Screening for Barrett’s esophagus after sleeve gastrectomy

Abstract

Sleeve gastrectomy (SG) is an increasingly popular bariatric surgical procedure in which the greater curvature of the stomach is resected, thereby increasing satiety and decreasing appetite through structural and neurohormonal changes. First performed in 1988 as a component of the biliopancreatic division with duodenal switch,1Hess D.S. Hess D.W. Biliopancreatic diversion with a duodenal switch.Obes Surg. 1998; 8: 267-282Crossref PubMed Scopus (640) Google Scholar SG has now evolved into a stand-alone procedure and, since 2013, has become the most common bariatric surgery performed. SG made up over three-quarters of primary procedures to treat obesity in the United States in 2018, with 154,976 cases reported by the American Society for Metabolic and Bariatric Surgery.2English W.J. DeMaria E.J. Hutter M.M. et al.American Society for Metabolic and Bariatric Surgery 2018 estimate of metabolic and bariatric procedures performed in the United States.Surg Obes Relat Dis. 2020; 16: 457-463Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar Although results from some of the initial studies were mixed regarding the increase in GERD after SG,3Chiu S. Birch D.W. Shi X. et al.Effect of sleeve gastrectomy on gastroesophageal reflux disease: a systematic review.Surg Obes Relat Dis. 2011; 7: 510-515Abstract Full Text Full Text PDF PubMed Scopus (181) Google Scholar more recent studies, which have allowed for longer follow-up, have demonstrated a more consistent link with both GERD symptoms and esophagitis and Barrett’s esophagus (BE). For example, Felsenreich et al4Felsenreich D.M. Kefurt R. Schermann M. et al.Reflux, sleeve dilation, and Barrett’s esophagus after laparoscopic sleeve gastrectomy: long-term follow-up.Obes Surg. 2017; 27: 3092-3101Crossref PubMed Scopus (157) Google Scholar followed 43 patients for 10 years after SG and reported that 14% of patients underwent conversion to Roux-en-Y gastric bypass due to reflux, 38% of nonconverted patients had symptomatic reflux, and most concerning, there was a 15% incidence of BE.4Felsenreich D.M. Kefurt R. Schermann M. et al.Reflux, sleeve dilation, and Barrett’s esophagus after laparoscopic sleeve gastrectomy: long-term follow-up.Obes Surg. 2017; 27: 3092-3101Crossref PubMed Scopus (157) Google Scholar In a larger study following 144 patients prospectively, 60% were found to have erosive esophagitis, and 13% had nondysplastic BE.5Soricelli E. Casella G. Baglio G. et al.Lack of correlation between gastroesophageal reflux disease symptoms and esophageal lesions after sleeve gastrectomy.Surg Obes Relat Dis. 2018; 14: 751-756Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar Sebastinelli et al6Sebastianelli L. Benois M. Vanbiervliet G. et al.Systematic endoscopy 5 years after sleeve gastrectomy results in a high rate of Barrett’s esophagus: results of a multicenter study.Obes Surg. 2019; 29: 1462-1469Crossref PubMed Scopus (108) Google Scholar further suggested this association in a multicenter series that included 90 consecutive patients undergoing esophagogastroduodenoscopy (EGD) 5 years after SG, 18% of whom were found to have BE. Furthermore, there are now 4 cases of esophageal adenocarcinoma (EAC) after sleeve gastrectomy in the literature.7El Khoury L. Benvenga R. Romero R. et al.Esophageal adenocarcinoma in Barrett's esophagus after sleeve gastrectomy: case report and literature review.Int J Surg Case Rep. 2018; 52: 132-136Crossref PubMed Scopus (23) Google Scholar Several mechanisms have been hypothesized to play a role in the increase of GERD after SG, involving anatomic changes as well as effects on motility. One anatomic change is the blunting of the angle of His, which serves as one of the barriers of the lower esophageal sphincter. Furthermore, by resecting the greater curvature of the stomach, there is reduced gastric compliance and volume, leading to an increase in intragastric pressures.8Mion F. Tolone S. Garros A. et al.High-resolution impedance manometry after sleeve gastrectomy: increased intragastric pressure and reflux are frequent events.Obes Surg. 2016; 26: 2449-2456Crossref PubMed Scopus (72) Google Scholar These anatomic changes also increase the risk of intrathoracic migration of the stomach, which can lead to progression or development of de novo hiatal hernias.9Runkel N. The gastric migration crisis in obesity surgery.Obes Surg. 2019; 29: 2301-2302Crossref PubMed Scopus (8) Google Scholar In addition to the anatomic changes, motility may also be altered. Disrupted autonomic connections may lead to reduced contractions and decreased gastric accommodation.10Coupaye M. Gorbatchef C. Calabrese D. et al.Gastroesophageal reflux after sleeve gastrectomy: a prospective mechanistic study.Obes Surg. 2018; 28: 838-845Crossref PubMed Scopus (26) Google Scholar Moreover, the increased afterload on the esophagus may trigger esophageal dysmotility, mimicking a pseudo-achalasia pattern.11Ravi K. Sweetser S. Katzka D.A. Pseudoachalasia secondary to bariatric surgery.Dis Esophagus. 2016; 29: 992-995Crossref PubMed Scopus (11) Google Scholar In this issue of Gastrointestinal Endoscopy, Qumseya et al12Qumseya B.J. Qumsiyeh Y. Ponniah S.A. et al.Barrett’s esophagus after sleeve gastrectomy: a systematic review and meta-analysis.Gastrointest Endosc. 2021; 93: 343-352Abstract Full Text Full Text PDF Scopus (16) Google Scholar set out to further assess the risk of BE after SG. The authors conducted a systematic review and meta-analysis, incorporating 10 studies and 680 patients. All patients had an EGD before SG, and at a minimum of 6 months postoperatively. Seven of the studies assessed patients after a minimum of 3 years. The pooled prevalence of BE was 11.4%. All cases of BE were de novo and nondysplastic. There was a linear relationship between time after SG and rate of esophagitis, with an increase of 13% each year. Similar to what has been reported in the general population, where the prevalence of BE has been found to be 5% to 15% in patients with GERD13Shaheen N.J. Richter J.E. Barrett's oesophagus.Lancet. 2009; 373: 850-861Abstract Full Text Full Text PDF PubMed Scopus (259) Google Scholar and up to 50% of patients with BE do not have GERD symptoms,14Rex D.K. Cummings O.W. Shaw M. et al.Screening for Barrett's esophagus in colonoscopy patients with and without heartburn.Gastroenterology. 2003; 125: 1670-1677Abstract Full Text Full Text PDF PubMed Scopus (395) Google Scholar this study did not find a statistically significant difference in the odds of having BE based on GERD symptoms. The pooled rate of BE in patients with and without GERD symptoms was only 18% and 10.3%, respectively. This study provides the most compelling evidence to date that SG may indeed lead to an increased risk of BE after SG. Because we are not even a decade out from a major increase in the incidence of SG procedures being performed, these ramifications may be even more consequential. With that said, is it time to recommend routine screening and surveillance for BE in patients after SG? Before making this recommendation, we must ensure that the benefits will outweigh the risks and costs to the health care system. Although BE is a risk factor for EAC, only a minority of patients with BE develop cancer; the annual risk is estimated at 0.1% to 0.5%.15Desai T.K. Krishnan K. Samala N. et al.The incidence of oesophageal adenocarcinoma in non-dysplastic Barrett's oesophagus: a meta-analysis.Gut. 2012; 61: 970-976Crossref PubMed Scopus (385) Google Scholar The biggest risk factor for EAC is the presence of dysplasia, and none of the cases of BE found in this study was dysplastic. Perhaps if we allow for longer follow-up, we will start to see evidence of dysplasia and EAC, but that begs this question: When is the right time to start screening after SG to have the most impact on cancer prevention? Should all patients be started on chemoprophylaxis with proton pump inhibitors to mitigate the risk? Moreover, further risk stratification based on an individual’s risk of developing BE and EAC could make a screening program more worthwhile. Perhaps there are other risk factors, such as age, sex, smoking status, obesity, that may be further propagating the patient’s risk of BE. By virtue of being a meta-analysis, the demographic data of the patients who developed BE are lacking. Future studies may be able to better delineate various risk factors to determine who would benefit most from screening and/or chemoprophylaxis. Although this study shows a risk of de novo BE, the risk of progression in patients with BE before SG remains unknown. In a survey of bariatric surgeons, the majority reported they would not perform SG on patients with known preoperative BE.16Gagner M. Hutchinson C. Rosenthal R. Fifth International Consensus Conference: current status of sleeve gastrectomy.Surg Obes Relat Dis. 2016; 12: 750-756Abstract Full Text Full Text PDF PubMed Scopus (159) Google Scholar What should be taken into account, however, is that obesity is itself a risk factor for both BE and progression to EAC,17Corley D.A. Kubo A. Levin T.R. Buffler P.A. et al.Abdominal obesity and body mass index as risk factors for Barrett's esophagus.Gastroenterology. 2007; 1331: 34-41Abstract Full Text Full Text PDF Scopus (282) Google Scholar and treatment with SG could provide these patients with protection against the metabolic and cardiovascular diseases associated with obesity, which are far more prevalent than dysplastic BE and EAC. An interesting question moving forward will be the implications of these findings on endoscopic sleeve gastroplasty (ESG). To date, there are no long-term data regarding the risk of BE after ESG. ESG may pose less risk because it does not involve the same degree of anatomic changes as SG, which are hypothesized to drive GERD, esophagitis, and BE. Although data about BE are unknown, a recent study by Fayad et al18Fayad L. Adam A. Schweitzer M. et al.Endoscopic sleeve gastroplasty versus laparoscopic sleeve gastrectomy: a case-matched study.Gastrointest Endosc. 2019; 894: 782-788Abstract Full Text Full Text PDF Scopus (67) Google Scholar found that new-onset GERD was significantly lower in the ESG group compared with the SG group (1.9% vs 14.5%, P < .05). Although additional data are needed, if ESG does not carry the same postoperative risks of BE as SG, this could further propel ESG into the mainstay of obesity treatment. In conclusion, Qumseya et al’s study12Qumseya B.J. Qumsiyeh Y. Ponniah S.A. et al.Barrett’s esophagus after sleeve gastrectomy: a systematic review and meta-analysis.Gastrointest Endosc. 2021; 93: 343-352Abstract Full Text Full Text PDF Scopus (16) Google Scholar adds to the mounting evidence that there is increased risk of BE after SG. Given the increasing popularity of SG as the treatment of choice for obesity, we may just be at the cusp of understanding the implications of this procedure. Thus, it will be helpful moving forward to better characterize the risk of the development of BE, and progression to dysplasia and cancer. In the meantime, based on the current data, this may be the time to initiate routine BE screening and surveillance after SG, especially in high-risk individuals. Dr Schulman is a consultant for and receives consulting fees from Apollo Endosurgery, Boston Scientific, and MicroTech, and receives research/grant support from GI Dynamics. Dr Platt disclosed no financial relationships. Barrett’s esophagus after sleeve gastrectomy: a systematic review and meta-analysisGastrointestinal EndoscopyVol. 93Issue 2PreviewSleeve gastrectomy (SG) has become significantly more common in recent years. Gastroesophageal reflux disease (GERD) is a major concern in patients undergoing SG and is the major risk factor for Barrett’s esophagus (BE). We aimed to assess the prevalence of BE in patients who had undergone SG. Full-Text PDF