Roux-en-Y Gastric Bypass as a Treatment for Barrett’s Esophagus after Sleeve Gastrectomy

The follow-up of this study was 33.4 ± 21.1 months with a minimal follow-up period of 6 months after the conversion to RYGB.

Patients were recruited via the Austrian Society for Bariatric and Metabolic Surgery, sending out a call to all Austrian hospitals offering bariatric surgery. Participants were then invited to the Medical University of Vienna for interviews, gastroscopy, 24 h pH-metry, and manometry.

The number of patients in this retrospective survey with prospective examinations is limited by the sum of conversions from SG to RYGB due to BE in Austria. Descriptive statistics was used in this study as it is based on quite a small patient collective. Data are presented within the median and range, by mean and standard deviation, or as percentages (where appropriate). %EWL was calculated based on an ideal BMI of 25 kg/m². Statistical calculations were performed using SPSS® v24 for Windows®.

This study’s participants had at least 3 gastroscopies at the following stages: before and after SG and after RYGB, the last one as part of the examinations done specifically for this study.

Gastroscopies done before SG did not reveal any abnormalities (i.e., no hiatal hernias, esophagitis, BE, helicobacter pylori, active gastritis, or ulcera were found).

The gastroscopies after SG were performed due to symptomatic reflux in all patients. Two (20.0%) had hiatal hernias, 8 (80.0%) had esophagitis, and BE was found in all 10 patients. Eight patients had short-segment Barrett’s and 2 were found to have long-segment Barrett’s. One patient had small areas of low-grade dysplasia (in the short-segment group). None of the patients was found to be helicobacter pylori positive.

The gastrocopies after RYGB as part of the present study were performed at our center according to the Seattle protocol (4 quadrant biopsies are taken at every cm with additional biopsies taken from areas of mucosal abnormalities). The gastroscopies revealed hiatal hernia in 0 and esophagitis in 2 patients (20.0%). Interestingly, BE was found in only 2 patients (20.0%), a short- and a long-segment one. The patient who had small areas of dysplasia before RYGB was not found to have BE any more, either (Table 2). The Prague classification for each patient may be found in Table 3.

The excluded patient with gastric banding before SG was converted to RYGB with hiatoplasty and had full remission of short-segment BE.

Five patients (45.5%) had a manometry and 24 h pH-metry before being converted to RYGB. Nine participants (81.8%) had both examinations after their conversion, specifically done for the purpose of this study.

The 24 h pH-metry results, however, improved considerably after the conversion to RYGB. Patients’ acid exposure time in 24 h was 36.8 ± 21.6% before and 3.8 ± 4.6 after the procedure on average (p value 0.004). The number of refluxes was a mean 162 ± 113 before and 49 ± 35 after RYGB (p value 0.04) and the DeMeester score was significantly lower after RYGB (before 110 ± 51.1; after 16.3 ± 14.2; p value 0.005) (Table 4).

Patients were asked to complete the Bariatric Outcome Score (BAROS) and the Gastro-Intestinal Quality of Life Index (GIQLI) during the course of the examinations performed after the conversion to RYGB. In total, the scores were completed by 8 (80.0%) participants. They scored 5.1 ± 2.1 on average in the BAROS, which denotes a very good outcome. An average of 113.5 ± 22.1 points was scored in the GIQLI, equaling a normal outcome (Table 1).

A few mid- and long-term SG studies report the occurrence of BE found in gastroscopy. Braghetto et al. included 231 SG patients in their study, 66 of them had a follow-up of over 5 years and BE was found in 2 cases (3%) [18]. Felsenreich et al. detected BE in 6 (14%) of their 44 SG patients who had gastroscopy after 11 years. None of them had reflux preoperatively. It should be noted here that none of these 6 patients was included in the present study as they chose close monitoring at regular intervals via gastroscopy over a conversion [6]. In a study of 110 SG patients who had gastroscopies after 58 months, Genco et al. found BE in 19 patients (17%). While 33.6% had symptomatic reflux preoperatively, none of their patients had BE before SG [5]. In an update of this study, Soricelli et al. included 144 SG patients and found BE in 19 (13%) cases via gastroscopy. Interestingly, 4 patients had developed BE without any reflux symptoms and the authors conclude that symptom detection only is not reliable in BE diagnosis. They recommend more objective testing such as gastroscopy instead [19]. In a multi-center study by Sebastianelli et al., 90 patients had gastroscopies 78 months after SG and BE was found in 17 cases (19%). Nineteen patients were suffering from preoperative symptomatic reflux. The authors report weight loss failure to have been significantly linked to BE and suggest providing systematic endoscopy in SG patients [7]. A very early occurrence of BE was found in the present study as well, with BE diagnosed after a mean 40.1 months after SG. One may thus consider performing regular gastroscopies 3 to 5 years postoperatively to detect an early appearance of BE in time. Finally, a meta-analysis on reflux and BE after SG has shown an occurrence of BE in 6% (8% in studies > 24 months follow-up) of SG patients [20]. One should add that Barrett’s metaplasia can be found in only 1.6% of the average population [21].

Esophageal adenocarcinoma after SG has been reported in a small number of cases [22, 23]. For instance, El Khoury et al. published a case report of esophageal adenocarcinoma in BE found even 3 years after SG [24]. It should be added here that the annual cancer transition rates for long- and short-segment BE to esophageal adenocarcinoma are only 0.22% and 0.03% [25]. This may seem very low indeed; however, the lifelong cancer risk is of course much higher, especially when talking about relatively young bariatric patients. A large English population-based cohort study by Markar et al. has shown that the absolute reduction in the risk of esophageal cancer in reflux patients who had antireflux surgery is relatively small, which is why the authors conclude that antireflux surgery remains a means of symptom relief. Thus, the need for ongoing surveillance of these patients should be stressed [26].

As the results of the studies mentioned above suggest, BE seems to be an issue occurring years after SG. One might assume that with an increasing number of long-term studies of SG being published, the number of BE cases reported after the procedure may rise as well. Hence, BE is certainly a problem to be addressed in the near future. Another point of discussion has been the question whether BE should be treated as a contraindication to SG, which has not yet been concluded [27].

There is a limited number of studies on the outcome of RYGB as a treatment for BE with small patient collectives available today. Patients in these studies did not have SG before RYGB.

First, Gorodner et al. included 11 patients with BE (9 short-segment and 2 long-segment BE) before the RYGB operation in their study with a mean follow-up of 41 months. Four patients (36%) had BE remission; none of the participants showed any signs of progression to dysplasia [15]. Second, in a study of 14 patients with RYGB for BE (5 also had hiatal hernia repair), Andrew et al. found remission of BE in 6 (43%) of them after a minimum follow-up of 1 year [14]. In their review article, Kindel and Oleynikov [28] recommended RYGB for patients with BE based on its superiority in reflux control (acid and non-acid events) compared with other bariatric procedures. Braghetto and Csendes come to a similar conclusion, being that RYGB is the procedure of choice for BE patients [29].

Finally, there are a couple of more dated reports of RYGB in patients with BE. Csendes et al. were the first to describe remission of BE after RYGB and presented a remission rate of 57% (4 out of 7) in patients with short-segment BE and 20% (1 out of 5) in patients with long-segment BE in 2002 [30]. Cobey published a case study of one patient who had gone into BE remission after RYGB in 2005 [31]. Houghton et al. presented a study on 5 patients with long-segment BE and a mean follow-up of 34 months. The authors reported full remission in 2 patients. Three patients also had dysplasia, 2 of whom were free of dysplasia after RYGB [32].

By comparison, the remission rate reported in the current study was slightly higher (80.0%, refer to Table 2). The reason for this might be that the period of time patients had BE was relatively short as it was not diagnosed at the time of their SG surgery. One may speculate that the chances of BE remission are higher the shorter the duration of time a patient suffers from it. Besides, the present study has shown that a conversion to RYGB caused a fair amount of additional weight loss.

One of the present study’s additional strengths is certainly that it is not only based on information gained from gastroscopies but also from 24 h pH-metry, which revealed a decrease in reflux activity and lower DeMeester score after the conversion to RYGB. However, these results may not last: Holmberg et al. found that reflux may remain or recur after RYGB as 50% of their patients are suffering from reflux 10 years after the procedure and maintain antireflux medication [13].

A final point can be made here on the improvement of SG patients’ quality of life after RYGB as treatment for BE. Comparing the BAROS and GIQLI scores of the current study’s collective with those of patients suffering from reflux after SG in a study published earlier, a distinct improvement may be noted: 1.6 and 104.6 [6] vs. 5.1 and 113.5 in the current study.

A systematic review by Musella et al. has shown that esophageal cancer after primary RYGB and SG is rare (0.02% or 8 out of 42,508 after RYGB and 0.003% or 1 out of 39,137 after SG) [33]. Also, Maret-Ouda et al. in a register-based cohort study found no evidence that bariatric surgery (74% of patients had RYGB) may lower the risk of esophageal adenocarcinoma [34].

There is a risk to miss remnant gastric cancer in primary RYGB patients as the remnant cannot be visualized during classic gastroscopy. Tornese et al. collected 17 cases of remnant gastric cancer after primary RYGB, which is of course irrelevant for SG patients converted to RYGB as this part of the stomach is resected during SG [35].

According to the AGA guidelines, patients with BE should have surveillance gastroscopies every 3 to 5 years at least [17]. Even shorter intervals may be advisable as the progression of BE after SG might be faster or more aggressive than BE in non-SG patients [36]. In any case, patients suffering from both reflux and BE should have symptomatic reflux therapy using PPI [17].

For patients with low- or high-grade dysplasia in BE, there are different endoscopic methods of therapy available, which may be selected individually. These are ablative therapy (e.g., radio-frequency ablation, photodynamic therapy, cryo-ablation, argon-plasma treatment) or resective therapy (such as endoscopic mucosal resection, endoscopic submucosal dissection) [37].