Adenocarcinoma of the gastro‐oesophageal junction after sleeve gastrectomy: a case report

Obesity is a growing health problem that causes major morbidity and mortality worldwide, and bariatric surgery has been demonstrated to be an effective treatment for weight loss as well as obesity-related conditions. Sleeve gastrectomy has been increasing in popularity as a restrictive weight loss procedure and is commonly performed laparoscopically. Known complications following sleeve gastrectomy include staple-line leaks, luminal strictures, nutritional deficiency, dumping syndrome and ulcer disease. A number of gastrooesophageal cancers have been reported in the literature following both gastric banding and gastric bypass surgery; there has been only one reported case of gastric adenocarcinoma following sleeve gastrectomy. Previous studies have found obesity to be associated with an increased risk of cancers of the oesophagus and gastric cardia; the relationship between bariatric surgery and gastric malignancy is unclear. A 44-year-old New Zealand European female underwent laparoscopic sleeve gastrectomy for morbid obesity (preoperative body mass index (BMI) 42 kg/m). She had a history of obstructive sleep apnoea, hypercholesterolaemia, chronic idiopathic neutropenia, previous bilateral oophorectomies for benign cysts and two caesarean sections. She was a non-smoker and teetotaler. There was no family history of gastric malignancy. She underwent an uncomplicated operation and made an unremarkable recovery in the immediate post-operative period. Histology confirmed normal gastric tissue with no evidence of malignancy and was negative for Helicobacter pylori infection. Post-operatively, she experienced intermittent vomiting and dysphagia that gradually improved, and by 18 months, she had minimal symptoms and had lost 32.4 kg achieving a BMI of 23.8. She did not experience reflux post-operatively. Two and a half years following her surgery, an iron deficiency was identified on routine testing despite oral supplementation. Full blood count showed a normal haemoglobin level of 135 g/L (range 115– 155) but the serum iron was low at 5 μmol/L (range 10–30), ironbinding capacity 42 μmol/L (range 45–75) and iron saturation 0.12 (range 0.15–0.50). Ferritin was high at 418 μg/L (range 20–160); B12 and folate were normal. She underwent upper and lower gastrointestinal endoscopy and an ulcerated mass at the gastrooesophageal junction was the pertinent finding (Fig. 1). Pathological examination following biopsy of the mass confirmed moderately differentiated adenocarcinoma. Staging positron emission tomography-computed tomography showed the gastro-oesophageal lesion extending to the fundus of the stomach, with no evidence of extensive local invasion or metastatic disease (Fig. 2). Subsequent staging laparoscopy was also negative for metastatic disease. The patient was referred to a medical oncologist and underwent neoadjuvant chemotherapy with epirubicin, cisplatin and capecitabine prior to surgery. Following the completion of chemotherapy, the patient underwent open oesophagogastrectomy with a Roux-en-Y oesophagojejunostomy reconstruction via an abdominal approach. There was no intra-abdominal metastatic disease found, and on table, endoscopy ensured adequate clearance. Histology showed a poorly differentiated adenocarcinoma with an R0 resection. Final tumour stage was T3N0M0. Adjuvant chemotherapy is planned. A number of gastric and oesophageal cancers have been reported following bariatric surgery in the literature. It is a rare occurrence and the exact aetiology is unclear, but it has been suggested that an association may exist due to the underlying obesity and coexisting reflux disease, which are both known risk factors for gastric and oesophageal malignancy. In this case, the patient did not have symptomatic reflux before or after surgery and did not have H. pylori infection, another established risk factor for gastric malignancy. The crucial learning point from this case is that in patients who have had bariatric surgery, symptoms that may be suggestive of