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Obesity Surgery (2018) 28:1441–1444


One Anastomosis Gastric Bypass and Risk of Cancer

Ahmed Guirat 1,2 & Hassan Majed Addossari

Published online: 8 March 2018

# Springer Science+Business Media, LLC, part of Springer Nature 2018

The one anastomosis gastric bypass (OAGB) is a recent procedure, which still raises controversies concerning its presumed role
in the genesis of biliary reflux and the risk of developing esophageal or gastric cancer. A review of the literature in order to have
evidence in favor of or against the risk of cancer after OAGB. We have conducted a review of the English literature using the
MEDLINE database. The theoretical risk of asymptomatic chronic biliary reflux after OAGB exists and may be responsible for
gastroesophageal cancer. It is justified to indicate OAGB for patients over 50 years of age. Otherwise, it is reasonable to indicate
endoscopic gastroesophageal examination periodically after OAGB in all patients in order to screen asymptomatic biliary reflux.

Keywords One anastomosis gastric bypass . Biliary reflux . Cancer

Introduction a risk of cancer? To get an answer, we conducted a review of

the literature to study the relationship between OAGB and
Bariatric surgery is the most effective treatment of morbid chronic biliary reflux and the risk of gastroesophageal cancer.
obesity [1]. Over the past two decades, several bariatric surgi-
cal techniques have emerged. In 1997, Rutledge began prac-
ticing one anastomosis gastric bypass (OAGB) (named previ-
ously mini gastric bypass) with the aim of having an alterna-
tive to the Roux-Y bypass. According to him, it is simpler and
We conducted a review of the English language literature using
efficient on weight loss and resolution of the obesity comor-
the MEDLINE database by basing the search on the following
bidities. The OAGB is a procedure using a long narrow gastric
keywords: Bone-anastomosis gastric bypass^ AND Bbiliary
tube and a single gastrojejunal anastomosis (performed be-
reflux,^ Bsingle anastomosis bypass^ AND Bbiliary reflux,^
tween 150 and 250 cm of the Treitz ligament). The results of
Bmini gastric bypass^ AND Bbiliary reflux,^ Bsingle anastomo-
the Rutledge series published in 2001 were very promising [2]
sis gastric bypass^ AND Bcancer,^ Bone-anastomosis bypass^
with positive effect in terms of weight loss and improvement
and Bcancer,^ Bmini gastric bypass^ AND Bcancer.^
of obesity-related comorbidities. Since then, several teams
have used this technique, whereas others had concerns about
the OAGB’s association with the Bold^ loop gastric bypass
and the alimentary limb reconstruction, which usually recalls OAGB and Symptomatic Biliary Reflux
the Billroth II reconstruction and could potentially increase
biliary reflux. Indeed, until now, the OAGB still raises con- In the literature, the definition of chronic biliary reflux after
troversies regarding the risk of gastroesophageal cancer sec- OAGB is unclear. According to Kular et al. [3], biliary reflux
ondary to the chronic biliary reflux. So, does the OAGB carry after bariatric surgery was defined as bilious and/or document-
ed bile in the esophagus on upper gastrointestinal (UGI) en-
doscopy with the presence of gastroesophageal reflux disease
* Ahmed Guirat (GERD)-like symptoms. The biliary reflux after OAGB prompted surgeons to lengthen the gastric tube and keep the
afferent loop higher than the efferent to avoid the risk of
Armed Forces Hospital, P.O. Box 228, Wadi Al Dawasir, Al esophagitis [4].
Riyadh 11991, Saudi Arabia After OAGB, some symptoms are typically suggestive of
Faculty of Medicine, University of Sfax, Sfax, Tunisia biliary reflux such as bilious vomiting and/or regurgitations
1442 OBES SURG (2018) 28:1441–1444

and nocturnal heartburn. Other symptoms are non-specific OAGB and Cancer
such as epigastric pain, nausea, belching, abdominal bloating,
nasopharyngeal and/or pulmonary signs… All of these symp- In a literature review published in 2013, Scozzari et al. [13]
toms should require UGI endoscopy to look for gastritis and/ reported 33 cases of gastroesophageal cancers after bariatric sur-
or esophagitis with evidence of bile in the gastric tube and/or gery. Among them, four cases of gastric cancers were reported
esophagus. In case of persistent doubt, impedancemetry [5] after surgery using the Bloop gastric bypass^ technique,
and hepato-biliary scintigraphy [6] are two very sensitive and Bancestor^ of the OAGB [14]. Three cases were carcinoma of
specific tests to confirm the diagnosis. the excluded stomach and one case was a gastric stump carcino-
The incidence of symptomatic biliary reflux is low and ma (GSC) which occurred 26 years after surgery. After OAGB,
does not exceed 2% in the largest series with a medium-term only one case of gastric cancer has been published in the litera-
follow-up (Table 1). This is an acceptable rate but it is consid- ture [15] and developed on the remnant stomach, occurring
ered by some to be underestimated given the number of cases 9 years after surgery in a 41-year-old woman operated on
of asymptomatic biliary reflux and the lack of longer-term in 2003. The HP profile has not been specified.
follow-up. In cases of refractory biliary reflux, it is reasonable Many hypotheses have been made in favor of or against the
to convert the procedure into BBraun jejunojejunostomy^ or risk of degeneration after OAGB. Many surgeons are con-
better into BRoux-en-Y gastric bypass.^ The conversion is vinced about the risk of degeneration after OAGB, because:
generally simple and safe.
– First: It has been demonstrated that bilio-pancreatic reflux
is directly responsible for esophageal adenocarcinoma in
the animal model [16].
OAGB and Asymptomatic Biliary Reflux – Second: According to some authors, excessive biliary re-
flux can lead to intestinal metaplasia, Barrett’s esophagus,
Asymptomatic biliary reflux after OAGB is theoretically pos- and gastric/esophageal cancer in humans [17, 18].
sible but difficult to document. Only one study detected this – Third: One randomized prospective study (non-bariatric),
reflux postoperatively after OAGB. Tolone et al. [12] studied comparing the BBillroth II^ technique to the Roux-en-Y
the effect of this procedure on the gastroesophageal junction on technique in 75 patients having antrectomy with selective
15 patients by clinical examination, UGI endoscopy, manome- bivagotomy [19], found a significant increase in intestinal
try, and impedancemetry before and 1 year after OAGB. No metaplasia (24 versus 3%, P < 0.0001) and chronic atro-
patient developed postoperative reflux symptoms. Endoscopy phic gastritis (39 versus 10%, P < 0.008) after Billroth II
revealed neither gastritis nor esophagitis. No pathological bili- compared with the Roux-en-Y reconstruction after a
ary reflux was observed. However, it is a series with a low mean follow-up of 15 years.
number of cases and short follow-up (12 months). Thus, no
conclusion can be reached and it seems reasonable to perform Conversely, many authors are convinced that there is no
periodically an endoscopic control after OAGB, even in the causal link between OAGB and cancer [4, 8], and are based
absence of symptoms of biliary reflux. Endoscopy should be on these arguments:
indicated periodically (every 2 to 3 years) in all patients to
screen asymptomatic biliary reflux. If confirmed, it is indicated – First: The implication of other factors in the genesis of
to convert the OAGB into Braun jejunojejunostomy or better gastric cancer (food habits, tobacco, Helicobacter pylori
into Roux-en-Y gastric bypass. infection) [20].

Table 1 Frequency of
symptomatic biliary reflux after Author Year Mean follow-up Case number Percentage of biliary reflux (%)
one anastomosis gastric bypass in (months)
the largest series
Rutledge [2] 2001 24 1240 0.6
Lee et al. [7] 2012 67 1163 0.3
Noun et al. [8] 2012 60 1000 0.4
Musella et al. [9] 2014 6 to 60 974 0.9
Kular et al. [3] 2014 72 1054 2
Chevalier [4] 2015 31 1000 0.7
Jammu and Sharma [10] 2016 53.5 473 0.4
Carbajo et al. [11] 2017 72 to 132 1200 2
OBES SURG (2018) 28:1441–1444 1443

– Second: The reported cases of cancer occurring on the in all patients after OAGB, to screen for asymptomatic biliary
remnant stomach after RYGB (14 cases) and vertical- reflux and thus to convert the procedure before the occurrence
banded gastroplasty (n = 9) [13, 21]. of intestinal metaplasia and/or Barrett’s esophagus.
– Third: No published cases of esophagus cancer or on the
remnant stomach after OAGB since 1997. Compliance with Ethical Standards
– Fourth: The results of the study by Bassily et al. [22] who
did not show a significant risk of gastric or/and esopha- Conflict of Interest The authors declare that they have no conflict of
geal cancer in 569 patients who had antrectomy for a
peptic ulcer and gastrojejunal anastomosis of the
Informed Consent Informed consent was obtained from all individual
Billroth II type (assembly similar to OAGB) between participants included in the study.
1957 and 1976 and after a mean follow-up of 17 years.
Human and Animal Rights This article does not contain any studies
However, when analyzing these results, we should be with human participants or animals performed by any of the authors.
aware about an important limitation regarding that the authors
focused only on the total number of the esophagogastric can-
cers and not their incidence. We should also take in consider-
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