Department of Surgery, New York Methodist Hospital, Brooklyn, New York, USA (all authors).

ABSTRACT

Introduction: Port site metastases are known phenomena associated with laparoscopic resection of intra-abdominal malignancies, but have not been well documented for gastric cancer. We report a case of port site metastases after laparoscopic subtotal gastrectomy for advanced gastric adenocarcinoma.

Case Description: A 71-year-old woman with a history of hypertension and diabetes mellitus presented with melena, weight loss, and signs of gastric outlet obstruction. Preoperative workup demonstrated a T3N1M0 mass extending along the lesser curvature of the stomach with biopsy confirming adenocarcinoma. The patient underwent an uneventful laparoscopic subtotal gastrectomy with D2 lymphadenectomy followed by adjuvant chemotherapy. Thirteen months after surgery, the patient presented with palpable subcutaneous nodules at two of the port sites. computed tomographic (CT) scan confirmed the isolated nodules without distant metastases and fine-needle aspirations confirmed gastric adenocar- cinoma. The patient was treated with another cycle of chemotherapy. A post treatment proton emission tomography (PET) scan did not show any other lesions, and the patient was scheduled for resection. During surgery the left upper quadrant mass was found to infiltrate the left colon and an additional mass was found at the prior umbilical port. Pathology was consistent with gastric adenocarcinoma for all the lesions. An excisional biopsy of the right upper quadrant lesion was completed.

Conclusion: Given the rarity of port site metastases after gastric adenocarcinoma, there is no conclusive literature regarding the management. Repeat chemotherapy followed by resection, if feasible, appears to be the most reasonable therapeutic intervention if there is no evidence of distant metastases.

Key Words: Chemotherapy, Gastric adenocarcinoma, Laparoscopic gastrectomy, Port site metastasis.

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Department of Surgery, New York Methodist Hospital, Brooklyn, NY, USA (all authors).

ABSTRACT

Introduction: Laparoscopic adjustable gastric banding (LAGB) has a potential for long-term complications. We report a case of LAGB slippage with extensive gastric necrosis managed with emergent sleeve gastrectomy.

Case Report: A 45-year-old man presented to the emergency department after returning from a distant trip and reported a 3-day history of progressively severe abdominal pain, nausea, vomiting, and fever. He had undergone placement of the LAGB 2 years before this presentation, which resulted in subsequent weight loss of 143 lb and resolution of his comorbidities. On admission, the patient was hypotensive, tachycardic, and oliguric, with evident peritonitis. A computed tomography scan revealed extensive intraperitoneal free air and intra-abdominal fluid. After intravenous fluid resuscitation, he underwent emergent exploratory laparoscopy. A slipped band with gastric prolapse and extensive gastric necrosis were found, with multiple perforations involving most of the greater curvature of the stomach. The LAGB was explanted and a laparoscopic sleeve gastrectomy was performed. A liquid diet was introduced on postoperative day 4. Immediate recovery was prolonged because of acute-onset chronic renal failure and requirement for optimization of nutrition. The patient was discharged home on postoperative day 13 and had a subsequent uneventful recovery.

Conclusion: Gastric prolapse complicated by gastric necrosis is a rare life-threatening complication of LAGB. Once acute LAGB slippage is suspected, urgent attention and treatment are needed to minimize the chance of gastric ischemia. Laparoscopic explanation of LAGB and emergent sleeve gastrectomy may be considered in similar clinical settings to optimize the outcome and minimize the morbidity of near total or total gastrectomy.

Key Words: Laparoscopic adjustable gastric banding, Morbid obesity, Gastric necrosis, Sleeve gastrectomy, Gastric prolapse, Lap band slip.

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