Background

Incidence of gastroesophageal reflux (GER) after sleeve gastrectomy (SG) is a concern considering the popularity of this procedure, lack of long-term data and theoretical risk of esophageal cancer development. Gastric bypass is considered the best therapeutic option for persisting reflux after SG. However up to 30% of patients suffer from post-operative GER. We present the case of a 44 year-old women with a BMI of 40, type 2 diabetes and past history of smoking. Pre-op gastroscopy showed a 2 cm hiatal hernia, without oesophagitis or Barrett’s oesophagus. In January 2015 she underwent SG and hiatal hernia repair. Her 2 years post SG %EBWL was 47.2% (BMI 32). Post-op SG barium study confirmed mild-to-severe reflux.

Methods

Conversion to Roux-Y-gastric bypass with hiatal hernia repair was performed in February 2017. PPI therapy was continued postoperatively due to GER persistence. Two years post RYGB BMI is 28.8 (%EBWL 71.4). Finally, an incidental oesophageal adenocarcinoma was diagnosed endoscopically during an EGD performed for persistent GER symptoms in February 2019. EUS was compatible with mucosal disease and the CT and PET-CT were negative for metastatic disease. She underwent an uneventful endoscopic resection (EMR) with negative margins and the final report showed a 8mm well-differentiated adenocarcinoma (T1a) without lymphovascular invasion. She is currently followed with serial endoscopic follow-up every 3 months.

Conclusions

Persistent GER after bariatric surgery may increase the risk for esophageal adenocarcinoma even in the absence of Barrett’s esophagus. It remains to be determined what endoscopic follow-up is warranted in this high risk group.