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Indian Journal of Surgery, Vol. 65, No. 2, March-April, 2003, pp. 193-195 Case report Emergency operation for haemorrhagic gastric stump lymphoma Takashi Yokota, Shuichi Ishiyama, Shu Kikuchi, Hidemi Yamauchi Department of Gastroenterolgical Surgery, Sendai National Hospital, Sendai 983-8520, Japan.
Paper Received: December 2001, Paper accepted: May 2002. Source of Support: Nil Code Number: is03038 ABSTRACT We report a case of malignant lymphoma developing in a gastric stump. The tumour was discovered 20 years after a subtotal gastrectomy. 29 such cases have been reported previously. Malignant lymphoma tended to occur sooner in patients with Billroth I anastomosis than in patients with Billroth II anastomosis. The possible relationship between malignant lymphoma and Helicobacter pylori infection has been presented in the literature. KEYWORDS: Malignant lymphoma, gastric stump, Helicobacter pylori How to cite this article: Yokota T, Ishiyama S, Kikuchi S, Yamauchi H. Emergency surgery for Haemorrhagic gastric stump lymphoma. Indian J Surg 2003;65:193-5. INTRODUCTION Gastric lymphoma comprises only 3-5 per cent of all the neoplasms of the stomach, and appears to be extremely rare in the `postoperative stomach'.1 We describe an emergency operation performed for a case of a lymphoma arising in the gastric stump 20 years after a subtotal gastrectomy for gastric cancer. CASE REPORT A 71-year-old woman with a history of a known malignant lymphoma was referred to our hospital with a complaint of abrupt onset of recurrent maelena. 20 years before this admission, she had undergone a subtotal gastrectomy for gastric cancer. The patient had been well until 6 years before this admission, when she was found to have inflammation of lymph nodes in the left side of her neck. The histological diagnosis of the resected lymph nodes was malignant lymphoma of diffuse, mixed B cell type. She had received 8 cycles of chemotherapy during this 6-year period. She had received a cycle of chemotherapy two weeks before admission and she had a fever and general fatigue one week after its completion. She was admitted to the hospital following onset of maelena two days earlier. A CT scan of the abdomen demonstrated thickening of the gastric wall (Figure 1a). No extension of the tumour outside the stomach or regional lymphadenopathy was seen. Examination with a fiberoptic endoscope showed multiple irregular ulcers, the edges of which were slightly elevated above the surrounding mucosa (Figure 1b). After conservative therapy, she continued to pass dark stools that were positive for occult blood, and there was evidence of mild hypotension ranging between 60 to 70 mmHg. The haemoglobin level on the second day of hospitalization was 5.1 gm per cent. An emergency laparotomy was performed. The patient underwent a total resection of the remnant stomach. Microscopic examination showed that the stomach wall was infiltrated by sheets of diffuse, large B-type lymphoma cells. The patient died 5 weeks after admission to our hospital in a debilitated state. DISCUSSION Primary lymphoma in a resected stomach is rare. Including our case, 29 cases have so far been reported.1,2 These patients included 20 men and 6 women with a mean age of 61.8 and 66.2 respectively at the time of surgery (the age was not known in three cases). The initial disease leading to gastrectomy was gastric ulcer (16 cases), duodenal ulcer (11 cases) and gastric cancer (2 cases). Partial gastrectomy had been performed 3 to 43 years (mean 19.6 years) before the diagnosis of malignant lymphoma. Billroth I anastomosis was performed in 8 cases and Billroth II in 18 cases. A significant difference was seen in the duration from the initial disease to the occurrence of malignant lymphoma between the Billroth I and Billroth II cases. The former was shorter than the latter (11.8 years vs 22.3 years) (Figure 2). There have been a number of studies on the risk of carcinoma developing in the remnant stomach and it has been suggested that postoperative atrophic gastritis caused by reflux of bile, and duodenal contents are responsible for mucosal metaplasia and subsequent malignant transformation in the remnant stomach.1 The cause of postoperative gastric lymphoma may not necessarily be the same as that of gastric stump carcinoma. Sigal et al suggested, on the basis of the results of immunohistochemical and gene rearrangement studies, that lymphomas may develop from lymphocytic infiltrate caused by chronic mucosal inflammation or ulceration.3 Helicobacter pylori infection is associated with an increased risk of gastric adenocarcinoma and is seen in 92 per cent of patients with primary B-cell gastric lymphoma.4 Considering that most of the initial diseases were peptic ulcers, it is possible that the previous gastric operation in the patients cured the ulceration but did not remove the bacterial infection that subsequently led to the development of gastric lymphoma. Stolte et al also reported that Helicobacter pylori infection plays a role in the pathogenesis of gastric MALT lymphoma.5 However, why the malignant lymphomas tend to occur sooner in patients with Billroth I anastomosis than in patients with Billroth II anastomosis remains unexplained. Careful follow-up by endoscopy of the remnant stomach should be carried out regularly in patients who have undergone subtotal gastrectomy. As the number of conservative operations for gastric cancer in Japan continues to increase, surgeons may be called on more frequently to evaluate patients with disease in the remnant stomach and who present with a severe illness. Malignant lymphoma, although rare, must also be considered. REFERENCES
Copyright 2003 - Indian Journal of Surgery. Also available online at http://www.indianjsurg.com The following images related to this document are available:Photo images[is03038f2.jpg] [is03038f1b.jpg] [is03038f1a.jpg] |
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