Obesity surgery and malignancy: our experience after 1500 cases

Newly diagnosed Crohn's disease, and hepatocellular and renal cell carcinoma in a bariatric surgery patient-dealing with the complexity of obesity-associated diseases: a case report and review of the literature

BACKGROUND

Bariatric surgery candidates commonly suffer from conditions that constitute the metabolic syndrome. But they also have a higher risk for autoimmune and malignant diseases. Obesity-associated comorbidities aside from the metabolic syndrome are often given insufficient attention in the clinical routine, including preoperative work-ups for bariatric surgery.

CASE PRESENTATION

We retrospectively report the case of a 65 years old Caucasian patient who was diagnosed with Crohn's disease prior to, a hepatocellular carcinoma during, and a renal cell carcinoma post bariatric surgery. The relevance of these diseases for decision making in bariatric procedures and current recommendations for preoperative bariatric work-ups are discussed. In our case, the diagnosis of Crohn's disease led to the performance of a sleeve gastrectomy instead of a Roux-en-Y gastric bypass and a previously unknown hepatocellular carcinoma was simultaneously removed by hepatic wedge resection.

CONCLUSIONS

Preoperative endoscopy and imaging techniques can be valuable since surprising pre- and intraoperative findings can force the bariatric surgeon to change the initially planned operative strategy. But the diagnostic accuracy of abdominal ultrasound may be limited in bariatric surgery patients. With the expansion of bariatric surgery, the complexity of bariatric surgery patients is also likely to increase. However, with the appropriate awareness and strategies, bariatric surgery can be safely executed and even contribute to the treatment of severe comorbidities that exceed the metabolic spectrum.

Obesity, Cancer, and Risk Reduction with Bariatric Surgery

The prevalence of noncommunicable diseases has increased dramatically in North America and throughout the world and is expected to continue increasing in coming years. Obesity has been linked to several types of cancers and is associated with increased morbidity and mortality following cancer diagnosis. Bariatric surgery has emerged as the prominent model to evaluate the effects of intentional weight loss on cancer incidence and outcomes. Current literature, comprising prospective cohort investigations, indicates site-specific reductions in cancer risk with select bariatric procedures. Future research is required to establish evidence-based indications for bariatric surgery in the context of cancer prevention.

Malignancy in bariatric surgery patients: a French multisite cohort

BACKGROUND

Bariatric surgery is associated with decreased cancer-related mortality. An indefinite proportion of patients that undergo bariatric surgery have a history of malignancy or will develop cancer. In these patients, weight loss and oncologic evolution needed to be assessed. The aim of this study was to report the results of patients diagnosed with malignancy before and after bariatric surgery in a French multisite cohort.

METHODS

We conducted a retrospective cohort study of all patients who underwent bariatric surgery in six university centers. Patients were divided in two groups: patients with a preoperative history of malignancy and patients diagnosed with malignancy during the follow-up. Both groups were compared with control groups of patients that underwent surgery during the same period.

RESULTS

From 2008 to 2018, 8927 patients underwent bariatric surgery. In patients with a history of malignancy (n = 90), breast and gynecologic cancers were predominant (37.8%). Median interval between malignancy and surgery was 60 (38-118) months. After a follow-up of 24 (4-52) months, 4 patients presented with cancer recurrence. Comparative analysis demonstrated equivalent weight loss one year after surgery. In patients with postoperative malignancy (n = 32), breast and gynecologic cancers were also predominant (40.6%). Median interval between surgery and malignancy was 22 (6-109) months. In the comparative analysis, weight loss was similar at 2 years.

CONCLUSIONS

History of malignancy should not be considered as an absolute contraindication for bariatric surgery. Gynecological cancer screening should be reinforced before and after surgery. The development of malignancy postoperatively does not seem to affect mid-term bariatric outcomes.

Lack of benefit of routine abdominal CT-scan before bariatric surgery

BACKGROUND

Scientific societies recommend to seek cancer prior to bariatric surgery. In our tertiary referral center, we aimed to study performance of abdominal CT-scan before bariatric surgery.

PATIENTS AND METHODS

We retrospectively included all patients who underwent bariatric surgery and a pre-operative abdominal CT-scan in our academic center, between January 2015 and December 2018.

RESULTS

We included 521 patients (417 women and 104 men) with a mean age of 48.0±11.5 years. Mean preoperative body mass index was 44.9±7.0kg/m². Among the 392 patients with abnormal CT-scan, mean number of anomalies per patient was of 2.2±1.2. Vast majority of anomalies (91.8%) were non-significant. Only 5 (1%) patients needed treatment prior to bariatric surgery. No factor predictive of abnormal CT-scan was found.

CONCLUSION

Only few patients had severe anomaly on CT-scan before bariatric surgery. Abdominal CT-scan could not be advocated to seek cancer before bariatric surgery.

Does Bariatric Surgery Affect the Incidence of Endometrial Cancer Development? A Systematic Review

Obesity has been linked to an increased prevalence in multiple cancers. Studies have suggested a reduction in the overall risk of cancer after bariatric surgery. We reviewed the evidence for bariatric surgery reducing the risk of endometrial cancer. Data was extracted from PubMed, EMBASE, and Medline to perform a systematic review. Thirty-one full text articles were identified from 265 abstracts. Nine observational studies were relevant to endometrial cancer. In the five controlled studies, 462 of 113,032 (0.4%) patients receiving bariatric surgery versus 11,997 of 848,864 (1.4%) controls developed endometrial cancer, odds ratio of 0.317 (95% CI 0.161 to 0.627) using random effects model (P < 0.001). Bariatric surgery seems to reduce the risk of endometrial cancer; however, more research is required.

Does Bariatric Surgery Affect the Incidence of Breast Cancer Development? A Systematic Review

We reviewed the evidence for bariatric surgery reducing the risk of breast cancer. Data was extracted from multiple libraries, including PubMed, EMBASE, and Medline, to perform a systematic review. Abstracts were reviewed by two independent reviewers. Thirty-eight full-text articles were identified from 1171 abstracts. Four studies were included for meta-analysis; 114 of 10,533 (1.1%) patients receiving bariatric surgery versus 516 of 20,130 (2.6%) controls developed breast cancer, odds ratio 0.564 (95% CI 0.453 to 0.702) using a fixed effects model (P < 0.001) and odds ratio 0.585 (95% CI 0.247 to 1.386) using a random effects model (P 0.223). Bariatric surgery may reduce the risk of breast cancer. More research is required due to heterogeneity of studies, difficulty in identifying accurate controls, and limited follow-up.

Peculiarities of the obese patient with cancer: a national consensus statement by the Spanish Society for the Study of Obesity and the Spanish Society of Medical Oncology

The relationship between obesity and cancer is clear and is present at all times during course of the disease. The importance of obesity in increasing the risk of developing cancer is well known, and some of the most prevalent tumours (breast, colorectal, and prostate) are directly related to this risk increase. However, there is less information available on the role that obesity plays when the patient has already been diagnosed with cancer. Certain data demonstrate that in some types of cancer, obese patients tolerate the treatments more poorly. Obesity is also known to have an impact on the prognosis, favouring lower survival rates or the appearance of secondary tumours. In this consensus statement, we will analyse the scientific evidence on the role that obesity plays in patients already diagnosed with cancer, and the available data on how obesity control can improve the quality of daily life for the cancer patient.

Experience of imaging following laparoscopic sleeve gastrectomy

BACKGROUND

We aimed to report our experience with upper gastrointestinal (UGI) contrast studies and computed tomography (CT) swallow studies after laparoscopic sleeve gastrectomy, and comment on the merits of each modality.

METHOD

Retrospective review of all patients undergoing laparoscopic sleeve gastrectomy (LSG) in a New Zealand hospital between 2011 and 2014 was conducted. Over this time period, routine UGI was replaced by CT swallow studies. All medical records and radiology were reviewed and pertinent findings reported.

RESULTS

Seventy-nine patients underwent LSG over this time period and one patient had to be excluded; 48 (61.5%) had a UGI study and 30 patients (38.5%) had CT swallow. There were no leaks in this study and no leaks became clinically significant. Sixteen of 30 patients (53.3%) undergoing CT swallow had significant incidental findings demonstrated on axial imaging that required follow-up.

CONCLUSION

CT swallow can provide the same information as a UGI but has a significant rate of incidental findings. The rate of incidental pathology on CT is higher than that quoted in the general population. In a bariatric population, this may allow early detection and treatment of co-existent pathology.

Incidence of cancer following bariatric surgery: systematic review and meta-analysis

Obesity is linked to the development of cancer. Previous studies have suggested that there is a relationship between bariatric surgery and reduced cancer risk. Data sources were from Medline, Embase, and Cochrane Library. From 951 references, 13 studies met the inclusion criteria (54,257 participants). In controlled studies, bariatric surgery was associated with a reduction in the risk of cancer. The cancer incidence density rate was 1.06 cases per 1000 person-years within the surgery groups. In the meta-regression, we found an inverse relationship between the presurgical body mass index and cancer incidence after surgery (beta coefficient -0.2, P < 0.05). Bariatric surgery is associated with reduced cancer risk in morbidly obese people. However, considering the heterogeneity among the studies, conclusions should be drawn with care.

Obesity and Weight Loss Attempts among Subjects with a Personal History of Cancer

OBJECTIVES

Obesity is a risk factor for many cancers and obese cancer patients have a poorer prognosis. This study aimed to evaluate the prevalence of obesity and attempts to lose weight among cancer survivors. The effects of cancer treatment and time since cancer treatment were also evaluated.

METHODS

The 2007 Health Information National Trends Survey data were analysed between 2011 and 2013; respondents with (n = 966) and without (n = 6,093) a personal history of cancer were identified. Each respondent's body mass index (BMI) was calculated using self-reported height and weight measurements and categorised as normal (<25 kg/m(2)), overweight (25-29.9 kg/m(2)) or obese (≥30 kg/m(2)).

RESULTS

Cancer survivors were older (mean age = 63.4 versus 44.7 years for those with no history of cancer). Overall, there were similar percentages of overweight (37.6% versus 34.1%; relative risk ratio [RRR] = 0.99; 95% confidence interval [CI]: 0.75-1.31) and obese (31.4% versus 27.5%; RRR = 1.04; 95% CI: 0.79 1.39) respondents among both cancer survivors and those without a history of cancer. Among overweight and obese participants, cancer survivors did not demonstrate increased weight loss attempts compared to those without a history of cancer (61.6% versus 66.3%; odds ratio = 0.94; 95% CI: 0.73 1.20).

CONCLUSION

A high prevalence of overweight and obese cancer survivors were identified without any association with cancer treatment. However, cancer survivors did not demonstrate increased attempts to lose weight in comparison to those without a history of cancer despite awareness of their degree of body fatness. Increased efforts to promote the maintenance of a healthy weight among cancer survivors are needed.

Effect of bariatric surgery on oncologic outcomes: a systematic review and meta-analysis

BACKGROUND

Obesity is a major public health issue and is associated with increased risk of several cancers, currently a leading cause of mortality. Obese patients undergoing bariatric surgery may allow for evaluation of the effect of intentional excess weight loss on subsequent risk of cancer. We aimed to evaluate cancer risk, incidence, and mortality after bariatric surgery.

METHODS

A comprehensive literature search was conducted using PubMed/MEDLINE and Embase with literature published from the inception of both databases to January 2012. Inclusion criteria incorporated all human studies examining oncologic outcomes after bariatric surgery. Two authors independently reviewed selected studies and relevant articles from their bibliographies for data extraction, quality appraisal, and meta-analysis.

RESULTS

Six observational studies (n = 51,740) comparing relative risk (RR) of cancer in obese patients undergoing bariatric surgery versus obese control subjects were analyzed. Overall, the RR of cancer in obese patients after undergoing bariatric surgery was 0.55 [95% confidence interval (CI) 0.41-0.73, p < 0.0001, I(2) = 83%]. The effect of bariatric surgery on cancer risk was modified by gender (p = 0.021). The pooled RR in women was 0.68 (95% CI 0.60-0.77, p < 0.0001, I(2) < 0.1%) and in men was 0.99 (95% CI 0.74-1.32, p = 0.937, I(2) < 0.1%).

CONCLUSIONS

Bariatric surgery reduces cancer risk and mortality in formerly obese patients. When stratifying the meta-analysis by gender, the effect of bariatric surgery on oncologic outcomes is protective in women but not in men.

Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery

The development of these updated guidelines was commissioned by the AACE, TOS, and ASMBS Board of Directors and adheres to the AACE 2010 protocol for standardized production of clinical practice guidelines (CPG). Each recommendation was re-evaluated and updated based on the evidence and subjective factors per protocol. Examples of expanded topics in this update include: the roles of sleeve gastrectomy, bariatric surgery in patients with type-2 diabetes, bariatric surgery for patients with mild obesity, copper deficiency, informed consent, and behavioral issues. There are 74 recommendations (of which 56 are revised and 2 are new) in this 2013 update, compared with 164 original recommendations in 2008. There are 403 citations, of which 33 (8.2%) are EL 1, 131 (32.5%) are EL 2, 170 (42.2%) are EL 3, and 69 (17.1%) are EL 4. There is a relatively high proportion (40.4%) of strong (EL 1 and 2) studies, compared with only 16.5% in the 2008 AACE-TOS-ASMBS CPG. These updated guidelines reflect recent additions to the evidence base. Bariatric surgery remains a safe and effective intervention for select patients with obesity. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.

Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery

The development of these updated guidelines was commissioned by the AACE, TOS, and ASMBS Board of Directors and adheres to the AACE 2010 protocol for standardized production of clinical practice guidelines (CPG). Each recommendation was re-evaluated and updated based on the evidence and subjective factors per protocol. Examples of expanded topics in this update include: the roles of sleeve gastrectomy, bariatric surgery in patients with type-2 diabetes, bariatric surgery for patients with mild obesity, copper deficiency, informed consent, and behavioral issues. There are 74 recommendations (of which 56 are revised and 2 are new) in this 2013 update, compared with 164 original recommendations in 2008. There are 403 citations, of which 33 (8.2%) are EL 1, 131 (32.5%) are EL 2, 170 (42.2%) are EL 3, and 69 (17.1%) are EL 4. There is a relatively high proportion (40.4%) of strong (EL 1 and 2) studies, compared with only 16.5% in the 2008 AACE-TOS-ASMBS CPG. These updated guidelines reflect recent additions to the evidence base. Bariatric surgery remains a safe and effective intervention for select patients with obesity. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.

Benign, premalignant, and malignant lesions encountered in bariatric surgery

BACKGROUND

Obesity is associated with several comorbidities like diabetes, hypertension, hyperlipidemia, and obstructive sleep apnea. It is also well established that obese patients have an increased risk of several types of cancer like kidney, pancreas, endometrial, breast, and others. The bariatric surgeon needs to be aware of the problem of benign tumors and cancer in obese patients as well as the optimal management of these conditions that may be present at the time of evaluation for bariatric surgery, during the surgical procedure, and in the postoperative period.

DATABASE

A PubMed search for the words "cancer" and "bariatric surgery" and subsequent review of the abstracts identified 40 articles concerning cancerous, benign, and premalignant conditions in bariatric surgery patients. Data were then extracted from full-text articles.

CONCLUSION

Bariatric surgery decreases cancer risk especially in women. RYGB can be an effective treatment for Barrett's esophagus. Patients having esophageal cancer should not undergo bariatric surgery, while those who develop the same postoperatively are usually managed by a combined abdominal and thoracic approach (Ivor Lewis technique). Gastric cancer of the remnant stomach is usually managed by a remnant gastrectomy. A remnant gastrectomy during RYGB would be necessary in conditions that require endoscopic surveillance of the stomach like gastric polyps, intestinal metaplasia, and carcinoid tumors. Sleeve gastrectomy is an excellent option in a patient with GIST or a carcinoid who needs a bariatric operation. Preoperative endoscopy usually does not detect malignant conditions. Postoperative evaluation of the bypassed stomach is possible using various percutaneous and novel endoscopic techniques.

Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery

The development of these updated guidelines was commissioned by the AACE, TOS, and ASMBS Board of Directors and adheres to the AACE 2010 protocol for standardized production of clinical practice guidelines (CPG). Each recommendation was re-evaluated and updated based on the evidence and subjective factors per protocol. Examples of expanded topics in this update include: the roles of sleeve gastrectomy, bariatric surgery in patients with type-2 diabetes, bariatric surgery for patients with mild obesity, copper deficiency, informed consent, and behavioral issues. There are 74 recommendations (of which 56 are revised and 2 are new) in this 2013 update, compared with 164 original recommendations in 2008. There are 403 citations, of which 33 (8.2%) are EL 1, 131 (32.5%) are EL 2, 170 (42.2%) are EL 3, and 69 (17.1%) are EL 4. There is a relatively high proportion (40.4%) of strong (EL 1 and 2) studies, compared with only 16.5% in the 2008 AACE-TOS-ASMBS CPG. These updated guidelines reflect recent additions to the evidence base. Bariatric surgery remains a safe and effective intervention for select patients with obesity. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.

Metabolic or bariatric surgery? Long-term effects of malabsorptive vs restrictive bariatric techniques on body composition and cardiometabolic risk factors

BACKGROUND

Obesity is an increasing health problem and surgery seems to be the only treatment effective in achieving weight loss without relapse. Among bariatric techniques, many differences exist in terms of weight loss and resolution of comorbidities. Up to now, there are no prospective studies comparing long-term effects of malabsorptive vs restrictive techniques.

OBJECTIVE

In this study, cardiometabolic risk factors and body composition changes after malabsorptive biliointestinal bypass (BIBP) and restrictive laparoscopic adjustable gastric banding (LAGB) were compared during a 4-year follow-up.

DESIGN

Prospective, case-control and cohort study.

PATIENTS

In all, 80 obese subjects, matched for weight and age. Altogether, 40 patients underwent BIBP and 40 underwent LAGB.

MEASUREMENTS

Weight, body composition, fasting and post-loading plasma glucose and insulin, homeostatic model assessment index (HOMA-I), lipid profile, blood pressure (BP), erythrocyte sedimentation rate and fibrinogen were monitored at baseline, 12 and 48 months.

RESULTS

At 12 months after surgery, a significant reduction in body mass index, total fat mass (FM), trunk FM (trFM), trFM/legs FM (lFM) ratio (trFM/lFM), triglycerides, BP and inflammation markers was observed in both groups. BIBP patients showed a significant reduction in total cholesterol (Tot-C), low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C), whereas the LAGB group showed a significant increase of HDL-C. A further improvement of all the parameters evaluated was seen in the BIBP group at 48 months after surgery.

CONCLUSIONS

Both bariatric procedures exerted positive effects on cardiometabolic risk factors and on weight loss in the population studied, but on the long-term period, HOMA-I, Tot-C/HDL-C ratio and body composition improvements were more evident after BIBP. We conclude that malabsorptive BIBP seems to be more effective than LAGB in treating visceral obesity and its metabolic complications.