Background

Gastroesophageal malignancy after sleeve gastrectomy is rare. Early recognition and treatment are critical for long-term survival.

Methods

A 70-year-old Caucasian male with a BMI of 46 and history of Afib, Hypertension, Diabetes, and OSA underwent an uncomplicated laparoscopic sleeve gastrectomy with a normal intra-operative endoscopy. By 10 months postop, patient had reduced BMI to 30.5 and resolved his diabetes. Eleven months postop, he presented with emesis to solid foods progressing to liquids. With symptoms progressing despite medical treatment for GERD, endoscopy showed severe stenosis at the GE junction. EUS showed a circumferential mass positive for adenocarcinoma with invasion into the muscularis propria.

Results

Patient had adenocarcinoma of the distal esophagus HER 3+ and MMR proficient, clinical T2N1. He underwent esophageal stent placement followed by neoadjuvant chemotherapy and radiation including FOLFOX. He tolerated FOLFOX poorly and was changed to carboplatin/taxol + Radiation Therapy which was complicated by a localized perforation managed with antibiotics. After PET scan of esophageal mass indicated response to therapy, he underwent an open distal esophagectomy, total gastrectomy with Roux-en-Y esophagojejunostomy and placement of feeding tube. Pathology revealed poorly differentiated invasive adenocarcinoma of the GE junction and cardia with negative margins. His nadir weight during treatment was 24.3.

Conclusions

In the US, this represents only the second adenocarcinoma following a sleeve gastrectomy and the first in a non-immune compromised patient. Previous case series indicate an additional 15 cases worldwide with average diagnosis at 33 months. This case illustrates the need for both pre- and postoperative endoscopy.