Abstract:
In selected patients with severe obesity, bariatric surgery is associated with more durable and significant weight loss, and improvements in blood pressure and glycemic control compared to non-surgical weight loss methods (1). Gastric bypass (GB) and sleeve gastrectomy (SG) is the most common bariatric surgical procedures, with similar mid-term weight loss and control of metabolic comorbidities (2,3). Nevertheless, there are specific conditions in which one surgical approach is preferred for patients who needs bariatric surgery. For instance, among patients with large hiatal hernias, severe gastroesophageal reflux, severe esophagitis (grades C&D) and Barret’ esophagus, Roux-en-Y gastric bypass(RYGB) is the best choice (4). A notable feature in GB, both with RYGB or one anastomosis gastric bypass (OAGB), is that the bypassed segment of the stomach and small intestine are kept in place, in contrast to SG where part of the stomach is resected. Notably, the bypassed segments (the gastric remnant) cannot be accessed with routine esophagogastrodudenoscopy (EGD). This limitation is particularly important among patients with existing pre-cancerous lesions—such as intestinal metaplasia or dysplasia—in the gastric remnant since surveillance of such lesions cannot be performed. Although the incidence of gastric cancer in the gastric remnant is rare (5), the estimated incidence of gastric intestinal metaplasia is relatively high with an increasing trend in Asia; therefore, clinicians should be aware of the possibility of gastric cancer and take the necessary steps to minimize its risk. Crucially, patients with a higher risk for the development of gastric cancer should be identified before bariatric surgery and the decision for selecting GB versus SG should be made concerning this risk. Herein, we propose performing gastric biopsy mapping according to the updated Sydney system (6), in addition to routine EGD (4), in candidates for bariatric surgery, especially in patients at higher risk for gastric cancer. This hypothesis should be first tested among candidates of GB with a strong family history of familial gastric cancer, older individuals, patients with multiple risk factors and those from ethnicities and geographies with a higher prevalence of gastric cancer (4,7). While studies are needed to test the feasibility and effectiveness of this proposed approach, clinicians should remain vigilant and be mindful of this important limitation posed by GB in the select group of patients undergoing bariatric surgery.
Audience Take Away:
- Attention to pre-cancerous lesion before bariatric surgery
- These days gastric atrophy (GA) and Intestinal metaplasia (GIM) is increasing so perform gastric biopsy mapping before bariatric surgery is recommended specially in high risk patient and the type of surgery should be chosen based on the biopsy results.
