Duodenogastric bile reflux after gastric bypass: a cholescintigraphic study

Gastric cancer after Bariatric Bypass Surgery. Do they relate? (A Systematic Review)

Bariatric bypass surgery has been an effective treatment for morbid obesity. However, there is an increasing number of reported cases of gastric cancer after bypass surgery. Our systematic review showed an increasing trend of gastric cancer cases after bariatric bypass surgery in the last decade, mostly located in the excluded stomach (77%) and diagnosed in an advanced stage. In addition to known risk factors such as tobacco smoking (17%), H. pylori infection (6%), and family history of gastric cancer (3%), bile reflux, a recently proposed cancer-promoting factor, was also estimated in 18% of the cases. Our data suggest that gastric cancer risk assessment should be considered before gastric bypass surgery, and further investigations are needed to determine the value of post-operative gastric cancer surveillance.

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.

Gastroesophageal Cancer After Gastric Bypass Surgeries: a Systematic Review and Meta-analysis

Data comparing the occurrence of gastroesophageal cancer after gastric bypass procedures are lacking and are only available in the form of case reports. We perform in this study a systematic review and a meta-analysis of all the reported cases of gastroesophageal cancer following Roux-en-Y gastric bypass (RYGB) and loop gastric bypass-one anastomosis gastric bypass/mini gastric bypass (LGB-OAGB/MGB). We conducted a systematic review of all the reported cases in articles referenced in PubMed/Medline, Cochrane, and Scholar Google. Only cases of gastro-esophageal adenocarcinoma following RYGB or LGB-OAGB/MGB are included. Statistical analysis was done accordingly. Fifty cases were identified, along with 2 reported in this paper. Sixty-one percent (27/44) of the cancers after RYGB were in the gastric tube compared to 37.5% (3/8) after LGB-OAGB/MGB. This resulted in an odds ratio of 0.38 (p-value = 0.26), which failed to prove an increase in cancer occurrence in the gastric tube after LGB-MGB/OAGB compared to RYGB. The most common symptoms were dysphagia for cancers occurring in the gastric tube (15/30) and abdominal pain for those occurring in the excluded stomach (10/22). Twenty-nine/thirty of the cancers in the gastric tube were diagnosed by gastroscopy and 13/22 of the cancers in the excluded stomach were diagnosed by CT scan. Gastroesophageal cancers after gastric bypass procedures occur commonly in the excluded stomach where many are not identified by conventional means. Physician awareness and patient education as well as lifelong follow-up are essential for maintaining bypass surgeries on the beneficial side.

HIDA and Seek: Challenges of Scintigraphy to Diagnose Bile Reflux Post-Bariatric Surgery

INTRODUCTION

Oesophageal bile reflux after bariatric surgery may trigger development of Barrett's oesophagus. Gastro-oesophageal reflux of bile is captured by hepatobiliary iminodiacetic acid (HIDA) scintigraphy; however, anatomical and physiological changes after bariatric surgery warrant protocol modifications to optimise bile reflux detection.

METHODS

HIDA scintigraphy occurred 6 months after either sleeve gastrectomy, Roux-en-Y gastric bypass or one-anastomosis gastric bypass. Standard HIDA scanning involves (i) 6-h fast and 24-h abstinence from opioids; (ii) IV administration of 99mTc di-isopropyl iminodiacetic acid; and (iii) dual anterior/posterior 60-min dynamic scanning of the duodenum, stomach and oesophagus. Three challenges were identified, and modifications were implemented, namely, (1) anatomical localisation of refluxed bile on planar scintigraphy was improved by adding a SPECT/CT for 3D imaging; (2) impaired cholecystokinin-controlled gallbladder emptying, following bypassed duodenum, was addressed by ingestion of a 'fatty meal'; and (3) intestinal hypomotility after gastric bypass was counteracted by longer scan duration (75-90 min) to allow bile to pass beyond the gastro-jejunal anastomosis.

RESULTS

HIDA scan was undertaken in 18 patients, 13 of whom underwent the modified protocol. The tailored protocol ameliorated issues identified with the standard HIDA scan protocol; thus, accurate anatomical localisation was achieved in all patients, no delayed gallbladder emptying was observed, and bile was observed beyond the gastro-jejunal anastomosis in all gastric bypass patients. The modified technique was well tolerated by patients.

CONCLUSION

A tailored HIDA scan protocol with addition of a SPECT-CT scan, ingestion of a fatty meal and prolonged scanning duration results in enhanced bile reflux detection in post-bariatric surgical patients.

Perforation of the excluded segment without pneumoperitoneum following Roux-en-Y gastric bypass surgery: case report and literature review

BACKGROUND

Because of the increasing prevalence of obesity and bariatric surgery (Roux-en-Y gastric bypass (RYGB) as the gold standard), there is a still growing population of people with altered post-operative anatomy. Although the most common early and late complications following RYGB are well known, they can still be difficult to diagnose. The altered anatomy after RYGB can create a real diagnostic and therapeutic challenge since routine examinations can be negative.

CASE REPORT

We present a rare case of a 38-year-old woman with acute abdominal pain and a history of RYGB who proved to have a duodenal perforation in the absence of free air on radiologic examination. The perforation was closed laparoscopically and proton pump inhibitors were administered.

CONCLUSIONS

Perforations of the excluded segment in RYGB patients are rare and represent a diagnostic challenge, as pneumoperitoneum is usually absent and the excluded segment is difficult to access. Despite negative diagnostic findings, laparoscopic exploration should always be considered.

Duodenogastric biliary reflux assessed by scintigraphic scan in patients with reflux symptoms after sleeve gastrectomy: preliminary results

BACKGROUND

Bile reflux is a factor in the appearance of severe esophagitis and Barrett's esophagus, which have been reported after sleeve gastrectomy (SG). Incompetent lower esophageal sphincter and increased gastroesophageal acid reflux have been demonstrated after this operation. Some reports have shown bile content in the antrum during endoscopic control, but no investigations objectively confirm the presence of duodenogastric bile reflux in these patients.

OBJECTIVES

To evaluate the presence of duodenogastric bile reflux (DGR) after SG in patients presenting reflux symptoms.

SETTING

University hospital.

METHODS

Prospective study of 22 patients presenting reflux symptoms who underwent SG for morbid obesity and who received endoscopic evaluation and scintigraphic study to confirm esophagitis and duodenogastric bile reflux.

RESULTS

Erosive esophagitis was observed in 11 patients and Barrett's esophagus in 2 patients. Seven patients (31.8%) presented positive DGR. Among them, 3 had type B and C esophagitis. The other 4 patients did not present esophagitis in spite of reflux symptoms.

CONCLUSION

DGR may be present in patients with gastroesophageal reflux after SG. This line of investigation requires further studies to confirm this hypothesis.

Exploring the Excluded Stomach: A Case Series of Novel Endoscopic Techniques to Diagnose Gastric Cancer in the Excluded Stomach After Roux-en-Y Gastric Bypass Surgery

Gastric cancer is the fifth most common malignancy worldwide and the fourth leading cause of cancer-related deaths. The diagnosis is usually made by direct visualization with supporting histopathology. However, patients with gastric bypass surgery pose a challenge in diagnosis due to the difficulty in the evaluation of the excluded stomach. We present two cases of gastric cancer in the excluded stomach after Roux-en-Y gastric bypass (RYGB) surgery was diagnosed using two different endoscopic approaches.

Laparoscopic subtotal gastrectomy in morbid obese patients: a valid option to laparoscopic gastric bypass in particular circumstances (prospective study)

BACKGROUND

Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) without resection of the distal stomach is largely performed over the world for morbid obesity. Potential risk of gastric remnant carcinoma development has been suggested.

PURPOSE

To present the results obtained after LRYGB with resection of distal stomach.

METHOD

This prospective study includes 400 consecutive patients. The mean body weight was 105.9 ± 16.8 Kg (range 83-145 kg), and body mass index (BMI) was 38.5 ± 4.4 kg/m² (32.9-50.3). Postoperative morbid-mortality and follow-up were analyzed.

RESULTS

Operative time was 128.5 ± 18.7 min, hospital discharge occurred at 3rd postoperative day, postoperative complications occurred in 9.25%, early surgical complications were observed in 3% and medical complications 4%, late surgical complications occurred 2.25%, no mortality was observed. At 1 year follow-up, BMI was 25.3 ± 2.7 kg/m² with % of weight loss (%WL) of 84.6 + 19.1%. At five years follow-up very similar values were observed.

CONCLUSION

The results obtained after LRYGB with resection of distal stomach are similar to results published after non resection LRYGB regarding early and late results and can be indicated in high risk areas of gastric carcinoma.

Bile reflux of the remnant stomach following Roux-en-Y gastric bypass: an etiology of chronic abdominal pain treated with remnant gastrectomy

BACKGROUND

Bile reflux gastritis of the remnant stomach following Roux-en-Y gastric bypass (RYGB) causing chronic abdominal pain has not been reported. We report a series of symptomatic patients with remnant gastritis treated effectively with remnant gastrectomy (RG).

OBJECTIVE

The objective was to report our experience with bile reflux remnant gastritis after RYGB and our outcomes following RG.

SETTING

Community teaching hospital.

METHODS

All patients undergoing RG were retrospectively reviewed for presenting symptoms, diagnostic workup, pathology, complications, and symptom resolution.

RESULTS

Nineteen patients underwent RG for bile reflux gastritis at a mean of 4.4 years (52.3 mo, range 8.5-124 mo) after RYGB. All patients were female and presented with pain, primarily epigastric (18/19; 95%), and described as burning (11/19; 58%), with 10 (53%) reporting nausea. Endoscopy was performed preoperatively on all patients with successful remnant inspection in 13 (68%), using push endoscopy (n = 10) or operative assist (n = 3), with 12 (of 13; 92%) biopsy-positive for reactive gastropathy. Seventeen (90%) completed a hepatobiliary scintigraphy scan with 100% positivity demonstrating bile reflux across the pylorus. Surgical approach was laparoscopic or robotic in 18 (95%) with a hospital length of stay of 2.7 days (range 0-12 d), with no major complications or readmissions. Pathology of the remnant confirmed reactive gastropathy in 90% (n = 17). Ninety percent of patients (n = 17) reported sustained symptom resolution, and 11% of patients (n = 2) remained symptomatic at last follow-up. We followed all patients for a mean of 6.6 years (1-194 mo).

CONCLUSION

Bile reflux gastritis of the remnant stomach is a new consideration for chronic abdominal pain months to years following RYGB. Hepatobiliary scintigraphy imaging and endoscopic biopsy are highly suggestive. RG is safe and effective treatment.

Influence of obesity and bariatric surgery on gastric cancer

Esophageal and gastric cancer (GC) are related to obesity and bariatric surgery. Risk factors, such as gastroesophageal reflux and Helicobacter pylori, must be investigated and treated in obese population. After surgery, GC reports are anecdotal and treatment is not standardized. This review aims to discuss GC related to obesity before and after bariatric surgery.

Esophagogastric cancer after bariatric surgery: systematic review of the literature

BACKGROUND

Because the number of patients with a previous bariatric procedure continues to rise, it is advisable for bariatric surgeons to know how to manage the rare event of the development of an esophagogastric cancer. The aim of the study was to perform a systematic review of all reported cases of esophagogastric cancers after bariatric surgery.

METHODS

Systematic review of English and French written literature in MEDLINE and EMBASE database.

RESULTS

Globally, 28 articles describing 33 patients were retrieved. Neoplasms were diagnosed at a mean of 8.5 years after bariatric surgery (range 2 months-29 years). There were 11 esophageal and 22 gastric cancers; although adenocarcinoma represented most cases (90.6%), a tubulovillous adenoma with high-grade atypia, an intramural gastrointestinal stromal tumor, and a diffuse large B-cell lymphoma of the gastric fundus were also reported. Node involvement was reported in 14 cases, and distal metastases in 5. The most frequently reported symptoms were dysphagia and food intolerance, vomiting, epigastric pain, and weight loss. Surgery was performed in 28 patients, although 4 underwent only chemotherapy and/or radiotherapy and 1 received palliative care. Reported mortality rate was 48.1%.

CONCLUSIONS

To date, it is not possible to quantify the incidence of esophagogastric cancer after bariatric surgery because of the paucity of reported data. Nevertheless, because the main concern is the delay in diagnosis, it is of critical importance to carefully evaluate any new or modified upper digestive tract symptom occurring during bariatric surgery follow-up.

Laparoscopic resectional gastric bypass in patients with morbid obesity: experience on 112 consecutive patients

INTRODUCTION

Gastric bypass, without gastric resection of the distal excluded stomach, is the surgical treatment more frequently performed for morbid obesity. Several postoperative complications related to the “in situ” distal stomach have been described, and few cases of undetected gastric carcinoma located in this segment of stomach have been published. In this paper, we present our early postoperative results in patients submitted to laparoscopic gastric bypass with resection of distal stomach in patients with morbid obesity.

METHODS

One hundred twelve consecutive patients were included in this study. The mean body weight was 112.15±5.1 (range 78–145), and BMI was 40.5±6.9 kg/m2 (32.9–50.3). Patients were submitted to resectional gastric bypass by laparoscopic approach. The operative time was 133.7±29.1 min (range 120–240).

RESULTS

Postoperative complications occurred in 12 patients (10.7%) without any mortality. Early complications were observed in 11 patients while one patient presented a late complication, four patients were re-hospitalized, three of them without operation and other four of them were re-operated due to early (three patients) or late complication (one patient). One hundred patients (89.2%) were discharged at fourth postoperative day, seven patients remained in hospital between 5 and 10 days, and four patients after the tenth day due to complications. Leaks were observed in three patients. The histological study of the resected specimen was normal in only 8.9%.

CONCLUSIONS

Laparoscopic resectional gastric bypass presents very similar results compared to classic gastric bypass, without significant increase of morbidity, mortality, early and late postoperative results, and therefore, it is an option for the surgical treatment of morbid obesity in countries with high risk of gastric carcinoma.

Gastrointestinal and nutritional complications after bariatric surgery

The prevalence of obesity has increased to epidemic proportions, making obesity and its comorbid conditions a major public health concern. Bariatric surgery is the most effective treatment, but it carries substantial morbidity. The subsequent gastrointestinal and nutritional complications are often not recognized or properly managed. As part of the multidisciplinary team taking care of obese patients, gastroenterologists should be familiar with the types of bariatric surgery and their associated complications. We review the most common gastrointestinal and nutritional complications after bariatric procedures and examine how gastroenterologists may best prevent, investigate, and treat them.

Endoscopic and histologic findings of the foregut in 426 patients with morbid obesity

BACKGROUND

Roux-en-Y gastric bypass is the most frequent bariatric operation. In this operation, the distal bypassed stomach is left in situ. We studied pre-operative clinical, endoscopic and histologic findings in a consecutive group of morbidly obese patients prior to bariatric surgery.

METHODS

A prospective study was conducted from August 1999 until May 2004, which consisted of 426 patients with morbid obesity. There were 94 men and 332 women, with mean age 39.5 years. In all patients prior to surgery, upper endoscopy was performed and biopsy samples were taken distal to squamo-columnar junction (cardiac biopsies), and in 232 of them also in at the antrum.

RESULTS

Pathological findings at the esophagus were seen in 55% of the patients, mainly related to reflux esophagitis. Barrett's esophagus was seen in 5.8%. In the stomach, pathological findings were seen in 32% of the patients. Active peptic ulcer was demonstrated in 2.6% of the cases. At the duodenum, pathologic findings were detected in 13.4% of the patients, showing an ulcer in 2.6%. At the stomach, chronic inactive gastritis and atrophic gastritis with intestinal metaplasia were found in 8.6% and 6.5% respectively. Antral adenoma with low-grade dysplasia was found in 1 patient, and 1 carcinoid tumor. H. pylori was present in 53% of the patients, mainly in the antrum.

CONCLUSION

In candidates for bariatric surgery, upper endoscopy with biopsy samples and determination of H. pylori should be routinely performed. If present, H. pylori should be eradicated. After surgery, if Barrett's esophagus was present, endoscopic surveillance is recommended.

What to expect in the excluded stomach mucosa after vertical banded Roux-en-Y gastric bypass for morbid obesity

Mucosal alterations after vertical banded Roux-en-Y gastric bypass have not been clearly evaluated. The aim of this paper was to analyze the histological findings and the presence of Helicobacter pylori in the excluded stomach. Forty consecutive patients who underwent Roux-en-Y gastric bypass longer than 36 months were selected for double-balloon enteroscopy. The excluded stomach was reached in 35/40 patients (88%). Morphological alterations were analyzed through hematoxilin and eosin and the presence of H. pylori was confirmed with Giemsa staining. Thirty patients (86%) were female, and the mean age was 43 years old. The mean postoperative time was 78 months (36-110 months). Histologically, all patients had chronic gastritis in the bypassed stomach, with pangastritis in 33/35 (94%). Five cases (5/35, 14%) presented atrophy and four of them also had intestinal metaplasia. Helicobacter pylori was detected in 7/35 (20%) of the excluded stomach and in 12/35 (34%) of the functional pouch. All patients positive for H. pylori in the excluded stomach were also positive in the functional pouch, p = 0.0005. Helicobacter pylori is still present in the excluded stomach after Roux-en-Y gastric bypass and might be considered for treatment. Histological findings indicated high prevalence of atrophy and intestinal metaplasia in this selected population.

Effects of duodenogastric reflux on gastrin cells, somatostatin cells and serotonin cells in human antral gastric mucosa

Duodenogastric reflux (DGR) has been found to give rise to a hypochlorhydria secondary to alkaline reflux. We investigated whether there is a link between DGR and the gastrin, somatostatin, and serotonin cell numbers and the granular content of gastrin, somatostatin, and serotonin in endocrine cells in human antral mucosa. We investigated 38 selected Helicobacter pylori-negative patients with visual primary excessive DGR in upper endoscopy and symptoms of epigastric pain and bile vomiting. Ten control patients were included in this study. None of the patients had peptic ulcer or had received any medication. Antrum (10 biopsies from five different zones: the lesser and major curvature, the anterior and posterior wall, and the pylorus) and corpus (two biopsies from major curvature about 10 cm below the cardia) biopsy specimens were collected for routine histology, as well as for light and electron immunohistochemistry. In patients without atrophy or intestinal metaplasia and in patients with mild atrophy or mild intestinal metaplasia, the number of gastrin and somatostatin cells was not different from that in controls. In moderate atrophy or moderate intestinal metaplasia, however, the number of gastrin and somatostatin cells decreased. Serotonin cell number was significantly higher in all patients with DGR as compared with controls. The mean somatostatin granular content was increased (3.6+/-0.2 vs. 3.2+/-0.1). In addition, lysosomes with engulfed somatostatin granules were found. The mean serotonin granular content was decreased (2.3+/-0.3 vs. 2.9+/-0.3), while the mean gastrin granular content remained unchanged (2.5+/-0.3 vs. 2.4+/-0.2). Ultrastructurally, the granules in serotonin-positive cells corresponded to the gastric variant or to the intestinal variant of serotonin cells. The endocrine cells were found to have few granules positive for serotonin. It is concluded that DGR inhibits somatostatin granular release, but stimulates both serotonin granular release and serotonin cell growth.

Effects of bile reflux and intragastric microflora changes on lesions of remnant gastric mucosa after gastric operation

AIM: To investigate the effects of bile reflux and intragastric microflora changes on lesions of remnant gastric mucosa after gastric operation.

METHODS: Concenration of bile acid and total bacterial counts (TBC) in gastric juice were measured in 49 patients with peptic ulcer before and after gastrectomy. One year after the operation, sample of gastric mucosa taken from all the patients were used for histological examination.

RESULTS: The concentration of gastric bile acid was significantly increased in group B-I, or B-II and SV + A than that in group HSV (P < 0.05-0.01). The abnormal histological changes in the remnant gastric mucosa were more common in the first 2 groups than in the last group.

CONCLUSION: The type of gastrtectomy can affect bile reflux. The abnormal histological changes in the remnant gastric mucosa are closely related to the elevation of bile acid concentration and increase of TBC in gastric juice. HSV can effectively prevent bile reflux and keep the gastric physiological functions stable.

Obesity Surgery: A Gastroenterologist's Perspective

Obesity is increasing at an alarming rate. Approximately 25% of adult women and 20% of adult men in the United States are obese. Obesity is increasing even more rapidly in children. The incidence of type 2 diabetes mellitus, hypertension, dyslipidemia, and liver disease is significantly increased in obese persons. Traditional methods of diet, exercise, drugs, and behavior modification are unsuccessful in the treatment of patients who are morbidly obese and have a body mass index of 40 kg/m(2) or a body mass index of 35 kg/m(2) with comorbidity. Multiple surgical alternatives to the traditional treatments are available and have been successful. Considerable weight loss may be achieved and maintained. Each procedure is associated with a variety of side effects and complications. The selection of patients for bariatric surgery requires a careful evaluation of their medical condition in addition to multiple psychological and social factors. Postoperative care entails careful medical follow-up and long-term support. Patients may have a difficult time adjusting to their new ability to eat normally.