Gastric Adenocarcinoma at the Anastomotic Site Three Decades after Gastrojejunostomy: A Case Report with Literature Review

Abstract

Malignancy at the gastrojejunostomy site, though rare, is a recognized long-term risk factor of the procedure. Such malignancies, though uncommon, pose diagnostic and therapeutic challenges. We report a case of a 63-year-old male presenting with a rare complication of gastric carcinoma at the loop gastrojejunostomy site 30 years after surgery for duodenal ulcer-induced gastric outlet obstruction. The patient’s symptoms included chronic intermittent upper abdominal pain, postprandial bilious vomiting, significant weight loss, and anorexia. The diagnosis was established through imaging and endoscopic biopsy, revealing a poorly differentiated carcinoma. Following preoperative optimization, the patient underwent subtotal radical gastrectomy with Roux-en-Y reconstruction with D2 lymphadenectomy. Histopathology confirmed poorly cohesive gastric carcinoma (signet ring cell type) with extensive lymph node metastasis (pT4a pN3a M0). Postoperative recovery was uneventful, and the patient was discharged on a CAPEOX regimen for adjuvant chemotherapy. This case highlights the importance of vigilance in patients with long-standing gastrojejunostomy, given the risk of malignancy at the anastomotic site.

INTRODUCTION

A gastrojejunostomy is a surgical procedure commonly indicated to bypass an obstruction in the distal stomach or proximal small bowel caused by conditions such as cancer or scarring from an ulcer.[1] In addition, it is used in weight-loss surgeries, such as the Roux-en-Y procedure, to bypass a significant portion of the small intestine.[2] The procedure may also be performed as part of reconstruction following a subtotal gastrectomy for cancer.[3] While this surgery generally alleviates symptoms, there is a well documented but rare risk of malignancy at the gastrojejunostomy site, typically occurring decades postoperatively.[4,5,6] Such malignancies, though uncommon, pose diagnostic and therapeutic challenges.

We present a case of a 63-year-old male presenting with gastric outlet obstruction secondary to gastric carcinoma at the stomal site of gastrojejunostomy 30 years after surgery for benign gastric outlet obstruction along with its presentation, diagnosis, management, and outcomes.

CASE REPORT

A 63-year-old male presented with a two-year history of intermittent upper abdominal pain, postprandial bilious vomiting, anorexia, and an unintentional weight loss of approximately 20 kilograms. The pain was insidious in onset, intermittent, and aggravated by food intake, with partial relief following vomiting. There were no associated symptoms of hematemesis, melena, jaundice, or fever. The patient revealed a 30-year-old history of a gastrojejunostomy with truncal vagotomy for gastric outlet obstruction. Since then, he had been asymptomatic until the current illness.

On examination, the patient had a BMI of 18.53 kg/m² and an Eastern Cooperative Oncology Group Performance Status of 3. He appeared chronically dehydrated, with sunken eyes and dry skin. Pallor was evident, but there was no jaundice, edema, or lymphadenopathy. Abdominal examination revealed a right paramedian scar, visible peristalsis, and a soft, nontender abdomen without organomegaly or palpable masses. Laboratory investigations showed severe anemia with hemoglobin of 4.7 g/dL, hypoproteinemia with albumin of 2.4 g/dL, and mild electrolyte disturbances. Kidney and liver function tests were within normal limits.

Upper gastrointestinal endoscopy identified ulcerations and irregular mucosa at the gastrojejunostomy site, and the biopsy confirmed a poorly differentiated carcinoma. Contrast-enhanced computed tomography of the abdomen and pelvis showed asymmetrical wall thickening of the gastrojejunostomy site and surrounding lymph nodes, raising suspicion of malignancy [Figure 1]. Preoperative optimization included transfusion of five packed red blood cells and three doses of 20% human albumin, which improved hemoglobin to 10.5 g/dL and albumin to 3 g/dL. Coagulation parameters were also corrected. The patient underwent subtotal radical gastrectomy with Roux-en-Y reconstruction with D2 lymphadenectomy. Intraoperatively, a tumor was identified at the gastrojejunostomy site with extensive adhesions and lymphadenopathy [Figure 2a and b]. Subtotal radical gastrectomy Roux-en-Y reconstruction with D2 lymphadenectomy was done, and the specimen was sent for Histopathology. There was no evidence of metastasis [Figure 3a and b]. Histopathological examination revealed a poorly cohesive gastric carcinoma (signet ring cell type) with 10 of 10 lymph nodes positive for metastasis, classified as pT4a pN3a M0 (AJCC 8^th edition) [Figure 4]. Postoperative recovery was uneventful, with enteral feeding initiated on the postoperative day 6 and drains removed on days 8 and 11. The patient was discharged with plans for adjuvant chemotherapy using the CAPEOX regimen.

Figure 1.

Computed tomography scan showing the asymmetrical circumferential wall thickening

Figure 2.

Intraoperative images showing the gastrojejunostomy site (a) and the Roux-en-Y site (b)

Figure 3.

Cut open section of the specimen showing the ulcer at the antrum (a) and stomal site of gastrojejunostomy (b)

Figure 4.

Histological findings of the resected specimen demonstrating signet ring cell carcinoma

DISCUSSION

Malignancy at the gastrojejunostomy site, though rare, is a recognized long-term complication of the procedure. Men are more likely to develop gastric cancer than women, with a ratio of 3–5:1 and an incidence of 1%–3%.[7] Proposed mechanisms include chronic bile reflux and mucosal injury, leading to carcinogenesis.[6,8] Anastomotic carcinoma has been known to develop late, referring to a minimum period of 15–25 years between the first and second surgery.[6] This case underscores the importance of long-term surveillance in patients with a history of gastrojejunostomy, particularly those presenting with new gastrointestinal symptoms after decades of asymptomatic status.

In the literature, several cases of late presentations of complications or secondary malignancies following previous gastrointestinal surgeries have been reported, with varying management strategies. Namikawa et al. described an 83-year-old male presenting 50 years after the initial surgery, managed with distal gastrectomy including the gastrojejunostomy site and Braun anastomosis, regional lymphadenectomy, and Billroth I reconstruction.[6] Vemulakonda et al. reported a 45-year-old female who presented 35 years postsurgery, requiring total gastrectomy with excision of the previous gastrojejunostomy loops, extending 10 cm along both the afferent and efferent jejunal loops.[4] Sahoo et al. documented a 75-year-old female presenting 25 years after surgery, managed with a distal subtotal gastrectomy, D1 lymph node dissection, and resection of the previously anastomosed jejunal stoma, followed by Roux-en-Y anastomosis.[9] Takeno et al. presented a 58-year-old male with symptoms 21 years after initial surgery who underwent a lower thoracic esophagectomy, total gastrectomy, cholecystectomy, splenectomy, lymph node dissection, and reconstruction using a modified Roux-en-Y method.[10] These cases highlight the importance of individualized surgical management tailored to the complexity of delayed presentations.

The reported incidence of malignancy at gastrojejunostomy sites remains low 1%–8%. The occurrence of carcinoma in gastrojejunostomy patients emphasizes the potential role of alkaline reflux gastritis as a carcinogenic factor.[9] Our findings align with this report but differ in the advanced stage of presentation and the histological subtype identified – a poorly cohesive carcinoma with signet ring cells. In contrast to previous cases where patients often presented with earlier-stage disease, our patient had extensive lymph node metastasis (10 out of 10 nodes positive), highlighting the aggressive nature of the carcinoma.[4,5,6] Furthermore, the interval of 30 years between the initial surgery and the diagnosis of malignancy in our case is among the longest documented, underscoring the necessity for lifelong vigilance in these patients. Management strategies have evolved, with a shift toward aggressive surgical resection followed by adjuvant chemotherapy, as evidenced in this case. The use of the CAPEOX regimen (capecitabine and oxaliplatin) is supported by recent clinical trials demonstrating improved survival in patients with advanced gastric cancer.[10,11,12,13,14]

This case also highlights the importance of preoperative optimization in patients with severe dehydration due to gastric outlet obstruction, anemia, and hypoproteinemia. Effective correction of these parameters enabled a smoother perioperative course, emphasizing the role of meticulous preoperative care in improving outcomes. Finally, the rarity of this condition calls for heightened awareness among clinicians and a multidisciplinary approach to management. Future research should focus on the molecular mechanisms underlying carcinogenesis at gastrojejunostomy sites and the potential benefits of surveillance programs for early detection.

CONCLUSION

A rare presentation of gastric carcinoma at a gastrojejunostomy site decades after surgery requires early recognition and prompt management. Most of the tumors are aggressive in nature. Radical surgical resection and adjuvant chemotherapy are crucial in optimizing patient outcomes. Long-term follow-up and awareness of this complication among healthcare providers are imperative for timely diagnosis and treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.