gastrectomy, and administration of hyperthermic chemotherapy to the peritoneal cavity. Magge et al. showed a 6-month survival advantage in patients with peritoneal carcinomatosis secondary to gastric cancer who underwent hyperthermic intraperitoneal chemotherapy [[3]Magge D. Zenati M. Winer J. et al.Aggressive locoregional surgical therapy for gastric peritoneal carcinomatosis.Ann Surg Oncol. 2014; 21: 448-455Crossref Scopus (49) Google Scholar]. Final pathology in our patient revealed moderately differentiated mucinous adenocarcinoma of the stomach involving the proximal duodenum with invasion through the muscularis propria, negative margins, perigastric fat implants, and 1 of 10 lymph nodes positive for tumor. There was no involvement of the omentum by metastatic carcinoma. The patient had an uneventful postoperative course. After discharge, he underwent 6 further cycles of adjuvant FOLFOX therapy and was noted to have no evidence of disease on his 6 month CT/PET. Our first patient is a 69-year-old male who had undergone a Roux-en-Y gastric bypass in 1986 as well as an open cholecystectomy in 1988. As a result of his gastric bypass, he initially lost approximately 50 kg but eventually regained the weight over the proceeding years. In February 2014, he presented to the hospital after having a syncopal event, reporting a 7-day history of abdominal discomfort with associated nausea and complete loss of appetite without vomiting. He experienced a 10-pound weight loss over a 2-week period; at the time of admission, he was also found to have significant anemia. He subsequently underwent a CT of the abdomen and pelvis, which revealed a mass associated with the patient’s excluded stomach versus proximal duodenum with significant dilation (Fig. 1). This imaging also revealed a thickened omentum and significantly enlarged perigastric lymph nodes. He underwent a mini-laparotomy and push enteroscopy, which confirmed the mass in the distal excluded stomach/antrum, biopsies of which were taken and revealed adenocarcinoma. During this operation, a G-tube was placed in the excluded stomach for decompression. Subsequently, the patient was seen in our Multidisciplinary GI Oncology Clinic and was evaluated by Surgical and Medical Oncology. The plan was to proceed with neoadjuvant chemotherapy followed by surgical resection. The patient underwent 6 cycles of 5-FU, Leucovorin, Oxaliplatin (FOLFOX) and was then scheduled to be taken to the operating room for definitive surgery. A repeat staging positron emission tomography (PET) and computed tomography (CT) scan of the patient’s chest, abdomen, and pelvis was performed after completion of his chemotherapy and before his operative intervention, which revealed persistent thickening of his omentum as well as perigastric lymphadenopathy and confirmed stable disease. Our surgical oncology service proceeded with surgery, and in the OR, he was found to have significant tumor involving the excluded stomach and adherent to the undersurface of the liver as well as the anterior border of the pancreas and porta hepatis. Thickening of the omentum was discovered without any other evidence of peritoneal-based disease. The patient underwent a radical intraperitoneal tumor debulking with complete omentectomy, peritonectomies, subtotal gastrectomy, and administration of hyperthermic chemotherapy to the peritoneal cavity. Magge et al. showed a 6-month survival advantage in patients with peritoneal carcinomatosis secondary to gastric cancer who underwent hyperthermic intraperitoneal chemotherapy [[3]Magge D. Zenati M. Winer J. et al.Aggressive locoregional surgical therapy for gastric peritoneal carcinomatosis.Ann Surg Oncol. 2014; 21: 448-455Crossref Scopus (49) Google Scholar]. Final pathology in our patient revealed moderately differentiated mucinous adenocarcinoma of the stomach involving the proximal duodenum with invasion through the muscularis propria, negative margins, perigastric fat implants, and 1 of 10 lymph nodes positive for tumor. There was no involvement of the omentum by metastatic carcinoma. The patient had an uneventful postoperative course. After discharge, he underwent 6 further cycles of adjuvant FOLFOX therapy and was noted to have no evidence of disease on his 6 month CT/PET. Case #2Our second patient presented to our institution during the summer of 2011. She had undergone a Roux-en-Y gastric bypass 25 years before her visit and complained of several months of abdominal distention and progressive weight loss. According to the patient, she had lost approximately 100 kg after her Roux-en-Y gastric bypass but gained back approximately half of this loss over the ensuing years. She first presented to an outside hospital, where she underwent a CT of the abdomen and pelvis, which revealed a mass involving the excluded stomach/proximal duodenum. She underwent an upper gastrointestinal (GI) series with small bowel follow-through which showed no evidence of a mass in her gastric pouch but revealed a mass involving the biliopancreatic limb of her Roux-en-Y anatomic configuration. She then underwent an upper endoscopy and was found to have a normal esophagus with an ulcerative mass involving the excluded stomach and proximal duodenum (Fig. 2). Pathology of the biopsied mass revealed poorly differentiated adenocarcinoma with signet ring cells. The patient underwent staging CT of the chest, abdomen, and pelvis before undergoing operative intervention.The patient was taken to the operating room and underwent an exploratory laparotomy, subtotal gastrectomy, and proximal duodenectomy without need for revision of the pre-existing gastrojejunal anastomosis or roux limb. She tolerated the procedure well with an uneventful postoperative recovery. She subsequently completed the Macdonald adjuvant therapy protocol with 5-FU/Leucovorin and radiation approximately 1 year after surgery. She had no evidence of disease recurrence on surveillance computed tomography of abdomen/pelvis (CTAP) at her 3-year follow-up visit. Our second patient presented to our institution during the summer of 2011. She had undergone a Roux-en-Y gastric bypass 25 years before her visit and complained of several months of abdominal distention and progressive weight loss. According to the patient, she had lost approximately 100 kg after her Roux-en-Y gastric bypass but gained back approximately half of this loss over the ensuing years. She first presented to an outside hospital, where she underwent a CT of the abdomen and pelvis, which revealed a mass involving the excluded stomach/proximal duodenum. She underwent an upper gastrointestinal (GI) series with small bowel follow-through which showed no evidence of a mass in her gastric pouch but revealed a mass involving the biliopancreatic limb of her Roux-en-Y anatomic configuration. She then underwent an upper endoscopy and was found to have a normal esophagus with an ulcerative mass involving the excluded stomach and proximal duodenum (Fig. 2). Pathology of the biopsied mass revealed poorly differentiated adenocarcinoma with signet ring cells. The patient underwent staging CT of the chest, abdomen, and pelvis before undergoing operative intervention. The patient was taken to the operating room and underwent an exploratory laparotomy, subtotal gastrectomy, and proximal duodenectomy without need for revision of the pre-existing gastrojejunal anastomosis or roux limb. She tolerated the procedure well with an uneventful postoperative recovery. She subsequently completed the Macdonald adjuvant therapy protocol with 5-FU/Leucovorin and radiation approximately 1 year after surgery. She had no evidence of disease recurrence on surveillance computed tomography of abdomen/pelvis (CTAP) at her 3-year follow-up visit. DiscussionThough the incidence of gastric malignancies in patients who have previously undergone bariatric surgery is rare, approximately 25–30 cases have been described between 2007 and 2014. The majority of these cancers are noted to be present in the excluded stomach, often leading to a delayed diagnosis. Both of our patients were diagnosed with gastric cancer relatively early, after recognition of their vague symptoms led to a definitive and thorough workup by our institution as well as an outside hospital. Unfortunately, this is often not the case, and patients’ symptoms either go unrecognized or are acknowledged relatively late. The etiology of gastric malignancy after gastric bypass has not been clearly demonstrated, but possible factors could be chronic reflux, bile reflux, undiagnosed Heliobacter pylori infection, and stasis of undigested food and acid in the remnant causing chronic mucosal irritation and neoplastic changes [[4]Raijman I. Strother S.V. Donegan W.L. Gastric cancer after gastric bypass for obesity: case report.J Clin Gastroenterol. 1991; 13: 191-194Crossref PubMed Scopus (76) Google Scholar].Patients with developing adenocarcinomas may present with vague symptoms, including abdominal discomfort, bloating, and nausea. Weight loss experienced with malignancy may be confused with weight loss secondary to the bypass itself. It is important for surgeons to fully assess patients presenting with these equivocal symptoms, including bloodwork, imaging, and endoscopic evaluation. Endoscopy with biopsy is the primary means of diagnosis [[5]Lord R.V. Edwards P.D. Coleman M.J. Gastric cancer in the bypassed segment after operation for morbid obesity.Aust N Z J Surg. 1997; 67: 580-582Crossref PubMed Scopus (95) Google Scholar]. Unfortunately, many centers are incapable of performing endoscopy after Roux-en-Y gastric bypass, making surveillance somewhat challenging. Studies described by Ziraik et al., Papakonstantinou et al., and Belhaj et al. have shown that patients with vertical-banded gastroplasties have been diagnosed more frequently with gastric adenocarcinomas given the ease of endoscopic evaluation [6Zirak C. Lemaitre J. Lebrun E. Journé S. Carlier P. Adenocarcinoma of the pouch after silastic ring vertical gastroplasty.Obes Surg. 2004; 12: 693-694Crossref Scopus (23) Google Scholar, 7Papakonstantinou A. Moustafellos P. Terzis I. Stratopoulos C. Hadjiyannakis E.I. Gastric cancer occurring after vertical banded gastroplasty.Obes Surg. 2002; 12: 118-120Crossref PubMed Scopus (27) Google Scholar, 8Belhaj A. Memmo L. Mehdi A. Mboti F. Closset J. Gastric adenocarcinoma following “silastic vertical ring gastroplasty”: case report.Rev Med Brux. 2010; 31: 459-462PubMed Google Scholar].An endoscopic evaluation of the remnant in an experienced center when a patient with Roux-en-Y gastric bypass presents with symptoms such as progressive weight loss, early satiety, anemia, or abdominal distention may aid in earlier diagnosis of gastric cancers after gastric bypass. In Western countries, routine surveillance for gastric cancer is not recommended universally. However, patients with significant risk factors or those who present with symptoms consistent with gastric cancer typically undergo upper endoscopy for further evaluation. This algorithm should be used for patients who have undergone previous gastric bypass as well, but given that the gastrointestinal tract is not in continuity and the fact that the tumor may involve the excluded stomach, a lower index of suspicion must be held to provide a patient with a timely diagnosis. If the patient is seen at a small volume center or is in the hands of less experienced endoscopists, accessing the excluded stomach may be difficult, making imaging modalities such as CT the primary means of diagnosis. If a small or large lesion is identified on imaging, the patient should be referred to a more experienced center for upper endoscopy. Additionally, H. pylori status may also be a preventable risk factor with routine screening and treatment for patients who have undergone gastric bypass surgery. Once a patient has been diagnosed with a gastric lesion, proper staging must be performed, including a contrasted CT scan of the chest/abdomen/pelvis, to reveal absence or presence of metastatic disease. Once a diagnosis is made of gastric adenocarcinoma, if it is deemed resectable, the patient may proceed to the operating room for surgical resection of the excluded stomach. Though the incidence of gastric malignancies in patients who have previously undergone bariatric surgery is rare, approximately 25–30 cases have been described between 2007 and 2014. The majority of these cancers are noted to be present in the excluded stomach, often leading to a delayed diagnosis. Both of our patients were diagnosed with gastric cancer relatively early, after recognition of their vague symptoms led to a definitive and thorough workup by our institution as well as an outside hospital. Unfortunately, this is often not the case, and patients’ symptoms either go unrecognized or are acknowledged relatively late. The etiology of gastric malignancy after gastric bypass has not been clearly demonstrated, but possible factors could be chronic reflux, bile reflux, undiagnosed Heliobacter pylori infection, and stasis of undigested food and acid in the remnant causing chronic mucosal irritation and neoplastic changes [[4]Raijman I. Strother S.V. Donegan W.L. Gastric cancer after gastric bypass for obesity: case report.J Clin Gastroenterol. 1991; 13: 191-194Crossref PubMed Scopus (76) Google Scholar]. Patients with developing adenocarcinomas may present with vague symptoms, including abdominal discomfort, bloating, and nausea. Weight loss experienced with malignancy may be confused with weight loss secondary to the bypass itself. It is important for surgeons to fully assess patients presenting with these equivocal symptoms, including bloodwork, imaging, and endoscopic evaluation. Endoscopy with biopsy is the primary means of diagnosis [[5]Lord R.V. Edwards P.D. Coleman M.J. Gastric cancer in the bypassed segment after operation for morbid obesity.Aust N Z J Surg. 1997; 67: 580-582Crossref PubMed Scopus (95) Google Scholar]. Unfortunately, many centers are incapable of performing endoscopy after Roux-en-Y gastric bypass, making surveillance somewhat challenging. Studies described by Ziraik et al., Papakonstantinou et al., and Belhaj et al. have shown that patients with vertical-banded gastroplasties have been diagnosed more frequently with gastric adenocarcinomas given the ease of endoscopic evaluation [6Zirak C. Lemaitre J. Lebrun E. Journé S. Carlier P. Adenocarcinoma of the pouch after silastic ring vertical gastroplasty.Obes Surg. 2004; 12: 693-694Crossref Scopus (23) Google Scholar, 7Papakonstantinou A. Moustafellos P. Terzis I. Stratopoulos C. Hadjiyannakis E.I. Gastric cancer occurring after vertical banded gastroplasty.Obes Surg. 2002; 12: 118-120Crossref PubMed Scopus (27) Google Scholar, 8Belhaj A. Memmo L. Mehdi A. Mboti F. Closset J. Gastric adenocarcinoma following “silastic vertical ring gastroplasty”: case report.Rev Med Brux. 2010; 31: 459-462PubMed Google Scholar]. An endoscopic evaluation of the remnant in an experienced center when a patient with Roux-en-Y gastric bypass presents with symptoms such as progressive weight loss, early satiety, anemia, or abdominal distention may aid in earlier diagnosis of gastric cancers after gastric bypass. In Western countries, routine surveillance for gastric cancer is not recommended universally. However, patients with significant risk factors or those who present with symptoms consistent with gastric cancer typically undergo upper endoscopy for further evaluation. This algorithm should be used for patients who have undergone previous gastric bypass as well, but given that the gastrointestinal tract is not in continuity and the fact that the tumor may involve the excluded stomach, a lower index of suspicion must be held to provide a patient with a timely diagnosis. If the patient is seen at a small volume center or is in the hands of less experienced endoscopists, accessing the excluded stomach may be difficult, making imaging modalities such as CT the primary means of diagnosis. If a small or large lesion is identified on imaging, the patient should be referred to a more experienced center for upper endoscopy. Additionally, H. pylori status may also be a preventable risk factor with routine screening and treatment for patients who have undergone gastric bypass surgery. Once a patient has been diagnosed with a gastric lesion, proper staging must be performed, including a contrasted CT scan of the chest/abdomen/pelvis, to reveal absence or presence of metastatic disease. Once a diagnosis is made of gastric adenocarcinoma, if it is deemed resectable, the patient may proceed to the operating room for surgical resection of the excluded stomach. ConclusionsThough gastric cancer is rare in patients who have previously undergone a gastric restrictive procedure, it is important to monitor these patients for development of malignancy and to complete a full and thorough evaluation of these patients if they develop vague symptoms. Thorough endoscopic evaluation as well as CT imaging play important roles in the diagnosis, and treatment of H. pylori is a potential preventative tool. Though gastric cancer is rare in patients who have previously undergone a gastric restrictive procedure, it is important to monitor these patients for development of malignancy and to complete a full and thorough evaluation of these patients if they develop vague symptoms. Thorough endoscopic evaluation as well as CT imaging play important roles in the diagnosis, and treatment of H. pylori is a potential preventative tool.