Diagnosis and Management of Oesophageal Cancer in Bariatric Surgical Patients

Distal esophageal spasm and gastroesophageal reflux disease: re-examining the association

Distal esophageal spasm (DES) is a rare motility disorder presenting with dysphagia or chest pain. Although studies suggest a link between DES and gastroesophageal reflux disease (GERD), data supporting a distinct GERD-related phenotype are limited. This study aims to investigate demographic, symptomatic, and physiologic differences between DES subjects with and without GERD. A retrospective cohort analysis of DES patients determined by high resolution manometry (HRM) was conducted between February 2020 and January 2023. Demographics, medications, symptoms, and quantitative reflux testing data were collected. DES subjects with reflux (R-DES) were defined by presence of Los Angeles Grade B/C/D esophagitis, Barrett's metaplasia, or abnormal pH testing. DES subjects without reflux (NR-DES) had normal parameters. Statistical analysis employed two-sided or Wilcoxon Rank-Sum, Chi-squared, or Fisher's exact tests, and multivariate logistic regression. Of 69 DES subjects, 32 (46.3%) had GERD. R-DES and NR-DES patients had similar demographic variables except for higher BMI in R-DES (30.41 vs. 26.88, P = 0.01). R-DES and NR-DES shared similar symptom profiles (heartburn P = 0.67, dysphagia P = 0.448, chest pain P = 0.32). Proton pump inhibitor use was similar between groups (78.1% vs. 91.9%, P = 0.202). HRM metrics were comparable except for basal LES tone (20.7 mmHg vs. 32.99 mmHg, P = 0.03) and median IRP 11.82 mmHg versus 17.20 mmHg, P = 0.017). This study found no distinguishing clinical or physiologic differences between DES patients with and without GERD, challenging the historical emphasis of GERD in DES pathogenesis. The impact of GERD management on the natural history of DES remains uncertain.

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.

Tubularized and Effaced Gastric Cardia Mimicking Barrett Esophagus following Sleeve Gastrectomy: Protocolized Endoscopic and Histological Assessment with High-Resolution Manometry Analysis

OBJECTIVE

To describe expected endoscopic and histological changes at gastro-esophageal junction (GEJ) and define diagnostic paradigms for Barrett esophagus (BE) post-sleeve gastrectomy (SG).

SUMMARY BACKGROUND DATA

De novo incidence of BE post-SG was reported as high as 18.8%. A confounding factor is the lack of standardized definition of BE post-SG, which may differ from the general population due to procedure-induced alterations of GEJ.

METHODS

Part 1 involved evaluating endoscopic changes of GEJ post-SG (N = 567) compared to pre-SG (N = 320), utilizing protocolized pre-operative screening, post-operative surveillance and synoptic reporting. Part 2 involved dedicated studies examining causes of altered anatomical and mucosal GEJ appearance using histopathology (N = 55) and high-resolution manometry (HRM) (N = 15).

RESULTS

Part 1 - A characteristic tubularized cardia segment projecting supra-diaphragmatically was identified and almost exclusive to post-SG (0.6%vs.26.6%, p < 0.001). True BE prevalence was low (4.1%pre-SG vs. 3.8%post-SG, p = 0.756), esophagitis was comparable (32.1%vs.25.9%, p = 0.056).Part 2 - Histologically-confirmed BE was found in 12/55 patients, but 70.8% had glandular-type gastric mucosa implying tubularized cardia herniation. HRM of tubularized cardia demonstrated concordance of supra-diaphragmatic cardia herniation between endoscopy and HRM (3cmvs.3.2 cm, p = 0.168), with frequent elevated isobaric intraluminal pressurizations in supra- and infra-diaphragmatic cardia compartments.

CONCLUSION

A novel appearance of tubularized cardia telescoping supra-diaphragmatically with flattening of gastric folds is common post-SG, likely associated with isobaric hyper-pressurization of proximal stomach. Incidence of true BE post-SG is low in short-intermediate term. These provided a clear framework for approaching endoscopic screening and surveillance, with correct anatomical and mucosal identifications, and clarified key issues of SG and BE.

Esophageal Cancer After Bariatric Surgery: Increasing Prevalence and Treatment Strategies

PURPOSE

The number of bariatric procedures has increased exponentially over the last 20 years. On the background of ever-increasing incidence of esophageal malignancies, the altered anatomy after bariatric surgery poses challenges in treatment of these cancers. In this study, an epidemiological estimate is presented for the future magnitude of this problem and treatment options are described in a retrospective multicenter cohort.

METHODS

The number of bariatric procedures, esophageal cancer incidence, and mortality rates of the general population were used for epidemiological estimates. A retrospective multicenter cohort was composed; patients were treated in three large oncological centers with a high upper gastrointestinal cancer caseload. Consecutive patients with preceding bariatric surgery who developed esophageal cancer between 2014 and 2019 were included.

RESULTS

Approximately 3200 out of 6.4 million post bariatric surgery patients are estimated to have developed esophageal cancer between 1998 and 2018 worldwide. In a multicenter cohort, 15 patients with esophageal cancer or Barrett's esophagus and preceding bariatric surgery were identified. The majority of patients had a history of Roux-en-Y gastric bypass (46.7%) and had an adenocarcinoma of the distal esophagus (60%). Seven patients received curative surgical treatment, five of whom are still alive at last follow-up (median follow-up 2 years, no loss to follow-up).

CONCLUSION

Based on worldwide data, esophageal cancer development following bariatric surgery has increased over the past decades. Treatment of patients with esophageal cancer after bariatric surgery is challenging and requires a highly individualized approach in which optimal treatment and anatomical limitations are carefully balanced.

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.

Perioperative screening, management, and surveillance of Barrett's esophagus in bariatric surgical patients

Obesity is a strong risk factor for Barrett's esophagus (BE), the only proven precursor lesion to esophageal adenocarcinoma (EAC). Bariatric surgery is currently the only reliable treatment that achieves long-term sustained weight loss; however, it can markedly affect the development of de novo BE, and the progression or regression of existing BE. Bariatric procedures may also have implications on future surgical management of any consequent EAC. In this review, we examine the current evidence and published guidelines for BE in bariatric surgery. Current screening practices before bariatric surgery vary substantially, with conflicting recommendations from bariatric societies. If diagnosed, the presence of BE may alter the type of bariatric procedure. A selective screening approach prevents unnecessary endoscopy; however, there is poor symptom correlation with disease. Studies suggest that sleeve gastrectomy predisposes patients to gastroesophageal reflux and de novo BE. Conversely, Roux-en-Y gastric bypass is associated with decreased reflux and potential improvement or resolution of BE. There are currently no guidelines addressing the surveillance for BE following bariatric surgery. BE is an important consideration in the management of bariatric surgical patients. Evidence-based recommendations are required to guide procedure selection and postoperative surveillance.

Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures - 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), American Society for Metabolic and Bariatric Surgery (ASMBS), Obesity Medicine Association (OMA), and American Society of Anesthesiologists (ASA) Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, algorithms, and checklists.

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include: contextualization in an adiposity-based chronic disease complications-centric model, nuance-based and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues.

Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures - 2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPG) was commissioned by the American Association of Clinical Endocrinologists, The Obesity Society, the American Society of Metabolic and Bariatric Surgery, the Obesity Medicine Association, and the American Society of Anesthesiologists boards of directors in adherence to the American Association of Clinical Endocrinologists 2017 protocol for standardized production of CPG, algorithms, and checklists.

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include contextualization in an adiposity-based, chronic disease complications-centric model, nuance-based, and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current healthcare arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence-based within the context of a chronic disease. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.

Esophagogastric Neoplasms Following Bariatric Surgery: an Updated Systematic Review

The risk of gastric and/or esophageal cancers after bariatric surgery has been previously discussed in literature. A systematic review was performed to identify articles published between June 2012 and December 2018 reporting new cases of esophageal or gastric cancer not included in previous systematic reviews. Ten gastric malignancies, 28 esophageal cancers, and 2 gastro-intestinal stromal tumors (GIST) were identified. Primary bariatric surgery was a restrictive procedure in 26 cases, a purely malabsorptive procedure in 1 subject, and a gastric bypass in 13 patients. Although the vast majority of bariatric procedures seem to present a negligible relationship with any esophagogastric (EG) malignancy, published data remain incomplete. It was however considered of interest to update the number of EG neoplasms arisen following bariatric surgery.

The Physiology and Pathophysiology of Gastroesophageal Reflux in Patients with Laparoscopic Adjustable Gastric Band

INTRODUCTION

The effect of the laparoscopic adjustable gastric band (LAGB) on esophageal acid exposure and reflux is poorly understood. Optimal technique and normative values for acid exposure have not been established in this group.

METHODS

High-resolution manometry (HRM) and 24-h ambulatory esophageal pH monitoring were performed in three groups: asymptomatic LAGB, symptomatic LAGB, and pre-operative reflux patients. This technique utilized intraluminal pressure signatures during HRM to guide accurate pH sensor placement.

RESULTS

The LAGB groups were well matched: age 48 vs 51 years (p = 0.249), weight loss 27.3 vs 26.7 kg (p = 0.911). The symptomatic group had a larger gastric pouch (5.2 vs 3.3 cm, p = 0.012), with higher esophageal acid exposure (10.8 vs 0.9%, p < 0.001). Two acidification patterns were observed: irritant and volume acidification, associated with substantial supine acidification. Symptomatic LAGB had altered esophageal motility, with poorer lower esophageal sphincter basal tone (8.0 vs 17.7 mmHg, p = 0.022) and impaired contractility of the lower esophageal segment (90 vs 40%, p = 0.009). Compared to pre-operative reflux patients, symptomatic LAGB patients demonstrated higher total and supine esophageal acid exposure (10.8 vs 7.0%, p = 0.010; 14.9 vs 5.1%, p < 0.001), less symptoms (2 vs 6, p = 0.001) and lower symptom index (0.7 vs 0.9, p = 0.010).

CONCLUSIONS

Ambulatory pH monitoring is an effective technique if the pH sensor is positioned appropriately using HRM. The correctly positioned LAGB appears associated with low esophageal acidification. In contrast, patients with symptoms or pouch dilatation can have markedly elevated esophageal acidification, particularly when supine. This is a different pattern compared to pre-operative patients and importantly can be disproportionate to symptoms.