Retrospective Study
Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Oncol. Jul 15, 2018; 10(7): 194-201
Published online Jul 15, 2018. doi: 10.4251/wjgo.v10.i7.194
Atypical anastomotic malignancies of small bowel after subtotal gastrectomy with Billorth II gastroenterostomy for peptic ulcer: Report of three cases and review of the literature
Efstathios Kotidis, Orestis Ioannidis, Manousos George Pramateftakis, Konstantinos Christou, Ioannis Kanellos, Konstantinos Tsalis
Efstathios Kotidis, Orestis Ioannidis, Manousos George Pramateftakis, Konstantinos Christou, Ioannis Kanellos, Konstantinos Tsalis, Fourth Surgical Department, Medical School, Aristotle University of Thessaloniki, Thessaloniki 57010, Greece
Author contributions: All authors helped to perform the research; Kotidis E, Ioannidis O, Pramateftakis MG and Christou K collected the data; Ioannidis O, Kanellos I and Tsalis K analyzed and interpreted the data; Kotidis E, Ioannidis O, Pramateftakis MG and Christou K designed and supervised the study; Kanellos I and Tsalis K significantly contributed to the literature review and linguistic formatting and correction of the manuscript; Kotidis E, Ioannidis O, Pramateftakis MG, Christou K, Kanellos I and Tsalis K critically revised the manuscript for important intellectual content; Kotidis E, Ioannidis O, Pramateftakis MG and Christou K drafted the manuscript and were responsible for final proof reading; all authors have read and approved the final version to be published.
Institutional review board statement: This study was reviewed and approved by the Ethics Committee of General Hospital “George Papanikolaou”, Thessaloniki, Greece.
Informed consent statement: Patients were not required to give informed consent to the study because the analysis used anonymous clinical data that were obtained after each patient agreed to treatment by written consent.
Conflict-of-interest statement: All authors declare no conflicts-of-interest related to this article.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Orestis Ioannidis, MD, MSc, PhD, Academic Fellow, Doctor, Surgeon, Fourth Surgical Department, Medical School, Aristotle University of Thessaloniki, Alexandrou Mihailidi 13, Thessaloniki 57010, Greece. iorestis@auth.gr
Telephone: +30-23-10814161 Fax: +30-23-10551301
Received: February 7, 2018
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
Processing time: 158 Days and 1.8 Hours
Abstract
AIM

To present 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 attempt to interpret the reasons those cancers developed to these postsurgical non-gastric sights.

METHODS

For the current retrospective study and review of literature, the surgical and histopathological records dated from January 1, 1993 to December 31, 2017 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.

RESULTS

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.

CONCLUSION

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.

Keywords: Anastomotic cancer; Efferent loop; Braun anastomosis; Adenocarcinoma; Anaplastic large cell lymphoma

Core tip: 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. In this paper, three patients who developed small-bowel malignancy at the level of the gastrointestinal anastomosis decades after a subtotal gastrectomy for ulcer are presented. The two most prominent pathogenetic mechanisms for those tumors are the stomach hypochlorhydria, allowing the formation of carcinogenic factors from food, and the substantial diversion of the potent carcinogenic pancreaticobiliary secretions through the Braun anastomosis.