Clinical Challenges in Upper Gastrointestinal Malignancies after Bariatric Surgery

Abstract

Background/Aims: The incidence of morbid obesity has exponentially increased over the last decades. Bariatric surgery (BS) has been proven effective in inducing weight loss and resolving comorbidities associated with morbid obesity. However, BS can also lead to major diagnostic and treatment challenges in patients who develop upper gastrointestinal malignancies. It is important to create awareness of this rising problem. Methods: Relevant literature was searched in PubMed. Results: (Formerly) obese patients are more prone to develop upper gastrointestinal malignancies, mainly adenocarcinoma of the distal esophagus, since obesity induces a chronic pro-inflammatory state due to endocrinological changes. When an upper gastrointestinal malignancy develops after BS, diagnosis is often delayed and challenging due to a different presentation of complaints and the altered anatomy following the earlier surgery. Also, a potentially curative resection is often more complex and reconstruction of the gastrointestinal continuity can be seriously hampered. Conclusion: Due to the growing incidence of obesity and the increasing number of bariatric surgical procedures that are performed each year, it is expected that over the years to come, more post-BS patients will be diagnosed with upper gastrointestinal malignancies, providing great diagnostic and treatment challenges. Clinicians should be aware of this rising problem.

Energy balance and gastrointestinal cancer: risk, interventions, outcomes and mechanisms

“…A population-based cohort study among individuals with an obesity diagnosis showed a worse rectal cancer prognosis among those who had undergone bariatric surgery; however, weaknesses of the study include the limited sample size ( n = 131 patients who were obese and underwent bariatric surgery with colorectal cancer) and the lack of adjustment for tumour stage 23 . Another emerging issue is that alterations in gastrointestinal anatomy resulting from bariatric surgery can lead to different presentation of symptoms, thus making diagnosis of cancer more challenging 24 .…”

Gastric adenocarcinoma in the excluded stomach 18 years after bariatric surgery: a case report

“…Obesity has a systemic carcinogenic effect, resulting in an increased risk of developing cancer in various organs, such as liver, pancreas and stomach [ 7 ]. Although the underlying mechanisms are not completely elucidated, various theories have been proposed, such as pro-inflammatory effect due to metabolic syndrome, chronic hyperinsulinemia exposing preneoplastic cells to tumorigenic effects and development of insulin resistance [ 9 , 12 ]. The weight loss obtained after BS also seems to be responsible for the reduced risk of cancer in these patients [ 13 ].…”

“…However, there are few reports of GC in the ES, occurring 5–22 years after surgery [ 6 , 8 ]. The diagnosis is challenging since there is no access to perform upper gastrointestinal endoscopy (UGE) in the ES and the symptoms are nonspecific [ 9 , 10 ]. The most important preventive measure is the systematic preoperative risk assessment, with a detailed evaluation of familial history, patients’ conditions and UGE for assessment of the presence of H. pylori [ 7 ].…”

ASMBS position statement on the relationship between obesity and cancer, and the role of bariatric surgery: risk, timing of treatment, effects on disease biology, and qualification for surgery

“…Obesity, gastroesophageal reflux disease and BE are identified risk factors for UGI malignancies, commonly lower esophageal cancers [63,64]. Vague UGI symptoms after bariatric surgery, such as nausea, dysphagia, or reflux, may cause delayed cancer diagnosis, as these can be common postbariatric surgery complaints; this can result in more advanced tumors at the time of diagnosis [65]. Periodic endoscopic surveillance in patients with known BE and early evaluation in patients who develop new symptoms, such as upper abdominal pain, dysphagia, reflux, or anemia, after bariatric surgery are also strongly encouraged [66].…”

“…After sleeve gastrectomy (SG), it is impossible to use the stomach for reconstruction after esophagectomy. In such circumstances, an esophagojejunostomy or colon interposition is necessary, likely increasing postoperative morbidity [65]. In cases of esophageal cancer after prior RYGB, experienced surgeons advise a close collaboration between bariatric and cancer surgeons to address a technically nuanced complex procedure for cancer resection and reconstruction [69].…”