Gastric and pancreatoduodenal resection for malignant lesions after previous gastric bypass-diagnosis and methods of reconstruction

Background: The diagnosis and treatment of gastric and pancreatoduodenal neoplasms after previous gastric bypass has been limited. Experience should increase in the future owing to the number of bariatric procedures being performed. The diagnosis and resection of these neoplasms and restoration of biliopancreatic intestinal continuity pose challenges. We present a 2-institutional experience of diagnosis and reconstruction after resection of gastric and pancreatoduodenal neoplasms and discuss the technical options for reconstruction. Methods: The medical records were reviewed retrospectively from 2003 to 2009 for patients with previous gastric bypass who developed a gastric or pancreatoduodenal neoplasm. Results: Of the available patients, 7 were identified with 2 remnant gastric cancers (2 signet ring cell adenocarcinomas), 4 pancreatic neoplasms (2 adenocarcinomas and 2 neuroendocrine cancers), and 1 ampullary cancer. The gastric neoplasms required complete remnant gastrectomy but did not require additional gastrointestinal reconstruction. The pancreatic and duodenal neoplasms required pancreatoduodenectomy, with 4 of 5 patients also undergoing remnant gastrectomy. The patients after pancreatoduodenectomy required biliary and pancreatic reconstruction with the pancreaticobiliary limb, Roux limb, or proximal common channel, depending on the limb length. Operative mortality was nil, and the morbidity rate was 28%. Conclusion: Gastric and pancreatoduodenal neoplasms after previous gastric bypass, although rare, will most likely increase as the number of bariatric operations increases. A high index of suspicion and focused diagnostic testing are key in identifying these lesions. Resection is feasible and safe but could require complex gastric and pancreatobiliary reconstruction.