Esophagogastric Cancer After Sleeve Gastrectomy: A Systematic Review of Case Reports

Esophageal Adenocarcinoma Causing Nonbacterial Thrombotic Endocarditis

Nonbacterial thrombotic endocarditis (NBTE) is a rare condition that causes noninfectious vegetative lesions of heart valves. NBTE is generally seen in association with advanced malignancy. The patient in this case is a 54-year-old Caucasian male with a history of rate-controlled atrial fibrillation on rivaroxaban and morbid obesity post sleeve gastrectomy in 2021, who was admitted for atrial flutter. Transesophageal echocardiogram (TEE) cardioversion was planned due to difficulty in controlling the heart rate. During the procedure, cardioversion was aborted due to TEE findings of large mobile vegetation on the left atrial side of the posterior mitral valve leaflet. The patient was afebrile for the entirety of his 10-day hospital stay, and four sets of blood cultures were negative. Further workup with esophagogastroduodenoscopy (EGD) revealed a large partially obstructing ulcerated mass in the middle and lower third of the esophagus arising in the setting of Barrett's esophagus which was biopsy positive for esophageal adenocarcinoma. The patient was found to have advanced malignancy with metastases to the liver, adrenal glands, and perirectal lymph nodes. This case emphasizes the utilization of a TEE prior to cardioversion and also highlights the importance of EGD prior to and post gastric sleeve surgery to evaluate for esophageal cancer.

Insights into the Paradox of the Weak Association Between Sleeve Gastrectomy and Barrett's Esophagus

Sleeve gastrectomy (SG) is deemed a refluxogenic operation but with a low incidence of postoperative Barrett´s esophagus (BE). We aimed to shed some light on the potential paradox of the weak association between SG, BE and esophageal adenocarcinoma (EAC). The high incidence of GERD after SG is not followed by an increased rate of BE and EAC, as these rates are similar to the general population. We hypothesized that this paradox may occur due to a difference in the gastro-esophageal reflux composition secondary to a lower content of bile, to a decrease in inflammation due to weight loss and hormonal changes, and to acquisition of healthier habits such as exercise, smoking cessation, and better eating behavior.

Risk of Esophageal and Gastric Cancer After Bariatric Surgery

Importance

Bariatric surgery has been associated with a reduced risk of cancer in individuals with obesity. The association of bariatric surgery with esophageal and gastric cancer is still controversial, however.

Objective

To compare the incidence of esophageal and gastric cancer between patients with obesity who underwent bariatric surgery and those who did not (control group).

Design, Setting, and Participants

This cohort study obtained data from a national discharge database, including all surgical centers, in France from January 1, 2010, to December 31, 2017. Participants included adults (aged ≥18 years) with severe obesity who underwent bariatric surgery (surgical group) or who did not (control group). Baseline characteristics were balanced between groups using nearest neighbor propensity score matching with a 1:2 ratio. The study was conducted from March 1, 2020, to June 30, 2021.

Exposures

Bariatric surgery (adjustable gastric banding, gastric bypass, and sleeve gastrectomy) vs no surgery.

Main Outcomes and Measures

The main outcome was incidence of esophageal and gastric cancer. A secondary outcome was overall in-hospital mortality.

Results

A total of 303 709 patients who underwent bariatric surgery (245 819 females [80.9%]; mean [SD] age, 40.2 [11.9] years) were matched 1:2 with 605 140 patients who did not receive surgery (500 929 females [82.8%]; mean [SD] age, 40.4 [12.5] years). After matching, the 2 groups of patients were comparable in terms of age, sex, and comorbidities (standardized mean difference [SD], 0.05 [0.11]), with some differences in body mass index. The mean follow-up time was 5.62 (2.20) years in the control group and 6.06 (2.31) years in the surgical group. A total of 337 patients had esophagogastric cancer: 83 in the surgical group and 254 in the control group. The incidence rates were 6.9 per 100 000 population per year for the control group and 4.9 per 100 000 population per year for the surgical group, resulting in an incidence rate ratio of 1.42 (95% CI, 1.11-1.82; P = .005). The hazard ratio (HR) of cancer incidence was significantly in favor of the surgical group (HR, 0.76; 95% CI, 0.59-0.98; P = .03). Overall mortality was significantly lower in the surgical group (HR, 0.60; 95% CI, 0.56-0.64; P < .001).

Conclusions and Relevance

In this large, nationwide cohort of patients with severe obesity, bariatric surgery was associated with a significant reduction of esophageal and gastric cancer incidence and overall in-hospital mortality, which suggests that bariatric surgery can be performed as treatment for severe obesity without increasing the risk of esophageal and gastric cancer.

Oesophageal and Gastric Cancer After Bariatric Surgery: an Up-to-Date Systematic Scoping Review of Literature of 324 Cases

BACKGROUND

This review aimed to give an updated overview of the occurrence, diagnosis, treatment and outcome of oesophageal and gastric cancer after bariatric and metabolic surgery (BMS).

METHODS

Two searches were done (one for original studies and one for systematic reviews) using an adapted form of "scoping review methodology". MEDLINE, Embase, CINAHL, Pubmed and the Cochrane Library were searched for studies on patients with either oesophageal or gastric cancer after BMS.

RESULTS

A total of 52 unique studies were included which reported on 324 patients, which included 110 (34%) males and 136 (42%) females. In the remaining 78 patients, gender was not specified. A mean of 62.95 ± 32.75 months was the time from BMS to diagnosis of cancer. Most of the patients had a Roux-en-Y gastric bypass (RYGB) as index bariatric surgical procedure, followed by gastric banding (GB) and sleeve gastrectomy (SG) (respectively, 133 (41.0%) RYGB, 97 (30.0%) GB and 58 (18.0%) SG). Seven cases have been reported after OAGB-MGB (3 in gastric remnant, 4 in oesophagus/gastric pouch). Seventy-seven (24%) had distant metastasis (≥ M1/Mx status). The majority of tumours were adenocarcinoma (n = 208, 87.4%). In the majority of the cases, a surgical approach was preferred with either adjuvant chemo or radiotherapy. In the course of the disease, 122 of 324 patients died (37.8%).

CONCLUSION

To our knowledge, this is the most up-to-date review addressing oesophageal and gastric malignancies after bariatric surgery. Future research should focus to optimise screening for oesophageal and gastric cancer after bariatric surgery.

Safety of biliopancreatic diversion with duodenal switch in patients with body mass index less than 50 kg/m2

INTRODUCTION

Biliopancreatic diversion with duodenal switch (BPD-DS) has often been reserved for patients with BMI > 50 kg/m². We aim to assess the safety of BPD-DS in patients with morbid obesity (BMI ³35 kg/m² and < 50 kg/m²) using a 150-cm common channel (CC), 150-cm Roux limb, and 60-fr bougie.

METHODS

A retrospective review was performed on patients with a BMI < 50 mg/k² who underwent a BPD-DS in 2016-2019 at a single institution. Limb lengths were measured with a laparoscopic instrument with minimal tension. Sleeve gastrectomy was created with 60-fr bougie. Variables were compared using paired t test, Chi-square analysis or repeated measures ANOVA where appropriate.

RESULTS

Forty-five patients underwent BPD-DS. CC lengths and Roux limb lengths were 158 ± 20 cm and 154 ± 18 cm, respectively. Preoperative BMI was 44.9 ± 2.3 kg/m² and follow-up was 2.7 ± 1.4 years. One patient required reoperation for bleeding and died from multiorgan failure and delayed sleeve leak. There was 1 (2.2%) readmission for contained anastomotic leak and 2 ED visits (4.5%) within 30 days. There were no marginal ulcers, limb length revisions, or need for parental nutrition. Percent excess weight loss was 67.2 ± 19.7%. 88.9% (N = 8), 86.6% (N = 13), and 55.5% (N = 5) of patients had resolution or improvement of their diabetes mellitus type II, hypertension, and hyperlipidemia, respectively. 40% (N = 4) of patients had resolution of their gastroesophageal reflux disease (GERD) and 11.4% (N = 5) developed de novo GERD. 32% (N = 14) of patients had vitamin D deficiency and 25% (N = 11) experienced zinc deficiency.

CONCLUSION

BPD-DS may be considered in patients with BMI < 50 kg/m² with 150-cm CC, 150-cm Roux limb, and a 60-fr bougie sleeve gastrectomy. There was sustained weight loss and no protein calorie malnutrition, but Vitamin D and zinc deficiency remained a challenge. Careful patient selection and proper counseling of the risks and benefits are necessary.