Diagnosis and Treatment > Intervention > Gastrectomy

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Bernardo Marques Endocrinology Department, Instituto Português de Oncologia de Coimbra Franscisco Gentil, EPE, Coimbra, Portugal

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Raquel G Martins Endocrinology Department, Instituto Português de Oncologia de Coimbra Franscisco Gentil, EPE, Coimbra, Portugal

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Guilherme Tralhão Surgery Department, Centro Hospitalar e Universitário de Coimbra, EPE, Coimbra, Portugal

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Joana Couto Endocrinology Department, Instituto Português de Oncologia de Coimbra Franscisco Gentil, EPE, Coimbra, Portugal

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Sandra Saraiva Gastroenterology Department, Instituto Português de Oncologia de Coimbra Franscisco Gentil, EPE, Coimbra, Portugal

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Henrique Ferrão Surgery Department, Instituto Português de Oncologia de Coimbra Franscisco Gentil, EPE, Coimbra, Portugal

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João Ribeiro Oncology Department, Instituto Português de Oncologia de Coimbra Franscisco Gentil, EPE, Coimbra, Portugal

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Jacinta Santos Endocrinology Department, Instituto Português de Oncologia de Coimbra Franscisco Gentil, EPE, Coimbra, Portugal

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Teresa Martins Endocrinology Department, Instituto Português de Oncologia de Coimbra Franscisco Gentil, EPE, Coimbra, Portugal

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Ana Teresa Cadime Gastroenterology Department, Instituto Português de Oncologia de Coimbra Franscisco Gentil, EPE, Coimbra, Portugal

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Fernando Rodrigues Endocrinology Department, Instituto Português de Oncologia de Coimbra Franscisco Gentil, EPE, Coimbra, Portugal

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Summary

Gastric neuroendocrine neoplasms (GNENs) are classified into three types according to their aetiology. We present a clinical case of a female patient of 66 years and a well-differentiated (grade 2), type 3 GNEN with late liver metastasis (LM). The patient underwent surgical excision of a gastric lesion at 50 years of age, without any type of follow-up. Sixteen years later, she was found to have a neuroendocrine tumour (NET) metastatic to the liver. The histological review of the gastric lesion previously removed confirmed that it was a NET measuring 8 mm, pT1NxMx (Ki67 = 4%). 68Ga-DOTANOC PET/CT reported two LM and a possible pancreatic tumour/gastric adenopathy. Biopsies of the lesion were repeatedly inconclusive. She had a high chromogranin A, normal gastrin levels and negative anti-parietal cell and intrinsic factor antibodies, which is suggestive of type 3 GNEN. She underwent total gastrectomy and liver segmentectomies (segment IV and VII) with proven metastasis in two perigastric lymph nodes and both with hepatic lesions (Ki67 = 5%), yet no evidence of local recurrence. A 68Ga-DOTANOC PET/CT was performed 3 months after surgery, showing no tumour lesions and normalisation of CgA. Two years after surgery, the patient had no evidence of disease. This case illustrates a rare situation, being a type 3, well-differentiated (grade 2) GNEN, with late LM. Despite this, it was possible to perform surgery with curative intent, which is crucial in these cases, as systemic therapies have limited efficacy. We emphasise the need for extended follow-up in these patients.

Learning points:

  • GNENs have a very heterogeneous biological behaviour.

  • Clinical distinction between the three types of GNEN is essential to plan the correct management strategy.

  • LMs are rare and more common in type 3 and grade 3 GNEN.

  • Adequate follow-up is crucial for detection of disease recurrence.

  • Curative intent surgery is the optimal therapy for patients with limited and resectable LM, especially in well-differentiated tumours (grade 1 and 2).

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Andrea Pucci Department of Medicine, Rayne Institute Centre for Obesity Research, University College London, 5 University Street, London, WC1E 6JJ, UK
UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery, University College London Hospitals, Ground Floor West Wing, 250 Euston Road, London, NW1 2PG, UK

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Wui Hang Cheung Department of Medicine, Rayne Institute Centre for Obesity Research, University College London, 5 University Street, London, WC1E 6JJ, UK
UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery, University College London Hospitals, Ground Floor West Wing, 250 Euston Road, London, NW1 2PG, UK

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Jenny Jones Department of Medicine, Rayne Institute Centre for Obesity Research, University College London, 5 University Street, London, WC1E 6JJ, UK

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Sean Manning Department of Medicine, Rayne Institute Centre for Obesity Research, University College London, 5 University Street, London, WC1E 6JJ, UK
UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery, University College London Hospitals, Ground Floor West Wing, 250 Euston Road, London, NW1 2PG, UK
National Institute of Health Research, Biomedical Research Centre, University College London Hospitals, London, W1T 7DN, UK

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Helen Kingett UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery, University College London Hospitals, Ground Floor West Wing, 250 Euston Road, London, NW1 2PG, UK

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Marco Adamo UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery, University College London Hospitals, Ground Floor West Wing, 250 Euston Road, London, NW1 2PG, UK

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Mohamed Elkalaawy UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery, University College London Hospitals, Ground Floor West Wing, 250 Euston Road, London, NW1 2PG, UK
Clinical and Experimental Surgery Department, Medical Research Institute, University of Alexandria, Hadara, Alexandria, 21561, Egypt

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Andrew Jenkinson UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery, University College London Hospitals, Ground Floor West Wing, 250 Euston Road, London, NW1 2PG, UK

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Nicholas Finer Department of Medicine, Rayne Institute Centre for Obesity Research, University College London, 5 University Street, London, WC1E 6JJ, UK
UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery, University College London Hospitals, Ground Floor West Wing, 250 Euston Road, London, NW1 2PG, UK

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Jacqueline Doyle UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery, University College London Hospitals, Ground Floor West Wing, 250 Euston Road, London, NW1 2PG, UK

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Majid Hashemi UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery, University College London Hospitals, Ground Floor West Wing, 250 Euston Road, London, NW1 2PG, UK

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Rachel L Batterham Department of Medicine, Rayne Institute Centre for Obesity Research, University College London, 5 University Street, London, WC1E 6JJ, UK
UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery, University College London Hospitals, Ground Floor West Wing, 250 Euston Road, London, NW1 2PG, UK
National Institute of Health Research, Biomedical Research Centre, University College London Hospitals, London, W1T 7DN, UK

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Summary

Sleeve gastrectomy (SG) is the second most commonly performed bariatric procedure worldwide. Altered circulating gut hormones have been suggested to contribute post-operatively to appetite suppression, decreased caloric intake and weight reduction. In the present study, we report a 22-year-old woman who underwent laparoscopic SG for obesity (BMI 46 kg/m2). Post-operatively, she reported marked appetite reduction, which resulted in excessive weight loss (1-year post-SG: BMI 22 kg/m2, weight loss 52%, >99th centile of 1-year percentage of weight loss from 453 SG patients). Gastrointestinal (GI) imaging, GI physiology/motility studies and endoscopy revealed no anatomical cause for her symptoms, and psychological assessments excluded an eating disorder. Despite nutritional supplements and anti-emetics, her weight loss continued (BMI 19 kg/m2), and she required nasogastric feeding. A random gut hormone assessment revealed high plasma peptide YY (PYY) levels. She underwent a 3 h meal study following an overnight fast to assess her subjective appetite and circulating gut hormone levels. Her fasted nausea scores were high, with low hunger, and these worsened with nutrient ingestion. Compared to ten other post-SG female patients, her fasted circulating PYY and nutrient-stimulated PYY and active glucagon-like peptide 1 (GLP1) levels were markedly elevated. Octreotide treatment was associated with suppressed circulating PYY and GLP1 levels, increased appetite, increased caloric intake and weight gain (BMI 22 kg/m2 after 6 months). The present case highlights the value of measuring gut hormones in patients following bariatric surgery who present with anorexia and excessive weight loss and suggests that octreotide treatment can produce symptomatic relief and weight regain in this setting.

Learning points

  • Roux-en-Y gastric bypass and SG produce marked sustained weight reduction. However, there is a marked individual variability in this reduction, and post-operative weight loss follows a normal distribution with extremes of ‘good’ and ‘poor’ response.

  • Profound anorexia and excessive weight loss post-SG may be associated with markedly elevated circulating fasted PYY and post-meal PYY and GLP1 levels.

  • Octreotide treatment can produce symptomatic relief and weight regain for post-SG patients that have an extreme anorectic and weight loss response.

  • The present case highlights the value of measuring circulating gut hormone levels in patients with post-operative anorexia and extreme weight loss.

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