Published online Jul 15, 2018. doi: 10.4251/wjgo.v10.i7.194
Peer-review started: February 7, 2018
First decision: March 7, 2018
Revised: May 25, 2018
Accepted: June 8, 2018
Article in press: June 9, 2018
Published online: July 15, 2018
Despite the fact that the small intestine makes up more than 90% of the surface area and 70% of the length of the gastrointestinal tract, small bowel malignancies are among the rarest cancers. Anastomotic gastric cancer following distal gastrectomy for peptic ulcer is a well-established clinical entity. However, malignancies of the afferent or efferent loop of the gastrointestinal anastomosis are extremely uncommon.
To present patients who developed small-bowel malignancy at the level of the gastrointestinal anastomosis decades after a subtotal gastrectomy for ulcer.
In this paper, we present three patients who developed small-bowel malignancy at the level of the gastrointestinal anastomosis decades after a subtotal gastrectomy for ulcer, to review relevant literature, and to interpret the reason that those cancers developed to these postsurgical nongastric sights.
For the current retrospective study and review of literature, the surgical and histopathological records of our department were examined, searching for patients who have undergone surgical treatment of small-bowel malignancy to identify those who have undergone subtotal gastrectomy for benign peptic ulcer. A systematic literature search was also conducted using PubMed, EMBASE, and Cochrane Library to identify similar cases.
We identified three patients who had developed small-intestine malignancy at the level of the gastrointestinal anastomosis decades after a subtotal gastrectomy with Billroth II gastroenterostomy for benign peptic ulcer-two patients with adenocarcinoma originated in the Braun anastomosis and one patient with lymphoma of the efferent loop. All three patients were submitted to surgical resection of the tumor with Roux-en-Y reconstruction of the digestive tract. In the literature review, we only found one case of primary small-intestinal cancer that originated in the efferent loop after Billroth II gastrectomy because of duodenal ulcer but none reporting Braun anastomosis adenocarcinoma following partial gastrectomy for benign disease. We also did not find any case of efferent loop lymphoma following gastrectomy.
Anastomotic gastric cancer following distal gastrectomy for peptic ulcer is a well-established clinical entity. However, malignancies of the afferent or efferent loop of the gastrointestinal anastomosis are extremely uncommon. The substantial diversion of the potent carcinogenic pancreaticobiliary secretions through the Braun anastomosis and the stomach hypochlorhydria, allowing the formation of carcinogenic factors from food, are the two most prominent pathogenetic mechanisms for those tumors.
The “by-pass” path of the bile made by a Braun anastomosis added to a Billroth II gastrectomy is the most prevalent hypothesis for the development of the two adenocarcinomas at the specific spot. Much more needs to be discovered about the ALCL ALK-negative type of lymphoma to make assumptions since it has not been studied for more than 20 years. However, we cannot be certain that the appearance of those small-intestinal tumors at those spots had a direct relation to the operations that occurred decades ago.