Recently, your journal published an interesting case report by V. Lucas et al.1 on the appearance of Barrett’s esophagus (BE) in a patient 8 years after sleeve gastrectomy (SG). This patient presented high-grade dysplasia on a lesion <1 cm and was successfully treated endoscopically. This is where the controversy appears: the authors state that a gastric bypass was also performed.
As described in the letter, in recent years there has been a significant concern regarding the appearance of de novo gastroesophageal reflux, esophagitis and BE, with or without symptoms of gastroesophageal reflux disease (GERD), in patients after SG.2–4 Reports of adenocarcinoma (ADC) of the esophagus in several cases within a few years of SG further added to the controversy.5,6 This undoubtedly raises concern among surgeons treating obesity and esophageal cancer, given that SG is the most widely used bariatric technique. The IFSO has already determined the optimal endoscopic follow-up after SG,7 but the question that remains (which they also leave open in the publication) is what to do with post-SG BE.
Regarding the patient who underwent the gastric bypass: what was her BMI? Did she report heartburn or frequent vomiting? Did she take medication for GERD?
I believe that all these data are important when making the decision to reoperate any patient with another surgery that is not without risks. This was already stated in 2020 by M. Guingand et al. in an interesting Letter to the Editor.8 These authors proposed performing endoscopic antireflux mucosectomy (ARMS) instead of gastric bypass and presented a case with good results.
As a surgeon, and perhaps at odds with gastroenterologists,9 I think that a patient with BE will benefit more from an antireflux operation than from chronic treatment with proton pump inhibitors (PPI), which only limits acid reflux and not bile reflux. However, a gastric bypass does not have the same morbidity as laparoscopic fundoplication.
What to do with an asymptomatic young woman with BMI <30 kg/m2 after SG with a diagnosis years later of short-segment BE without dysplasia?
In the first case (and the reason for this letter), I agree that gastric bypass could be the best option due to the appearance of high-grade dysplasia on BE, although endoscopic treatment was effective and other important data are lacking that would help make the decision. However, in the last proposed case, I would be more inclined towards medical treatment of GERD and endoscopic follow-up, in accordance with international guidelines.9,10
Please cite this article as: de Tomás J. Reconversión a bypass gástrico en pacientes con esófago de Barrett tras una gastrectomía vertical. Cir Esp. 2021;99:397–398.
