Impact of bariatric surgery on surveillance and treatment outcomes of Barrett's esophagus: A stage-matched cohort study

GERD after Bariatric Surgery: A Review of the Underlying Causes and Recommendations for Management

PURPOSE OF REVIEW

GERD after bariatric surgery is an ongoing concern for bariatric surgeons and their patients. This paper reviews the association of persistent or de novo GERD after multiple types of bariatric surgery, and focuses on the work up and management of GERD after SG.

RECENT FINDINGS

Two recent large, multicenter randomized clinical trials have shown stronger associations between SG and GERD compared to RYGB. A large group of internationally recognized bariatric surgeons collaborated on 72 consensus statements to help guide the bariatric community on the subject of redo surgeries after SG, including as it pertains to GERD. We present an algorithm that consolidates the best-practices recommendations of the work-up and management of GERD after sleeve gastrectomy, and mention areas of persistent controversy where future research is warranted.

Gastroesophageal Reflux Disease in Obesity: Bariatric Surgery as Both the Cause and the Cure in the Morbidly Obese Population

Gastrointestinal reflux disease (GERD) is a chronic, highly prevalent condition in the United States. GERD can significantly impact quality of life and lead to complications including aspiration pneumonia, esophageal stricture, Barrett's esophagus (BE) and esophageal cancer. Obesity is a risk factor for GERD, which often improves with weight loss and bariatric surgery. Though the incidence of bariatric surgery, in particular, minimally invasive sleeve gastrectomy, has risen in recent years, emerging data has revealed that the severity or new onset of GERD may follow bariatric surgery. We performed a literature review to provide a detailed analysis of GERD with an emphasis on bariatric surgery as both the cure and the cause for GERD in the morbidly obese population. We also describe the pathophysiological mechanisms, management approach and treatment strategies of GERD following bariatric surgery.

Perioperative Interventions to Prevent Gastroesophageal Reflux Disease and Marginal Ulcers After Bariatric Surgery - an International Experts' Survey

OBJECTIVE

This study aimed to survey international experts in metabolic and bariatric surgery (MBS) to improve and consolidate perioperative interventions to prevent gastroesophageal reflux disease (GERD) and marginal ulcers (MU) after MBS.

BACKGROUND

Very important long-term complications after MBS include GERD, Barrett's esophagus, and MU. Prevention might be fundamental to reduce the incidence, severe complications, and the increasing number of revisional bariatric surgeries.

METHODS

An international scientific team designed an online confidential questionnaire with 45 multiple-choice questions. The survey was sent to 110 invited experts and 96 of them (from 41 different countries) participated from 21 July 2022 to 4 September 2022.

RESULTS

Most experts (≥ 90%) prescribe postoperative acid suppression agents after MBS. Life-long proton pump inhibitors prophylaxis in smokers with avoidance of non-steroidal anti-inflammatory drugs are recommended by most of the experts (66%, 73%) after any type of gastric bypass. Two-thirds of experts (69%) perform Helicobacter pylori eradication prior to MBS. Two-thirds of experts (68%) routinely perform EGD and biopsy before MBS. Follow-up esophagogastroduodenoscopy (EGD) and timing threshold for revisional and conversional MBS were variable among experts.

CONCLUSION

This expert survey underlines important perioperative interventions that reached a two-thirds consensus among MBS international experts. Variability in follow-up EGD, approach to complication management, and thresholds for revisional and conversional MBS emphasize the need for further researches and consensus guidelines.

Esophagectomy for Barrett's adenocarcinoma after multiple bariatric surgeries: A case report

INTRODUCTION

Bariatric surgery diminishes the incidence of many kinds of neoplasms, but gastro-esophageal cancers may occur after bariatric procedures. Most esophageal neoplasms arise on Barrett's esophagus, which may be worsened by bariatric surgery, especially restrictive procedures. Endoscopic resections may cure cancer in its early stages, but surgery may be required in more advanced cases.

PRESENTATION OF CASE

A 62-year-old patient with history of adjustable gastric banding, sleeve gastrectomy then Roux-en-Y gastric bypass presented with an early Barrett's adenocarcinoma. Endoscopic treatment was first applied but the patient required surgery due to positive margins on the resected specimen. As the early tumor was located in the esophagus' lower third, a limited resection with eso-jejunal anastomosis was planned. However, as the previous bariatric did not allow a proper reconstruction, a total esophagectomy with colonic interposition had to be performed.

DISCUSSION

Eso-gastric malignancies remain rare after weight loss procedures, but more cases will arise due to the increasing incidence of bariatric surgery. Esophageal resection and reconstruction becomes increasingly challenging along with the number of bariatric procedures performed on the same patient. Endoscopic screening is of paramount importance before any obesity surgery or to assess any new onset of symptoms after a bariatric procedure, as endoscopic resections may cure cancer in its early stages.

CONCLUSION

Endoscopic screening and treatment remains of paramount importance, especially after multiple bariatric procedures as surgery and reconstruction gets increasingly challenging. Whenever surgery is required, a proper planning and individual approach is compulsory, as well as a back-up plan.