- Email: [email protected]
Unanticipated findings at bariatric surgery
Surgery for Obesity and Related Diseases 1 (2005) 22–24
Original article
Unanticipated findings at bariatric surgery David Greenbaum, M.D.*, David Friedel, M.D. Lourdes Medical Center of Burlington County, Willingboro, New Jersey
Abstract
Background: Obesity is associated with an increased prevalence of various intra-abdominal malignancies. There is little consensus as to the screening of the morbidly obese for these malignancies, and there are no guidelines for screening these subjects before bariatric surgery or performing a survey examination during abdominal bariatric surgery. Methods: A prospective analysis of 400 consecutive patients (362 women and 38 men) undergoing gastric bypass surgery was performed to identify the incidence of unanticipated intra-abdominal pathology. Results: All patients underwent abdominal exploration via an upper midline abdominal incision before gastric bypass surgery. Of the 400 patients, abnormalities were found in 31 (8%); 25 of these abnormalities were related to the ovaries. In only three cases (one case each of carcinoid of the appendix, Sertoli-Leydig cell tumor of the ovary, and serous cystadenocarcinoma of the ovary) would there have been a significant difference in the patient’s prognosis had the problem been left undiagnosed. Conclusion: It is reasonable to at least evaluate the ovaries in all female patients before proceeding with weight-loss surgery. © 2005 American Society for Bariatric Surgery. All rights reserved.
Keywords:
Bariatric surgery; Weight loss surgery; Ovarian cysts; Dermoid tumors; Ovarian cancer; Stomach gist tumor; Diverticulitis; Ovarian Sertoli-Leydig tumor; Intraoperative cancer screening
There has been a burgeoning use of bariatric surgery in confronting the obesity epidemic [1,2]. Unfortunately, there is little consensus on what constitutes an appropriate intraabdominal survey during and before actual bariatric surgery [3]. Such a survey is particularly relevant in those obese patients who are more prone to malignancy than their agematched normal-weight peers [4,5]. Laparoscopy or laparotomy may allow early diagnosis of premalignant or malignant conditions in the setting of bariatric surgery. It can also identify causes of abdominal or pelvic pain that were previously unknown. Of course, there is a price for performing such a survey—the increased time needed to do it either through the “open” technique or laparoscopically, which can increase the risk of postoperative complications. Methods Over a 5-year period (September 1997–June 2002), 400 patients (age 20 – 67 years) underwent bariatric surgery at a *Reprint requests: Dr. David Greenbaum, Lourdes Medical Center, 1000 Salem Road, Willingboro, NJ 18046. E-mail: [email protected]
single community nonteaching hospital with the same principal operating surgeon. All of these patients were screened in a uniform manner by medical, surgical, and psychiatric personnel. All of the patients were morbidly obese by body mass criteria, and many had significant comorbidities (eg, hypertension, diabetes, sleep apnea). The patients did not have any antecedent diagnostic examinations other than routine laboratory data, gallbladder ultrasonography, and specific tests dictated by their cardiopulmonary status (ie, stress tests, PFTs). In particular, few preoperative abdominal radiologic or endoscopic studies were performed on these patients. All patients underwent a Roux-en-Y gastric bypass via an “open” technique. A thorough preliminary survey of the abdominal cavity was performed in each case before initiation of the gastric bypass operation. Results The preliminary survey yielded significant findings in 31 patients (8%). The significance of the “incidental” pathology was inferred by consideration given to aborting the bypass surgery, and most of the findings mandated unex-
1550-7289/05/$ – see front matter © 2005 American Society for Bariatric Surgery. All rights reserved. doi:10.1016/j.soard.2004.12.008
D. Greenbaum and D. Friedel / Surgery for Obesity and Related Diseases 1 (2005) 22–24
pected additional resections or biopsies. Specifically, 12 patients (3%) had frozen-section biopsies. Gynecologic consultation was often necessary. Seventeen patients had large ovarian cysts that in the surgeon’s opinion were prone to complications and thus were treated by aspiration. Small cysts were not addressed. Uterine fibroids and nonalcoholic fatty liver disease, although fairly frequent, were not specifically evaluated either. One patient presented with asymptomatic acute diverticulitis of the sigmoid colon. In this patient, surgery was aborted for fear that potential complications from this condition could have been confused with potential postsurgical complications from her gastric bypass or that she may have had an unrecognized colon carcinoma. Antibiotic treatment and follow-up colonoscopy were provided before proceeding with her gastric bypass. Eight patients with solid ovarian tumors (four dermoid tumors, one Sertoli-Leydig cell tumor, one serous cystadenocarcinoma, and two benign masses) underwent gynecologic consultation at the time of surgery. A decision on whether or not to abort the gastric bypass centered on whether local excisional treatment would be sufficient or whether ongoing treatment—surgical, radiation, or medical—would complicate the postoperative course. The patients with Sertoli-Leydig tumor and dermoid tumor underwent salpingo-oopherectomy, which was thought to be sufficient. In the patient with serous cystadenocarcinoma of the ovary, the tumor was resected. Because of the tumor’s stage and grade, the gynecologist felt that no further treatment was warranted at that time. Gastric bypass was also performed in all of the patients at the same operation. In the latter case, a gynecologic oncologist later recommended total abdominal hysterectomy, lymph node dissection, and removal of the other ovary. This was done, and no further pathology was found. A carcinoid tumor, ⬍ 2 cm in size with no lymphatic invasion, was found in one patient. Appendectomy was felt to be sufficient before the gastric bypass was performed. In one patient, an ectopic pancreas was noted on the small intestine; after resection and frozen section diagnosis, the gastric bypass was performed. Wide excision of two gastrointestinal stromal tumors was thought to be satisfactory and easily done, because they were located in what would be the bypassed stomach. A single large Meckel’s diverticulum was also resected. Discussion The most striking finding from our project is the large proportion (1/12) of obese patients who had significant peritoneal pathology incidental to the bariatric procedure. Most (80%) of the findings were related to the ovaries. Large cysts (17/31) could be left alone, but may undergo torsion or may in fact be responsible for abdominal or pelvic pain that was not present before the surgery. Cyst aspiration
23
is quite simple and may eliminate this pain and prevent further problems. Solid ovarian masses, of which two were malignant, definitely needed to be addressed. Only three cases (carcinoid tumor of the appendix, Sertoli-Leydig tumor, serous cystadenocarcinoma of the ovary) turned out to be of major concern related to curing cancer before it progressed. The patient with acute sigmoid diverticulitis may have developed significant morbidity if not diagnosed and treated appropriately. We did not have screening data for our patients regarding the use of gynecologic services in reference to cancer screening. There is some suggestion that obese patients are usually more difficult to examine. There also is some suggestion that obese patients are less likely to follow recommended cancer prevention protocols [6]. Ultrasound is less sensitive in obese patients, due to this modality’s relative limited energy penetration [7]. There are weight/size restrictions on many radiologic scanning instruments. Computed tomography and magnetic resonance imaging interpretation may be hindered by obesity [8]. Thus, obese patients may have unappreciated peritoneal pathology before proposed bariatric surgery. Obese patients are more likely than thinner patients to have certain malignancies, compounding the aforementioned screening difficulties. Uterine carcinoma is clearly more prevalent in obese patients [9,10]. Unfortunately, a peritoneal survey is ineffective in making this diagnosis. Ovarian cancers are not usually associated with increased body mass index, but nonetheless, they are common in the bariatric surgery age range [11]. Survival of both of these malignancies is exponentially greater with early (ie, presymptomatic) discovery. Gastrointestinal pathology is of lesser consequence. Gastric leiomyomas are common and usually small and benign [12]. Diagnosing and resecting them before they become separated from the gastrointestinal continuity is nonetheless quite important. Fortunately, they are easy to identify during the gastric bypass procedure, allowing the surgeon to treat them appropriately. Gastrointestinal carcinoids have been previously noted to be an incidental finding during bariatric surgery; they are usually slow-growing and initially not hormonally active [13]. However, they will continue to grow, can metastasize, and can be life-threatening if undiagnosed before symptoms occur. Meckel’s diverticuli usually do not manifest clinical problems [14]; the single case identified in our series was resected because of its large size and the ease with which it could be resected, but it could have been left in situ. Ectopic pancreas is clinically inconsequential, but before frozen section, the diagnosis was unclear. Conclusion The findings from this study suggest that it is worthwhile to examine at least the ovaries and treat any potential pathology before performing weight loss surgery. This can be done rather easily either through the “open” technique or
24
D. Greenbaum and D. Friedel / Surgery for Obesity and Related Diseases 1 (2005) 22–24
laparoscopically. The only other significant pathology identified in our series was acute sigmoid diverticulitis, which would have been easily noted when examining the ovaries, and a carcinoid tumor of the appendix, which would have been quite difficult to diagnose without a thorough abdominal examination. Because of the low incidence of this problem, and because no other significant pathology was found in thorough exploration, the time and potential morbidity associated with thorough exploration (especially when done laparoscopically) may not be warranted. References [1] Giusti V, Suter M, Heraief E, et al. Rising role of obesity surgery caused by increase of morbid obesity, failure of conventional treatments and unrealistic expectations: trends from 1997 to 2001. Obes Surg 2003;13:693–98. [2] Steinbrook R. Surgery for severe obesity. N Engl J Med 2004;350: 1075–79. [3] Consensus Development Conference Panel. Gastrointestinal surgery for severe obesity. Ann Intern Med 1991;115:956 – 61. [4] Deslypere JP. Obesity and cancer. Metabolism 1999;44(9 Suppl): 24 –27.
[5] Abu-Abid S, Szold A, Klausner J. Obesity and cancer. J Med 2002; 33:73– 86. [6] Fontaine KR, Faith MS, Allison DB, et al. Body weight and health care among women in the general population. Arch Fam Med 1998; 7:381– 4. [7] Fiegler W, Felix R, Langer M, et al. Fat as a factor affecting resolution in diagnostic ultrasound: possibilities for improving picture quality. Eur J Radiol 1985;5:304 –9. [8] Low RN, Barone RM, Lacey C, et al. Peritoneal tumor: MR imaging with dilute oral and intravenous gadolinium-containing contrast agents compared with unenhanced MR imaging and CT. Radiology 1997;204:513–20. [9] Purdie DM, Green AC. Epidemiology of endometrial cancer. Best Pract Res Clin Obstet Gynaecol 2001;15:341–54. [10] Kaaks R, Lukanova A, Kurzer MS. Obesity, endogenous hormones, and endometrial risk: a synthetic review. Cancer Epidemiol Biomarkers Prev 2002;11:1531– 43. [11] Lukanova A, Toniolo P, Lundin E, et al. Body mass index in relation to ovarian cancer: a multi-centre nested case-control study. Int J Cancer 2002;99:603– 8. [12] Yan H, Marchettini P, Acherman YI, et al. Prognostic assessment of gastrointestinal stromal tumor. Am J Clin Oncol 2003;26:221– 8. [13] Keshisian A, Hamilton J, Hwang L, et al. Carcinoid tumor and bariatric surgery. Obes Surg 2002;12:874 –5. [14] Soltero MJ, Bill AH. The natural history of Meckel’s diverticulum and its relation to incidental removal. Am J Surg 1976;132:168 –73.
Original article
Unanticipated findings at bariatric surgery David Greenbaum, M.D.*, David Friedel, M.D. Lourdes Medical Center of Burlington County, Willingboro, New Jersey
Abstract
Background: Obesity is associated with an increased prevalence of various intra-abdominal malignancies. There is little consensus as to the screening of the morbidly obese for these malignancies, and there are no guidelines for screening these subjects before bariatric surgery or performing a survey examination during abdominal bariatric surgery. Methods: A prospective analysis of 400 consecutive patients (362 women and 38 men) undergoing gastric bypass surgery was performed to identify the incidence of unanticipated intra-abdominal pathology. Results: All patients underwent abdominal exploration via an upper midline abdominal incision before gastric bypass surgery. Of the 400 patients, abnormalities were found in 31 (8%); 25 of these abnormalities were related to the ovaries. In only three cases (one case each of carcinoid of the appendix, Sertoli-Leydig cell tumor of the ovary, and serous cystadenocarcinoma of the ovary) would there have been a significant difference in the patient’s prognosis had the problem been left undiagnosed. Conclusion: It is reasonable to at least evaluate the ovaries in all female patients before proceeding with weight-loss surgery. © 2005 American Society for Bariatric Surgery. All rights reserved.
Keywords:
Bariatric surgery; Weight loss surgery; Ovarian cysts; Dermoid tumors; Ovarian cancer; Stomach gist tumor; Diverticulitis; Ovarian Sertoli-Leydig tumor; Intraoperative cancer screening
There has been a burgeoning use of bariatric surgery in confronting the obesity epidemic [1,2]. Unfortunately, there is little consensus on what constitutes an appropriate intraabdominal survey during and before actual bariatric surgery [3]. Such a survey is particularly relevant in those obese patients who are more prone to malignancy than their agematched normal-weight peers [4,5]. Laparoscopy or laparotomy may allow early diagnosis of premalignant or malignant conditions in the setting of bariatric surgery. It can also identify causes of abdominal or pelvic pain that were previously unknown. Of course, there is a price for performing such a survey—the increased time needed to do it either through the “open” technique or laparoscopically, which can increase the risk of postoperative complications. Methods Over a 5-year period (September 1997–June 2002), 400 patients (age 20 – 67 years) underwent bariatric surgery at a *Reprint requests: Dr. David Greenbaum, Lourdes Medical Center, 1000 Salem Road, Willingboro, NJ 18046. E-mail: [email protected]
single community nonteaching hospital with the same principal operating surgeon. All of these patients were screened in a uniform manner by medical, surgical, and psychiatric personnel. All of the patients were morbidly obese by body mass criteria, and many had significant comorbidities (eg, hypertension, diabetes, sleep apnea). The patients did not have any antecedent diagnostic examinations other than routine laboratory data, gallbladder ultrasonography, and specific tests dictated by their cardiopulmonary status (ie, stress tests, PFTs). In particular, few preoperative abdominal radiologic or endoscopic studies were performed on these patients. All patients underwent a Roux-en-Y gastric bypass via an “open” technique. A thorough preliminary survey of the abdominal cavity was performed in each case before initiation of the gastric bypass operation. Results The preliminary survey yielded significant findings in 31 patients (8%). The significance of the “incidental” pathology was inferred by consideration given to aborting the bypass surgery, and most of the findings mandated unex-
1550-7289/05/$ – see front matter © 2005 American Society for Bariatric Surgery. All rights reserved. doi:10.1016/j.soard.2004.12.008
D. Greenbaum and D. Friedel / Surgery for Obesity and Related Diseases 1 (2005) 22–24
pected additional resections or biopsies. Specifically, 12 patients (3%) had frozen-section biopsies. Gynecologic consultation was often necessary. Seventeen patients had large ovarian cysts that in the surgeon’s opinion were prone to complications and thus were treated by aspiration. Small cysts were not addressed. Uterine fibroids and nonalcoholic fatty liver disease, although fairly frequent, were not specifically evaluated either. One patient presented with asymptomatic acute diverticulitis of the sigmoid colon. In this patient, surgery was aborted for fear that potential complications from this condition could have been confused with potential postsurgical complications from her gastric bypass or that she may have had an unrecognized colon carcinoma. Antibiotic treatment and follow-up colonoscopy were provided before proceeding with her gastric bypass. Eight patients with solid ovarian tumors (four dermoid tumors, one Sertoli-Leydig cell tumor, one serous cystadenocarcinoma, and two benign masses) underwent gynecologic consultation at the time of surgery. A decision on whether or not to abort the gastric bypass centered on whether local excisional treatment would be sufficient or whether ongoing treatment—surgical, radiation, or medical—would complicate the postoperative course. The patients with Sertoli-Leydig tumor and dermoid tumor underwent salpingo-oopherectomy, which was thought to be sufficient. In the patient with serous cystadenocarcinoma of the ovary, the tumor was resected. Because of the tumor’s stage and grade, the gynecologist felt that no further treatment was warranted at that time. Gastric bypass was also performed in all of the patients at the same operation. In the latter case, a gynecologic oncologist later recommended total abdominal hysterectomy, lymph node dissection, and removal of the other ovary. This was done, and no further pathology was found. A carcinoid tumor, ⬍ 2 cm in size with no lymphatic invasion, was found in one patient. Appendectomy was felt to be sufficient before the gastric bypass was performed. In one patient, an ectopic pancreas was noted on the small intestine; after resection and frozen section diagnosis, the gastric bypass was performed. Wide excision of two gastrointestinal stromal tumors was thought to be satisfactory and easily done, because they were located in what would be the bypassed stomach. A single large Meckel’s diverticulum was also resected. Discussion The most striking finding from our project is the large proportion (1/12) of obese patients who had significant peritoneal pathology incidental to the bariatric procedure. Most (80%) of the findings were related to the ovaries. Large cysts (17/31) could be left alone, but may undergo torsion or may in fact be responsible for abdominal or pelvic pain that was not present before the surgery. Cyst aspiration
23
is quite simple and may eliminate this pain and prevent further problems. Solid ovarian masses, of which two were malignant, definitely needed to be addressed. Only three cases (carcinoid tumor of the appendix, Sertoli-Leydig tumor, serous cystadenocarcinoma of the ovary) turned out to be of major concern related to curing cancer before it progressed. The patient with acute sigmoid diverticulitis may have developed significant morbidity if not diagnosed and treated appropriately. We did not have screening data for our patients regarding the use of gynecologic services in reference to cancer screening. There is some suggestion that obese patients are usually more difficult to examine. There also is some suggestion that obese patients are less likely to follow recommended cancer prevention protocols [6]. Ultrasound is less sensitive in obese patients, due to this modality’s relative limited energy penetration [7]. There are weight/size restrictions on many radiologic scanning instruments. Computed tomography and magnetic resonance imaging interpretation may be hindered by obesity [8]. Thus, obese patients may have unappreciated peritoneal pathology before proposed bariatric surgery. Obese patients are more likely than thinner patients to have certain malignancies, compounding the aforementioned screening difficulties. Uterine carcinoma is clearly more prevalent in obese patients [9,10]. Unfortunately, a peritoneal survey is ineffective in making this diagnosis. Ovarian cancers are not usually associated with increased body mass index, but nonetheless, they are common in the bariatric surgery age range [11]. Survival of both of these malignancies is exponentially greater with early (ie, presymptomatic) discovery. Gastrointestinal pathology is of lesser consequence. Gastric leiomyomas are common and usually small and benign [12]. Diagnosing and resecting them before they become separated from the gastrointestinal continuity is nonetheless quite important. Fortunately, they are easy to identify during the gastric bypass procedure, allowing the surgeon to treat them appropriately. Gastrointestinal carcinoids have been previously noted to be an incidental finding during bariatric surgery; they are usually slow-growing and initially not hormonally active [13]. However, they will continue to grow, can metastasize, and can be life-threatening if undiagnosed before symptoms occur. Meckel’s diverticuli usually do not manifest clinical problems [14]; the single case identified in our series was resected because of its large size and the ease with which it could be resected, but it could have been left in situ. Ectopic pancreas is clinically inconsequential, but before frozen section, the diagnosis was unclear. Conclusion The findings from this study suggest that it is worthwhile to examine at least the ovaries and treat any potential pathology before performing weight loss surgery. This can be done rather easily either through the “open” technique or
24
D. Greenbaum and D. Friedel / Surgery for Obesity and Related Diseases 1 (2005) 22–24
laparoscopically. The only other significant pathology identified in our series was acute sigmoid diverticulitis, which would have been easily noted when examining the ovaries, and a carcinoid tumor of the appendix, which would have been quite difficult to diagnose without a thorough abdominal examination. Because of the low incidence of this problem, and because no other significant pathology was found in thorough exploration, the time and potential morbidity associated with thorough exploration (especially when done laparoscopically) may not be warranted. References [1] Giusti V, Suter M, Heraief E, et al. Rising role of obesity surgery caused by increase of morbid obesity, failure of conventional treatments and unrealistic expectations: trends from 1997 to 2001. Obes Surg 2003;13:693–98. [2] Steinbrook R. Surgery for severe obesity. N Engl J Med 2004;350: 1075–79. [3] Consensus Development Conference Panel. Gastrointestinal surgery for severe obesity. Ann Intern Med 1991;115:956 – 61. [4] Deslypere JP. Obesity and cancer. Metabolism 1999;44(9 Suppl): 24 –27.
[5] Abu-Abid S, Szold A, Klausner J. Obesity and cancer. J Med 2002; 33:73– 86. [6] Fontaine KR, Faith MS, Allison DB, et al. Body weight and health care among women in the general population. Arch Fam Med 1998; 7:381– 4. [7] Fiegler W, Felix R, Langer M, et al. Fat as a factor affecting resolution in diagnostic ultrasound: possibilities for improving picture quality. Eur J Radiol 1985;5:304 –9. [8] Low RN, Barone RM, Lacey C, et al. Peritoneal tumor: MR imaging with dilute oral and intravenous gadolinium-containing contrast agents compared with unenhanced MR imaging and CT. Radiology 1997;204:513–20. [9] Purdie DM, Green AC. Epidemiology of endometrial cancer. Best Pract Res Clin Obstet Gynaecol 2001;15:341–54. [10] Kaaks R, Lukanova A, Kurzer MS. Obesity, endogenous hormones, and endometrial risk: a synthetic review. Cancer Epidemiol Biomarkers Prev 2002;11:1531– 43. [11] Lukanova A, Toniolo P, Lundin E, et al. Body mass index in relation to ovarian cancer: a multi-centre nested case-control study. Int J Cancer 2002;99:603– 8. [12] Yan H, Marchettini P, Acherman YI, et al. Prognostic assessment of gastrointestinal stromal tumor. Am J Clin Oncol 2003;26:221– 8. [13] Keshisian A, Hamilton J, Hwang L, et al. Carcinoid tumor and bariatric surgery. Obes Surg 2002;12:874 –5. [14] Soltero MJ, Bill AH. The natural history of Meckel’s diverticulum and its relation to incidental removal. Am J Surg 1976;132:168 –73.