Increased Duodeno-Gastro-Esophageal Reflux (DGER) in symptomatic GERD patients with a history of cholecystectomy

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.

Gallstone, cholecystectomy and risk of gastric cancer

Backgrounds/Aims

The aim of this retrospective study is to compare stomach cancer incidence, characteristics between gallstones, cholecystectomy and control groups. It also aims to investigate key variables' potential effects on overall survival.

Methods

A total of 99 patients, diagnosed with stomach cancers between April 1994 and December 2015, were identified. We excluded stomach cancer patients, accrued during the first year of follow-up in both the gallstones and cholecystectomy groups, assuming that they missed cancers. The main analyses addressing the objective were a chi-square analysis and a survival analysis.

Results

The incidence of stomach cancers was increased in both the gallstone and cholecystectomy groups, compared with the control group (p=0.003). Multivariate regression analysis showed that the overall survival in gallstones, cholecystectomy group patients as compared with those in the control group decreased (HR=6.66, 95 CI: 1.94–22.80, p=0.003). Also, T-stage was found to statistically affect the rate of overall survival (HR=9.85, 95% CI: 3.09–31.39, p=.000). The stomach cancer showed the worse survival at the posterior, greater curvature location than anterior, lesser curvature of the stomach. (HR=0.30, 95% CI: 0.11–0.80, p=0.017).

Conclusions

We provided an awareness of the possible increased risks of stomach cancer in gallstone and cholecystectomy group patients, which might be induced by duodenogastric bile reflux. Also, the survival rate was poor (p<0.000). Therefore, close follow-up strategies for early detection are recommended for such patients.

Cholecystectomy and the risk of alimentary tract cancers: A systematic review

AIM: To investigate the association between cholecystectomy and gastro-intestinal tract (GIT) cancers.

METHODS: We conducted a systematic review according to the PRISMA guidelines. A MEDLINE search was performed with predefined search criteria for English Language articles on the association between cholecystectomy and GIT cancers. Additional articles were retrieved by manual search of references. All relevant articles were accessed in full text. Data on study type; cases; controls; country; effect estimate; adjustments for confounders and quality of publication were extracted. The quality of the publications were scored by adherence to the STROBE checklist. The data for each part of the GIT were presented in separate tables.

RESULTS: Seventy-five studies and 5 meta-analyses satisfied the predefined criteria for inclusion and were included in this review. There were inconsistent reports and no strong evidence of an association between cholecystectomy and cancers of the oesophagus (Adenocarcinoma), pancreas, small bowel and right-sided colon cancers. In squamous cancer of the oesophagus, cancers of the stomach, liver, bile ducts, small bowel and left sided colon cancers, good quality studies suggested a lack of association with cholecystectomy. Equally, distal colon and rectal cancers were found not to be associated with cholecystectomy. Several mechanisms for carcinogenesis/promotion of carcinogensis have been proposed. These have focused on a role for bile salts in carcinogenesis with several potential mutagenic molecular events and gut metabolic hormones signaling cell proliferation or initiation of carcinogenesis.

CONCLUSION: This is a comprehensive review of the association between GIT cancers and cholecystectomy. This review found no clear association between cholecystectomy and GIT cancers.

Controversy surrounding 'mini' gastric bypass

Mini gastric bypass is a modification of Mason loop gastric bypass with a longer lesser curvature-based pouch. Though it has been around for more than 15 years, its uptake by the bariatric community has been relatively slow, and the procedure has been mired in controversy right from its early days. Lately, there seems to be a surge in the interest in this procedure, and there is now published experience with more than 5,000 procedures globally. This review examines the major controversial aspects of this procedure against the available scientific literature. Surgeons performing this procedure need to be aware of these controversies and counsel their patients appropriately.

Does modified Braun enteroenterostomy improve alkaline reflux gastritis and marginal ulcer after pancreaticoduodenectomy?

BACKGROUND

The safety of pancreaticoduodenectomy has improved significantly. However, alkaline reflux gastritis and marginal ulcer are two substantial problems after pancreaticoduodenectomy.

AIMS

To identify whether Child reconstruction with a modified Braun enteroenterostomy decreases the incidence of alkaline reflux gastritis and marginal ulcer after pancreaticoduodenectomy better than Roux-en-Y reconstruction.

METHODS

Data on 57 consecutive patients who underwent standard pancreaticoduodenectomy between January 1, 2008 and January 31, 2012 were collected prospectively. Data on early and late complications of the Child reconstruction with a modified Braun enteroenterostomy and Roux-en-Y were gathered. The risk factors of alkaline reflux gastritis and marginal ulcer were also investigated by using univariate and multivariate analyses.

RESULTS

Twenty-five patients received Roux-en-Y and 32 underwent Child reconstruction with a modified Braun enteroenterostomy. Early complications after the two reconstruction methods were insignificant. Significant differences in terms of later postoperative morbidity (P = 0.01) and change in body mass index (P = 0.03) were found 12 months after pancreaticoduodenectomy. No significant difference for alkaline reflux gastritis was observed between the two methods (14.8 vs. 28.6 %, P = 0.24). Marginal ulcer occurred significantly lower in patients with the modified reconstruction than in those with Roux-en-Y reconstruction (11.1 vs. 47.6 %, P = 0.01). Peptic ulcer history, diabetes mellitus, and reconstruction type had a significant effect on marginal ulcer formation.

CONCLUSIONS

Child reconstruction with a modified Braun enteroenterostomy offers an advantage with respect to marginal ulcer after standard pancreaticoduodenectomy, potentially decreasing the incidence of alkaline reflux gastritis as effectively as Roux-en-Y reconstruction.

New understandings about gallbladder function

The function of the gallbladder is to store and concentrate bile. Due to the high incidence of diseases such as gallstones, cholecystectomy has become one of the most common surgical procedures. Although cholecystectomy is a successful treatment for most patients, the loss of gallbladder function may contribute to chronic diarrhea and increase the incidence of proximal colon cancer, pancreatic cancer, hepatocellular carcinoma and esophageal adenocarcinoma. With the development of endoscopic technology and introduction of drugs that may prevent recurrence of gallstones, cholecystolithotomy with gall bladder preservation has become another choice for symptomatic gallstones, and it preserves the function of the gallbladder after the removal of gallstones. This may avoid the complications associated with the loss of gallbladder function.

Cholecystectomy and risk of laryngeal and pharyngeal cancer

Duodeno-gastro-esophageal reflux of bile might cause laryngeal and pharyngeal cancer, but more research is required. Since cholecystectomy is followed by an increased risk such reflux, the risk of developing laryngeal or pharyngeal cancer after cholecystectomy was addressed. A population-based cohort study was conducted in Sweden during the period 1965-2008. The number of laryngeal or pharyngeal cancer cases observed in a large cohort of cholecystectomized patients was compared with the expected number, calculated from the entire Swedish population of corresponding age, gender and calendar year. Risk of laryngeal or pharyngeal cancer was calculated as standardized incidence ratio (SIR) with 95% confidence interval (CI). The cholecystectomy cohort included 345,251 patients who were followed up for 1-43 years and contributed 4,854,969 person-years at risk. The 192 new cases of laryngeal cancer and the 175 cases of pharyngeal cancer were not greater than the expected, providing SIR 0.99 (95% CI 0.85-1.14) and SIR 1.06 (95% CI 0.91-1.23), respectively. A longer latency period after cholecystectomy was not associated with any increased risk of any of these tumors. No differences between age groups or sexes were detected. Analyses restricted to verified squamous-cell carcinomas revealed similar results. In conclusion, cholecystectomy does not appear to be followed by any increased risk of laryngeal or pharyngeal cancer.

Cholecystectomy as a risk factor for oesophageal adenocarcinoma

BACKGROUND

Owing to an increased risk of oesophageal bile exposure after cholecystectomy, an association with oesophageal adenocarcinoma is possible. There are some data in support of this hypothesis, and the aim of this study was to ascertain whether the association could be confirmed.

METHODS

A population-based cohort study was undertaken to compare the number of cases of oesophageal adenocarcinoma observed in a cohort of patients who have had a cholecystectomy in Sweden during 1965-2008 with the expected number, calculated from the entire Swedish population of corresponding age, sex and year. The risk of oesophageal adenocarcinoma was assessed by calculating the standardized incidence ratio (SIR) with 95 per cent confidence intervals.

RESULTS

The cholecystectomy cohort included 345 251 patients who were followed up for a mean of 15 years and contributed 4 854 969 person-years at risk. The total of 126 new cases of oesophageal adenocarcinoma was greater than expected (SIR 1.29, 1.07 to 1.53). The strength of the association between cholecystectomy and oesophageal adenocarcinoma tended to increase with longer follow-up after cholecystectomy. There was no association between cholecystectomy and oesophageal squamous cell carcinoma (SIR 0.93, 0.81 to 1.08), and in an unoperated cohort of 192 960 patients with gallstones no increased risk of oesophageal adenocarcinoma was identified (SIR 0.99, 0.71 to 1.35).

CONCLUSION

Cholecystectomy appears to be linked to an increased risk of oesophageal adenocarcinoma, but the absolute risk is small.