Barry R. Sanchez

Incidental Finding of Gastrointestinal Stromal Tumors (GISTs) during Laparoscopic Gastric Bypass

Background: Gastrointestinal stromal tumors (GISTs) are rare tumors, accounting for <1% of all neoplasms of the alimentary tract. GISTs have not been previously reported in association with gastric bypass surgery. Methods: This study is a retrospective review of 517 consecutive morbidly obese patients who underwent laparoscopic Roux-en-Y gastric bypass (LRYGBP) between January 2002 and August 2005. Incidental intraoperative findings of gastric GIST were recorded. Results: 4 patients (0.8%) were noted to have GISTs intra-operatively upon inspection of the stomach prior to partition. All GISTs were identified along the anterior aspect of the upper third of the stomach and were removed by laparoscopic wedge excision with at least a 1 cm margin. The 4 tumors were <1 cm in size and all had immunohistochemical analysis positive for CD117 (c-kit). None of the tumors had determinants of malignant behavior (high mitotic rate, necrosis or pleomorphism). Conclusion: We have found a 0.8% incidence of gastric GISTs in our morbidly obese patients undergoing LRYGBP. All of these small, benign tumors were found incidentally in asymptomatic patients. This case series underscores the need to fully assess the stomach prior to gastric pouch formation. Without the ability to grossly determine the benign or malignant behavior of GISTs, all these tumors found incidentally should be resected with adequate margins.

Refractory pseudoachalasia secondary to laparoscopically placed adjustable gastric band successfully treated with Heller myotomy

Over the last 3 decades, the top 3 bariatric procedures have been the laparoscopic Roux-en-Y gastric bypass, the laparoscopic sleeve gastrectomy, and the laparoscopic adjustable gastric band (LAGB). There has been a recent decline in use of the lap band as a primary bariatric procedure; however, it was one of the most used bariatric procedures 10 years ago. Livingston [1] reported approximately 42,000 LAGBs were placed in 2006, representing 37% of the total bariatric procedures that year. While each bariatric procedure offers its own set of risks and benefits, the LAGB faces scrutiny for its own set of issues, such as chronic acid reflux erosion and need for reoperation; one series reports a band removal rate of 50% at 10 years [2], while Lewin et al. [3] found that over 22% of their patients needed some sort of revision operation within 10 years. Another series [4] found a 29% band loss rate and a high overall complication rate over a minimum 9year follow-up. Himpens et al. [5] report neutral subjective outcomes in terms of satisfaction from patients, as well as significant weight loss; however, they ultimately argue that these data need to be weighed against the long-term complications and reoperation rate they found. Additionally, Kasza et al. [6] suggest that LAGB may not be suitable for certain patient populations. The trends in the United States seem to agree; while the total number of bariatric surgeries has increased since Livingston’s report, the