Sleeve-Band Esophageal Cancer

Sleeve & Band:20-30% New Onset GERD

GERD =>Increased Risk of

Esophageal Cancer

Dr. Rutledge

Gastroesophageal reflux disease and sleeve gastrectomy

• USA

• Germany

• France

• Netherlands

• Many more...

Sleeve Gastrectomy Quickly Leads to New Onset GE Reflux & Weight Regain

• Analysis of conversion from SG to Roux-en-Y

• Time to Revision < 2 yrs

• 30% for "Severe Reflux"• Obes Surg. 2012 Sep 23. Results of Conversion from

Sleeve Gastrectomy to Roux-en-Y Gastric Bypass. Gautier T, Caen Cedex, France

Sleeve Revision for Weight Loss and Reflux

• 106 procedures for

• Insufficient weight loss or weight regain in 88 cases.

• *** Sixteen (15%) patients had severe gastroesophageal reflux

• Obes Facts. 2011, Failure of laparoscopic sleeve gastrectomy, Weiner RA Frankfurt, Germany.

Gastroesophageal reflux disease and sleeve gastrectomy USA

• Postoperatively, 49% complained of immediate (within 30 d) GERD symptoms,

• 47.2% had persistent GERD symptoms that lasted >1 month after LSG, and

• 33.8% of patients were taking medication specifically for GERD after LSG.

• Surg Obes Relat Dis. 2011 Gastroesophageal reflux disease and sleeve gastrectomy. Carter PR LaGrange, IL USA.


• The most common symptoms were heartburn (46%),

• followed by heartburn associated with regurgitation (29.2%).



• "LSG correlated with the persistence of GERD symptoms in patients with GERD preoperatively. "

• "Patients who did not have GERD preoperatively had an increased risk of postoperative GERD symptoms."


Revisional Surgery After Failed Sleeve Gastrectomy

• 416 pts 23 Revisions (5.5%) < 4 yrs

• For Reflux & Weight Loss Failure

• 23% complications• Obes Surg. 2012 Sep 22. Outcomes of Revisional

Surgery After Failed Sleeve Gastrectomy. van Rutte PW Eindhoven, The Netherlands.

Gastroesophageal reflux disease and sleeve gastrectomy

• Many studies designed to evaluate the outcome of reflux symptoms following conventional and surgical treatment of obesity.

• Among bariatric procedures, gastric sleeve and banded gastroplasty have been shown to worsen reflux symptoms in the postoperative setting.

• Curr Gastroenterol Rep. 2011 Jun, Obesity and GERD: pathophysiology and effect of bariatric surgery.Tutuian R. Bern, Switzerland.

Silastic® ring Sleeve Gastrectomy

• 33 SRSG Postop an increase in Erosive Esophagitis in the Silastic® ring Sleeve Gastrectomy group to 14 (45.2%)!!

• "After 1 year of follow-up, we observed a worsening evolution of Erosive Esophagitis in the SRSG group"

• Obes Surg. 2011 Feb Erosive esophagitis after bariatric surgery Miguel GP Vitória, ES, Brazil.

A Question

• We Know Esophageal Cancer Dangerous Deadly and Rising Rapidly

• We Know That Acid Reflux (GERD) Is a Strong Causative Factor in Esophageal Ca

• Numerous Studies Including the Sleeve Consensus Conference Show That Band and Sleeve Cause 20-30% New Onset GE Reflux

• Are The Sleeve And Band Pre-cancerous Lesions In Up To 1/4 Of Patients?

Imagine; Your Post Op Sleeve or Band Patient

• Post Op Patient Visit"

• "Dr. I found out the operation that you performed on me may cause cancer, esophageal cancer. You did not tell me this."

• Your answer?

• Do we need to warn our patients?

Sleeve & Band,

30% New Onset GE Reflux (2yr FU),

GE Reflux is a Major Risk Factor Esophageal Cancer

IFSO Varianational Committee Survey

Over 100 Surgeons from Around the World:

1. GE Reflux => Esophageal Cancer

Survey 120 Bariatric Surgeons

"GERD Increases Risk of Cancer of Esophagus. Longer GERD = More

Risk."

AGREE 100%

65. GERD Increases Risk of Cancer of Esophagus. Longer GERD = More

Risk.

• GERD can cause Barrett's = even higher risk, from the American Cancer Society.

• JAMA. 2002 Gastroesophageal reflux, barrett esophagus, and esophageal cancer: scientific review. Shaheen N,

• Survey 102 Surgeons 100% Agreement

• 66. Treating or Avoiding GERD may protect & prevent Barrett's & Esophageal cancer.

• 100% of Expert Bariatric Surgeons Agreed

Numerous Studies Now Show that the Band and the Sleeve can increase acid

reflux and be associated with Barretts & Esophageal Caner.

• Dis Esophagus. 2011 Jan;24(1):E8-10. Esophageal adenocarcinoma after laparoscopic gastric band placement for obesity Stauffer JA, Mathew J, Odell JA, Department of General Surgery, Mayo Clinic, Jacksonville, Florida, USA.

• Ann Surg. 2010 Aug;252(2):319-24. Long-term results of laparoscopic sleeve gastrectomy for obesity. Himpens J, Division of Bariatric Surgery, AZ St-Blasius, Kroonveldlaan, Dendermonde, Belgium.

• Obes Facts. 2011;4 Suppl 1:42-6. Epub 2011 Apr 4. Failure of laparoscopic sleeve gastrectomy--further procedure? Weiner RA, Theodoridou S, Weiner S. Department of Surgery, Krankenhaus Sachsenhausen, Frankfurt/M, Germany. [email protected]

• Surg Obes Relat Dis. 2011 Nov-Dec;7(6):709-13. Epub 2011 Aug 16. Gastroesophageal reflux after sleeve gastrectomy in morbidly obese patients. Howard DD, Caban AM, Cendan JC, Ben-David K. Department of Surgery, Minimally Invasive, Gastroesophageal and Bariatric Surgery Service, University of Florida, Gainesville, Florida 32610, USA.

• Obes Surg. 2010 Feb;20(2):244-6. Epub 2009 Dec 8, Barrett's esophagus: a late complication of laparoscopic adjustable gastric banding, Varela JE., Minimally Invasive and Bariatric Surgery, Washington University, 660 South Euclid, Box 8109, St Louis, MO 63110, USA. [email protected]

2. Band and Sleeve => 30% GE Reflux

"Sleeve gastrectomy produces an important decrease in LES pressure, which can cause reflux symptoms and esophagitis"

Obes Surg. 2010 Mar;20(3):357-62. Epub 2009 Dec 15.Manometric changes of the lower esophageal sphincter after sleevegastrectomy in obese patients.Braghetto I,

Gastroesophageal reflux after sleeve

• All patients had a pre- and postop swallow

•18% New-onset GERD on UGI • GERD score questionnaire, •22% New-onset GERD

symptoms • In spite receiving daily Anti-Acid Rx

• Surg Obes Relat Dis. 2011 Gastroesophageal reflux after sleeve gastrectomy in morbidly obese patients. Howard DD, University of Florida, Gainesville, Florida 32610, USA

0%

5%

10%

15%

20%

25%

30%

35%

Band Sleeve RNY MGB

Dyspepsia %

31%

22%

5%

6%

0%

20%

40%

60%

80%

100%

Band Sleeve RNY MG/OA

GE Reflux / Nausea & Vomiting is Common

93%

70%

7%

4%

Pe

rcen

t (%

)

0%

5%

10%

15%

20%

Band Sleeve RNY MGB

Pre op GE Reflux rate (%)

10%

11%

17%

19%

0%

5%

10%

15%

20%

25%

30%

Band Sleeve RNY MGB

Postop GE Reflux rate (%)

24%

27%

6%

4%

Risk of Esophageal Cancer?

Band & Sleeve

Esophageal carcinoma after band & sleeve

• Esophageal carcinoma after sleeve gastrectomy. Scheepers AF, Schoon EJ, Nienhuijs SW. Surg Obes Relat

Dis. 2011 Jul-Aug;

• Esophageal adenocarcinoma after laparoscopic gastric band placement for obesity. Stauffer JA, Mathew J, Odell JA. Dis Esophagus. 2011 Jan;

• Adenocarcinoma of the lower esophagus after placement of a gastric band. Korswagen LA, Schrama JG, Bruins Slot W, Hunfeld

MA. Obes Surg. 2009 Mar;

1. Esophageal Cancer Rapidly Rising in USA and Around the World

2. Acid Reflux is one of the leading preventable causes of Esophageal

Cancer

3. Band Sleeve => 30% New Onset Acid GE Reflux, Increased Risk of

Esophageal Cancer4. Surgeons Should Warn Their

Patients: Risk of Esophageal Cancer after Band Sleeve

5. Sleeve and Band Patients Need Lifetime monitoring for new onset

symptomatic and asymptomatic GE Reflux

Best Practices

• What happens,• When your sleeve patients find

that• They may be at increased risk for

Esophageal Cancer• Their surgeons could or should

have known about it • But Did Not Warn Them?

Education

Sleeve-Band Esophageal Cancer