P5095 - Unveiling the Hidden: Discovering Gastric Adenocarcinoma in Roux-en-Y Anatomy via GG Fistula

Stephanie Ibarra Lepe, MD¹, Abdulazeez Swaiti, MD², Christin Wilkinson, MD², Jinye Liu, DO¹, Christina Santana, MD¹, Saeed Graham, MD², Amy Chang, MD¹, Michelle Cooley, BS³, M Danial Ali Shah, MD⁴, Catherine Gray, BS³, Matthew Tugman, BA³, Zarak Khan, MD⁵, Rahul Pamarthy, MD², Hassam Ali, MD², Muhammad Farooq, MD⁵, Danielle Hoo-Fatt, MD⁵, Kara Regan, MD^5
1East Carolina University Medical Center, Greenville, NC; ²East Carolina University, Greenville, NC; ³East Carolina University Brody School of Medicine, Greenville, NC; ⁴King Edward Medical University, Lahore, Punjab, Pakistan; ⁵East Carolina Gastroenterology, Greenville, NC

Introduction: In the US, gastric cancer has an incidence of 5.6 per 100,000 individuals, and adenocarcinoma represents 90-95% of all stomach cancers. Roux-en-y gastric bypass (RYGB) is a surgery performed by creating a small gastric pouch from the existing stomach along with a jejunojejunostomy and gastrojejunostomy; weight loss occurs through restriction and malabsorption. Late complications of RYGB include anastomotic strictures, fistulae, and various nutritional deficiencies. Rarely are cases of gastric cancer reported developing in the remnant stomach, such as a narrative review describing 17 cases in which 80% were adenocarcinoma.

Case Description/Methods: A 78-year-old female with PMHx of CAD s/p DES to RCA, HFpEF, Tolosa-Hunt Syndrome, and laparoscopic RYGB initially presented to the hospital for SOB, found with a left pleural effusion. Incidental nodular soft tissue thickening near the GE junction and gastric cardia was also found, raising concerns for malignancy. EGD showed Roux-en-Y gastrojejunostomy with healthy appearing gastrojejunal anastomosis. Biopsies obtained were positive only for H. pylori. The patient was treated accordingly. Eight months later, the patient presented back with chronic nausea and vomiting, weight loss, and reduced PO intake. CT abdomen revealed gastric pouch thickening suspicious for carcinoma with suspected extension to the excluded gastric body. A fistula tract from the gastric pouch into the remnant stomach was found on repeat EGD. Upon entering the fistula, a circumferential necrotic mass involving most of the body and antrum was found, later diagnosed as stage IIA gastric adenocarcinoma.

Discussion: Traditional endoscopic evaluation in patients with RYGB anatomy presents a significant challenge in advanced gastroenterology. While gastric bypass offers a weight loss solution for selected obese patients, it limits the ability to visualize abnormalities in the excluded stomach. Despite gastric cancer being the fourth leading cause of cancer death worldwide, its true incidence in the excluded stomach following gastric bypass remains unknown, with some literature suggesting an incidence of around 0.03%. Some theorize that inflammatory-related physiological changes following invasive surgical procedures may increase susceptibility to malignant transformation. Nonetheless, the occurrence and prognosis of gastric adenocarcinoma in the excluded stomach after RYGB is poorly documented due to its uniqueness and challenging diagnosis.



Disclosures:


Stephanie Ibarra Lepe, MD¹, Abdulazeez Swaiti, MD², Christin Wilkinson, MD², Jinye Liu, DO¹, Christina Santana, MD¹, Saeed Graham, MD², Amy Chang, MD¹, Michelle Cooley, BS³, M Danial Ali Shah, MD⁴, Catherine Gray, BS³, Matthew Tugman, BA³, Zarak Khan, MD⁵, Rahul Pamarthy, MD², Hassam Ali, MD², Muhammad Farooq, MD⁵, Danielle Hoo-Fatt, MD⁵, Kara Regan, MD⁵. P5095 - Unveiling the Hidden: Discovering Gastric Adenocarcinoma in Roux-en-Y Anatomy via GG Fistula, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.