“Expected” Side Effects of Bariatric Surgery Masquerading Esophageal Cancer: A Case for Perioperative Endoscopy

Abstract

Case Presentation: A 70-year-old obese male underwent laparoscopic banding in 2010. Two years later he experienced worsening gastroesophageal reflux (GERD), indigestion, nausea, and vomiting. An esophagogastroduodenoscopy (EGD) with biopsy confirmed an adenocarcinoma of the gastroesophageal junction. A 61-year-old obese female underwent laparoscopic banding in 2010. She initially developed intermittent dysphagia, which she attributed to the lap-band. One year postsurgery, she presented with worsening symptoms and subsequent imaging revealed a 2.9 x 1.8 cm mass within the distal esophagus. EGD with biopsy confirmed an invasive high-grade esophageal adenocarcinoma (Figure 1).Figure 1: Distal esophageal adenocarcinoma 1 year after restrictive bariatric surgery.Discussion: A thorough review of literature reveals at least nine reports involving obese patients undergoing bariatric surgery and subsequently being diagnosed with esophageal cancer. Five of these patients, in addition to the two patients mentioned above, underwent a restrictive bariatric procedure, specifically1. While there is no confirmed relationship between the two, the symptoms of esophageal cancer, which include weight loss, reflux, and dysphagia, are easily overlooked and attributed to the “expected” side effects of gastric banding. This leads to a delay in diagnosis, and ultimately increased morbidity and mortality. One case report identifies a patient diagnosed with esophageal cancer as early as 4 months after bariatric surgery. This suggests that the cancer was likely present prior to the procedure and would have been detected via pre-operative endoscopy1. Conclusion: Obesity is a known risk factor for upper gastrointestinal cancer. We recommend heightened suspicion for upper gastrointestinal malignancy in bariatric surgery patients to avoid attributing symptoms of cancer (i.e., dysphagia and worsening reflux) to the restrictive bariatric procedure itself. This may be accomplished by considering a protocol for pre-operative endoscopy to detect incidental lesions and maintaining a low threshold for repeat post-operative endoscopy in those expressing new symptoms.