GREEN, A. E.*; ESCOBAR, P. F.†; STELLATO, T.‡; HALLOWELL, P.‡; VON GRUENIGEN, V. E.*
*Division of Gynecologic Oncology, Department of Reproductive Biology, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, Ohio
†Gynecologic Oncology Program, Department of Obstetrics and Gynecology, The Cleveland Clinic Foundation, Cleveland, Ohio
‡Department of Surgery, University Hospitals of Cleveland, Cleveland, Ohio
Address correspondence and reprint requests to: Vivian E. von Gruenigen, MD, Division of Gynecologic Oncology, University MacDonald Women's Hospital, Room 7128, 11100 Euclid Avenue, Cleveland, OH 44106, USA. Email: firstname.lastname@example.org
Accepted for publication May 12, 2005
Obesity has become a major public health problem due to the increasing incidence of and association with higher morbidity and mortality. Fifty percent of US adults are overweight and one out of five adults are obese(1). Recent research has indicated that poor diet and physical inactivity may soon overtake tobacco as the leading cause of death attributable to lifestyle choices(2). Bariatric surgery has shown a marked trend in the United States, increasing from 16,000 procedures in the early 1990s to approximately 103,000 in 2003(3). Obesity is an independent risk factor for diseases such as cancer (including endometrial cancer), diabetes, hypertension, arthritis, and coronary heart disease(4). It also negatively affects quality of life(5).
The following cases include three patients who presented to the bariatric service for elective gastric bypass surgery and were discovered to have a diagnosis of gynecological cancer preoperatively, intraoperatively, or postoperatively. Each case represents unique challenges for both the gynecological oncologist and the bariatric surgeon.
A 38-year-old female weighing 342 pounds (body mass index [BMI] of 50.4) in 1982 elected to have vertical ring gastroplasty. In 1998 at the age of 54 she experienced postmenopausal bleeding. Endometrial sampling revealed a grade 1 endometrial adenocarcinoma. She underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy, and lymph node dissection. The procedure was not complicated by her previous surgery since her gastroplasty involved only her stomach and was thus confined to her upper abdomen. She was diagnosed with a stage IB, grade 1 adenocarcinoma of the endometrium and received adjuvant vaginal cuff brachytherapy. She has been without evidence of disease since 1998. During this interval, she regained most of her weight. Multiple weight loss attempts were unsuccessful and consequently she underwent elective Roux-en-Y gastric bypass in 2000 when she was 317 pounds. Her Roux-en-Y was uncomplicated, and at her last follow-up visit, she was 196 pounds (BMI of 28.9) and was without evidence of disease. She has lost a total of 146 pounds from her initial 1982 surgery.
A 56-year-old female with a medical history including noninsulin diabetes and chronic hypertension, with a BMI of 60, was scheduled for elective Roux-en-Y. Upon abdominal entry, she was found to have extensive ascites and carcinomatosis. Biopsies were taken, and the procedure was terminated. Pathology revealed a papillary serous cystadenocarcinoma. Computed tomography (CT) scan and pelvic/transvaginal ultrasound performed postoperatively were nondiagnostic. However, she did have a markedly elevated CA125 weeks after recovery from her surgery. She was given platinum and taxane–based combination chemotherapy. After six cycles and a slowly declining CA125 level, she was taken to the operating room for interval staging. She underwent a suboptimal debulking for primary peritoneal carcinoma as there was extensive upper abdominal disease. The patient was given further adjuvant chemotherapy but progressed as evidenced by an elevating CA125.
A 42-year-old female with a BMI of 44.6 underwent a laparoscopic Roux-en-Y in 2002. She subsequently lost 86 pounds. She presented to her gynecologist in 2003 for a routine exam. Due to her body habitus, her physical exam was not adequate and an ultrasound was ordered which revealed an enlarged ovary. She was taken to the operating room in May 2003 and was found to have a stage IA granulosa cell ovarian cancer. The adhesions from the Roux-en-Y were minimal and did not interfere with either the lymph node dissection or the omentectomy. In October 2003, she presented with an acute abdomen. Radiologic studies revealed pneumoperitoneum. Exploratory laparotomy revealed a disrupted vaginal cuff, 5 months postoperative from her hysterectomy.
These three cases highlight the increasing relationship between obesity, bariatric surgery, and gynecological cancer in the United States. With bariatric surgery becoming more common, it is anticipated that there will be an increased number of incidental findings of cancer in patients undergoing this procedure(3). Endometrial cancer is the most common gynecological malignancy and obesity is a prominent risk factor for the disease. The incidence of obesity is rising in the United States, which may be a factor in the rising incidence of endometrial cancer(6). It is anticipated that the occurrence of endometrial cancer in gastric bypass patients seen both preoperatively and postoperatively will be increasing.
The finding of abdominal carcinomatosis was not anticipated by the primary surgical team in the second case. Imaging with CT scan and ultrasound did not show evidence of metastatic peritoneal cancer in this obese patient(7). The morbidly obese woman presents a diagnostic problem as illustrated in cases 2 and 3 as physical exam is limited and may prevent an accurate diagnosis(8). It is unclear in the ovarian cancer staging literature, if obesity impedes optimal debulking. In addition, gynecological oncologists may have more difficulty operating and performing staging in the upper abdomen following gastric bypass surgery. Vaginal cuff dehiscence, in case 3, is an unusual complication of hysterectomy(9,10). Since postoperative incisional hernia risk is higher in the obese, the incidence of vaginal dehiscence may also be higher in the obese(11).
The gynecological oncologist should be familiar with the methods by which bariatric surgical procedures are performed, so they can manage the surgical exploration and cancer resections of patients who have had these procedures. Whenever possible, the gynecological oncologist should discuss the bariatric operation with the patient's surgeon. If direct dialogue is not possible, the surgeon should review the operative report and any perioperative records(12).
There were approximately 40,000 bariatric procedures performed in the United States in 2001(13). It is estimated that tripling this number would not support the anticipated need over the coming decade, given the currently increasing rate of demand. There have evolved three major forms of bariatric surgery: malabsorptive, restrictive, and combined versions. Each form has been successfully performed laparoscopically, and it is expected that this will be the preferred modality in the near future.
Malabsorptive procedures represent the initial foray into bariatric surgery(13). Early complications, and side effects were high, and the procedures lost popularity. Although the next attempt to surgically manage obesity involved gastric bypass, this was abandoned in favor of a purely restrictive procedure, the gastroplasty. This initial attempt was refined as the Vertical Banded Gastroplasty (VBG); although still used today, the most recent modification is the adjustable gastric band placed laparoscopically (the LapBand). These procedures are designed to limit the volume of the stomach to induce early satiety. They are much more physiologic, as there is no rerouting of the gastric contents. They are also much easier to perform. The goal is to create a gastric volume that is <15 mL. The laparoscopic adjustable band uses an adjustable silicon ring that exits the abdomen via a subcutaneous port that allows adjustments to maintain the volume of the reservoir (12).
While the initial attempts to create a malabsorptive state were fraught with complications, procedures to create selective maldigestion and absorption continue to be developed and performed. The biliopancreatic diversion and its modification, the duodenal switch are two such examples. The goal is to decrease the absorption of fats and starches. In the duodenal switch procedure, the greater curvature of the stomach is removed, preserving the pylorus. This is termed a partial or ‘sleeve’ gastrectomy. This leaves a tubular portion of the stomach remaining that is primarily the lesser curvature and has a capacity of 150–200 mL. The biliopancreatic diversion portion involves dividing the duodenum two centimeters from the pylorus. Approximately 50 cm of terminal ileum is used for the final common pathway. Another 150 cm of ileum is measured and divided. The distal end of the division is anastomosed with the pylorus. The remaining proximal end of the divided ileum is then anastomosed to the site 50 cm from the terminal ileum. This creates a pathway for the biliary and pancreatic contents to reach the digestive site, now the terminal ileum(14).
The combined malabsorptive and restrictive procedures are currently the most popular procedures. They are characterized by making a small gastric pouch with a small outlet. The Roux-en-Y is the most commonly performed. There are two key components. First, a Roux limb gastrojejunostomy provides an outlet for stomach contents. Then, at minimum, the distal stomach, duodenum, and initial portion of the jejunum are bypassed. The length of the Roux limb is frequently fashioned according to the body mass index (BMI) of the patient. Various lengths (often between 80 and 150 cm) are used. The proximal jejunum is then anastomosed to this point on the jejunum. The Roux limb (also known as the alimentary limb) can reach the pouch via a number of different routes: retrocolic-retrogastric, retrocolic antegastric, antecolic-antegastric or antecolic-retrogastric. A 10 to 15 mL proximal gastric pouch is created and either divided from the remainder of the stomach or left incontinuity but with the staple line preventing food from entering the distal stomach. The Roux limb is anastomosed to the pouch by either stapling or hand sewing. Thus digestion will not begin until the reservoir's contents meet the biliopancreatic contents at the downstream jejunojejunostomy (Fig. 1)(14).
Any surgeon who contemplates operating on this patient population should be aware that there are many modifications to the above procedures and that these descriptions are only general guidelines. It is recommended that before any subsequent operation, the bariatric surgeon who operated on the patient be consulted so that the exact details of the procedure can be determined. If this is not possible, careful review of the operative details and the patient's records are helpful, as these may contain both descriptive and pictorial information regarding the altered anatomy (12). Complications from open and endoscopic procedures include anastomotic leaks, and sepsis. The patient in case 1 previously had undergone a purely restrictive bariatric procedure with subsequent failure and weight regain. Purely restrictive procedures fail to alter the patient's physiology, ie, there is minimal or no alteration in the hunger hormone, ghrelin. The Roux-en-Y gastric bypass dramatically suppresses ghrelin and consequently has a much more durable and successful outcome with lifetime success rates in the range of 85–90%. With the widespread training and improvement of laparoscopic techniques, many surgery centers are moving toward laparoscopic bariatric procedures(12). More than 800 gastric bypass procedures have been performed at the University Hospitals of Cleveland from March 1998 to the present. While minimally invasive surgery is relatively new to the field of bariatric surgery, it is may decrease the overall morbidity and potentially the cost of the procedure.
Many of these women will not be evaluated for gynecologic diseases preoperatively. Gonzales, et. al. reviewed their series and found 10 of 408 patients (2.5%) with an undiagnosed mass. Interestingly, two of these were malignant and as indicated by the article; however, neither underwent comprehensive staging, even though frozen section revealed a malignancy in each case. The authors do call for intraoperative consultation with a gynecologist in their proposed treatment algorithm. This hopefully will fall to the gynecologic oncologist who must be familiar with the bariatric procedures to safely perform the complete staging operations(15).
The proven clinical applications of minimally invasive surgery have led to the development of more advanced operative laparoscopic techniques for a wide spectrum of gynecological diseases. Literature exists regarding the impact of obesity on technical feasibility and postoperative outcomes in laparoscopic surgery for gynecological malignancies. Overall, obesity may not be a contraindication to laparoscopic pelvic and para-aortic lymph node dissection. Single-institution studies reveal shorter hospital stays, less postoperative pain, and fewer wound infections when compared with obese patients who undergo laparotomy(16–18). The outcomes of laparoscopic cancer staging following laparoscopic bariatric surgery are unknown.
With the continuously expanding field of bariatric surgery, it can be predicted that there will be more cases involving gynecological malignancies. The gynecological oncologist needs to be aware of the differences, and increased trends of minimally invasive surgery in gastric bypass procedures. Preoperative counseling and work-up is crucial to document the risk and clinical patterns of potential synchronous gynecological cancers in this patient population. Knowledge of the clinical patterns and outcomes in these patients should influence surveillance and management strategies.
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