#OxfordClinicalCase: Incidental finding after laparoscopic g
Patient is a 43-year-old female with past medical history of hypothyroidism and obesity. She sought surgical consultation since her body mass index (BMI) was high (36) and she had failed numerous attempts to lose weight over the past 10 years. Preoperative exams including an upper endoscopy were normal. LGS was planned. During the procedure, we used one 15 mm port, one 12 mm port and three 5 mm ports. A 30 telescope was used during the procedure to achieve visualization of the angle of his, a grasper was used as a liver retractor and a 36 French bougie was inserted to decompress the stomach. The incisura was located and a small window in the lesser sac was created 4 cm away from the incisura, the omentum was mobilized cranially, the bougie was advanced to the first part of the duodenum and staplers were used to create the sleeve.

After this, the staple line was reinforced using a 3-0 synthetic absorbable monofilament suture. The specimen was retrieved from the 15 mm port, and the procedure was completed without complications. During the procedure, no lymph nodes or masses were seen. The patient underwent full recovery and was discharged without any apparent complications. Five days later, pathology reported that on the specimen, a small 4-mm polyp was detected in the staple line in the upper part of the fundus, a finding that was not detected on the previous endoscopy. After further evaluation, a grade II well-differentiated multifocal neuroendocrine tumor with vascular and perineural invasion was detected. Ki 67 index was 17% and 3/10 hpf mitosis were discovered.

The prognosis changed immediately, the patient was immediately notified of this finding and a new contrast-enhanced computed tomography revealed no masses or lymph nodes, therefore a D2 radical gastrectomy reconstructed with an esophagojejunal roux-en-y was performed, a drain was placed near esophagojejunal anastomosis and the remainder of the procedure was achieved without any complications. Pathology reported the same neuroendocrine tumor without lymph nodes involvement. After recovery, oncologist consultation was needed and five cycles of adjuvant chemoradiotherapy were achieved. One year after initial surgery and after psychiatric aid, the patient is doing well.

Source: https://academic.oup.com/jscr/article/2020/6/rjaa121/5855423