Journal of Surgery and Transplantation Science

From Bariatric to Oncological Surgery: The Role of Routine Preoperative Upper Endoscopy in Bariatric Surgery

Case Series | Open Access Volume 4 | Issue 3 |

  • 1. Department of Surgery, Clínica Universidad de Navarra, Spain
  • 2. CIBER Fisiopatología de la Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, Spain
  • 3. Metabolic Research Laboratory, Clínica Universidad de Navarra, Spain
  • 4. Obesity and Adipobiology Group, Instituto de Investigación Sanitaria de Navarra, Spain
  • 5. Department of Anesthesiology, Clínica Universidad de Navarra, Spain
  • 6. Department of Internal Medicine, Clínica Universidad de Navarra, Spain
  • 7. TRUEHF, Instituto de Investigación Sanitaria de Navarra, Spain
  • 8. Department of Endocrinology, Clínica Universidad de Navarra, Spain
+ Show More - Show Less
Corresponding Authors
Victor Valenti, Department of Surgery, Bariatric and Metabolic Surgery, Clínica Universidad de Navarra Avenida Pío XII, 36, 31008 Pamplona, Navarra, Spain

Background: Routine preoperative upper gastrointestinal endoscopy (UGE) for bariatric surgery is still controversial. The optimal assessment for upper gastrointestinal tract in bariatric patients is not well defined although the prevalence of clinically relevant lesions found on the UGI is described in some observational studies.

Methods: The present study highlights the clinical usefulness of preoperative UGE based on two real cases taking place in our practice.

Results: Preoperative routine UGE prior to laparoscopic revisional surgery and gastric bypass surgery, showed adenocarcinoma in asymptomatic patients changing the initial surgical bariatric approach to an Oncological surgery.

Conclusions: Preoperative routine UGE for bariatric surgery has a high diagnostic significance and low cost in relation to its effectiveness. Since, findings with this conventional exploration allow changes in the therapeutic strategy and also provide an adjustable treatment to every patient, preoperative routine UGE should be recommended.


Valenti V, Tuero C, Ahechu P, Cienfuegos JA, Moncada R, et al. (2016) From Bariatric to Oncological Surgery: The Role of Routine Preoperative Upper Endoscopy in Bariatric Surgery. J Surg Transplant Sci 4(3): 1030.


•    Bariatric surgery
•    Upper endoscopy
•    Gastric cancer


UGE: Upper Gastrointestinal Endoscopy


The rising prevalence of obesity and the success of bariatric surgery in durable and significant weight loss, have increased the number of surgeries performed in recent years [1]. Despite substantial improvements in bariatric surgery, there are a number of comorbid conditions and preoperative findings that require prior optimization to obtain the best surgical outcomes. Most guidelines for preoperative assessment, recommend UGE when the patient refers reflux symptoms, dysphasia and/or dyspepsia in the anamnesis [2,3]; otherwise there is evidence that UGE in patients without symptoms can identify lesions that potentially can modify surgical management. Contrast studies have been posted as an alternative to an UGE because they may provide complementary information [3]. Nevertheless, when small tumors are developing in initial stages, contrast studies are limited to identify these early tumors. It is in these particular cases when more accurate preoperative diagnosis needs to be done in order to identify potentially curable diseases at early stages. The present study highlights the clinical usefulness of preoperative UGE based on two real cases taking place in our practice


Case 1

A 62-year-old lady with BMI 44 kg/m2 and 120 kg weight with hypertension and joint pain was operated in 2001 in our University Hospital performing a laparoscopic lap band. Two years after the operation, the patient had a BMI of 34 kg/m2 and a 22 kg weight loss. Ten years after the last follow up visit in our unit, the patient came back complaining of nausea and vomiting during two months with occasional regurgitation and dysphasia for solids, we also advertised weight regain and a BMI of 39 kg/ m2 .

Her analytics were normal including blood, renal and hepatic tests, glycemia and cholesterolemia. The contrast swallow study showed a pouch enlargement with band slippage and partial obstruction of the stomach (Figure 1). Band deflation was impossible to perform due to port-site infection and port breakage. Prior to laparoscopic revision surgery for band removal, we consider possible division of the band trough endoscopy, however findings after preoperative work-up for bariatric surgery with routine UGE, showed partial rejection of the band into the gastric body and the presence of a bulky tumor above the band infiltrating the distal esophagus which made not possible this initial not surgical approach (Figure 2). A biopsy was taken and the histological exam showed a well differentiated adenocarcinoma. A thoracic-abdominal CT scan was done discarding metastatic disease and infiltration of surrounding structures or carcinomatosis (Figure 3). An Ivory Lewis esophago-gastrectomy was performed without postoperative complications. Examination of the surgical specimen showed a T3N1 gastric neoplasia with tumor-free margin resection (Figure 4).

Case 2

A 57 years old man consulted the colorectal surgery unit of our hospital for recurrent episodes of diverticulitis. His medical history showed grade II obesity associated with metabolic syndrome and obstructive sleep apnea. Multiple failure attempts of weight loss with several diets and subsequent weight regain had been documented. The initial weight was 114 kg and his BMI 41 kg/m2 . The patient was transferred to our bariatric surgery unit for possible evaluation of laparoscopic gastric bypass. The preoperative routine UGE showed a lesion in the incisura angular is, 1.5 cm in diameter, with well- defined edges, and a shallow central ulceration, suggesting early gastric carcinoma (Figure 5).

A biopsy was taken and the histological studies showed a welldifferentiated adenocarcinoma. An abdominal CT scan was done to complete tumor stage stadification. No metastatic disease was found. Laparoscopic subtotal gastrectomy with Roux-en-Y reconstruction was performed with an alimentary limb of 150 cm as a technical option to intend both an Oncological solution and a lasting weight-loss effect. The surgical specimen confirmed a well differentiated early adenocarcinoma affecting the lamina propria and free lymph nodes of 28 resected.


Association between cancer and obesity has been widely shown in large epidemiologic series [4,5]. Adenocarcinoma has been described in the gastric pouch after vertical banded gastroplasty and gastric banding and in the bypassed stomach after Roux- en-Y gastric bypass (RYGBP) [6-8]. Because of this possible association between cancer and obesity it is important to perform a routine complete preoperative work up to all bariatric surgery candidates so that pathologies that could have further implications are not passed by European guidelines of the International Federation of Bariatric Surgery and the European Association for the Study of Obesity recognize and recommend the importance of studying preoperative Gastroesophageal reflux disease (GERD) without clearly defining the type of exam and the best candidates to apply it [2]. The American Association of Clinical Endocrinologist, The Obesity Society and the American Association for Metabolic and Bariatric Surgery based their recommendations on the presence or absence of reflux symptoms or dysphasia [3]. In this sense, we must bear in mind that in most cases where a carcinoma in situ or early gastric cancer is diagnosed, there are no digestive symptoms associated.

Carabotti et al., performed a prospective analysis with 142 patients demonstrating that the presence of symptoms may not be a reliable base to indicate an UGE. In this study the prevalence of endoscopic findings was similar in symptomatic and asymptomatic patients [9], showing that symptomatology itself would not be a reference to indicate this exploration. Estevez -Fernandez et al., in a prospective review of 331 candidates for bariatric surgery, conclude that preoperative UGE performed regardless of symptomatology, changed the therapeutic management in 52.6% of cases [10]. Finally Zeni et al., conducted another retrospective study with UGE in 159 patients showing that in 15 of these (9.4%) an unexpected pathology was detected delaying or modifying the initial surgical management [11].

In our first case the contrast study showed an obstruction of the stomach due to a possible band rejection and gastric erosion.

Revisional surgery was the initial surgical approach converting the lap band to a gastric bypass. After the routine UGE results, Oncological surgery became the new indication, changing the surgical approach and prognosis of the patient. In spite of this and looking to literature available, cross-sectional imaging with computed tomography should be considered first before UGE, especially when previous contrast study showed important complications due to band erosion and complete pre-operative information was required to plan the operation [12]. In our case this exam was done it after UGE. In fact cross-sectional imaging should be considered first especially before revisional surgery as it can guide surgery. In the second case, without a routine preoperative UGE, the gastric bypass would have been performed leaving in the bypassed stomach an initial adenocarcinoma lesion with the further impossibility to have access by conventional UGE for diagnosis and early treatment. Taking into account previous studies together with our own experience, we can conclude that preoperative routine UGE for bariatric surgery has a high diagnostic significance and low cost in relation to its effectiveness. Since, findings with this conventional exploration allow changes in the therapeutic strategy and also provide an adjustable treatment to every patient, preoperative routine UGE should be recommended.


Assistance with the study: We would like to thank especially general surgery nurses team for his assistance with the study during the patient’s hospitalization.


1. Angrisani L, Santonicola A, Iovino P, Formisano G, Buchwald H, Scopinaro N, et al. Bariatric surgery worldwide 2013. Obes Surg. 2015; 25:1822-1832.

2. Fried M, Yumuk V, Oppert JM, Scopinaro N, Torres AJ, Weiner R, et al. Interdisciplinary European Guidelines on metabolic and bariatric surgery. Obes Facts. 2013; 6: 449-468.

3. Mechanick JI, Youdim A, Joner DB, Garvey WT, Hurley DL, McMahon MM, et al. Clinical practice guidelines fot the perioperative nutritional, metabolic and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Obesity. 2013: 21: 1-27.

4. Lin XJ, Wang CP, Liu XD, Yan KK, Li S, Bao HH, et al. Body mass index and risk of gastric cancer: a meta-analysis. Jpn J Clin Oncol. 2014; 44: 783-791.

5. Yang P, Zhou Y, Chen B, Wan HW, Jia GQ, Bai HL, et al. Overweight, obesity and gastric cancer risk: results from a meta-analysis of cohort studies. Eur J Cancer. 2009; 45: 2867-2873.

6. Escalona A, Guzmán S, Ibáñez L, Meneses L, Huete A, Solar A, et al. Gastric cancer after Roux-en-Y gastric bypass. Obes Surg. 2005; 15: 423-427.

7. Khitin L, Roses RE, Birkett DH. Cancer in the gastric remnant after gastric bypass: a case report. Curr Surg. 2003; 60: 521-523.

8. Jain PK, Ray B, Royston CM. Carcinoma in the gastric pouch years after vertical banded gastroplasty. Obes Surg. 2003; 13: 136-137.

9. Carabotti M, Avallone M, Cereatti F, Paganini A, Greco F, Scirocco A, et al. Usefulness of Upper Gastrointestinal Symptoms as a Driver to Prescribe Gastroscopy in Obese Patients Candidate to Bariatric Surgery. A Prospective Study. Obes Surg. 2016; 26: 1075-1080.

10. Estevez-Fernandez S, Sanchez-Santos R, Mariño-Padin E, Gonzalez Fernandez S, Turnes-Vazquez J. Esophagogastric pathology in morbid obese patient: Preoperative diagnosis and influence in the selection of surgical technique. Rev Esp Enferm Dig. 2015; 107: 408-412.

11. Zeni TM, Frantzides CT, Mahr C, Denham EW, Meiselman M, Goldberg MJ, et al. Value of preoperative upper endoscopy in patients undergoing laparoscopic gastric bypass. Obes Surg. 2006; 16: 142-146.

12. Rengo M, Bellini D, Iorio O, De Cecco CN, Rizzello M, Cavallaro G, et al. Role of preoperative imaging with multidetector computed tomography in the management of patients with gastro esophageal reflux disease symptoms after laparoscopic sleeve gastrectomy. Obes Surg. 2013; 23:1981-1986.

Received : 21 Mar 2016
Accepted : 25 May 2016
Published : 15 Jun 2016
Annals of Otolaryngology and Rhinology
ISSN : 2379-948X
Launched : 2014
JSM Schizophrenia
Launched : 2016
Journal of Nausea
Launched : 2020
JSM Internal Medicine
Launched : 2016
JSM Hepatitis
Launched : 2016
JSM Oro Facial Surgeries
ISSN : 2578-3211
Launched : 2016
Journal of Human Nutrition and Food Science
ISSN : 2333-6706
Launched : 2013
JSM Regenerative Medicine and Bioengineering
ISSN : 2379-0490
Launched : 2013
JSM Spine
ISSN : 2578-3181
Launched : 2016
Archives of Palliative Care
ISSN : 2573-1165
Launched : 2016
JSM Nutritional Disorders
ISSN : 2578-3203
Launched : 2017
Annals of Neurodegenerative Disorders
ISSN : 2476-2032
Launched : 2016
Journal of Fever
ISSN : 2641-7782
Launched : 2017
JSM Bone Marrow Research
ISSN : 2578-3351
Launched : 2016
JSM Mathematics and Statistics
ISSN : 2578-3173
Launched : 2014
Journal of Autoimmunity and Research
ISSN : 2573-1173
Launched : 2014
JSM Arthritis
ISSN : 2475-9155
Launched : 2016
JSM Head and Neck Cancer-Cases and Reviews
ISSN : 2573-1610
Launched : 2016
JSM General Surgery Cases and Images
ISSN : 2573-1564
Launched : 2016
JSM Anatomy and Physiology
ISSN : 2573-1262
Launched : 2016
JSM Dental Surgery
ISSN : 2573-1548
Launched : 2016
Annals of Emergency Surgery
ISSN : 2573-1017
Launched : 2016
Annals of Mens Health and Wellness
ISSN : 2641-7707
Launched : 2017
Journal of Preventive Medicine and Health Care
ISSN : 2576-0084
Launched : 2018
Journal of Chronic Diseases and Management
ISSN : 2573-1300
Launched : 2016
Annals of Vaccines and Immunization
ISSN : 2378-9379
Launched : 2014
JSM Heart Surgery Cases and Images
ISSN : 2578-3157
Launched : 2016
Annals of Reproductive Medicine and Treatment
ISSN : 2573-1092
Launched : 2016
JSM Brain Science
ISSN : 2573-1289
Launched : 2016
JSM Biomarkers
ISSN : 2578-3815
Launched : 2014
JSM Biology
ISSN : 2475-9392
Launched : 2016
Archives of Stem Cell and Research
ISSN : 2578-3580
Launched : 2014
Annals of Clinical and Medical Microbiology
ISSN : 2578-3629
Launched : 2014
JSM Pediatric Surgery
ISSN : 2578-3149
Launched : 2017
Journal of Memory Disorder and Rehabilitation
ISSN : 2578-319X
Launched : 2016
JSM Tropical Medicine and Research
ISSN : 2578-3165
Launched : 2016
JSM Head and Face Medicine
ISSN : 2578-3793
Launched : 2016
JSM Cardiothoracic Surgery
ISSN : 2573-1297
Launched : 2016
JSM Bone and Joint Diseases
ISSN : 2578-3351
Launched : 2017
JSM Bioavailability and Bioequivalence
ISSN : 2641-7812
Launched : 2017
JSM Atherosclerosis
ISSN : 2573-1270
Launched : 2016
Journal of Genitourinary Disorders
ISSN : 2641-7790
Launched : 2017
Journal of Fractures and Sprains
ISSN : 2578-3831
Launched : 2016
Journal of Autism and Epilepsy
ISSN : 2641-7774
Launched : 2016
Annals of Marine Biology and Research
ISSN : 2573-105X
Launched : 2014
JSM Health Education & Primary Health Care
ISSN : 2578-3777
Launched : 2016
JSM Communication Disorders
ISSN : 2578-3807
Launched : 2016
Annals of Musculoskeletal Disorders
ISSN : 2578-3599
Launched : 2016
Annals of Virology and Research
ISSN : 2573-1122
Launched : 2014
JSM Renal Medicine
ISSN : 2573-1637
Launched : 2016
Journal of Muscle Health
ISSN : 2578-3823
Launched : 2016
JSM Genetics and Genomics
ISSN : 2334-1823
Launched : 2013
JSM Anxiety and Depression
ISSN : 2475-9139
Launched : 2016
Clinical Journal of Heart Diseases
ISSN : 2641-7766
Launched : 2016
Annals of Medicinal Chemistry and Research
ISSN : 2378-9336
Launched : 2014
JSM Pain and Management
ISSN : 2578-3378
Launched : 2016
JSM Women's Health
ISSN : 2578-3696
Launched : 2016
Clinical Research in HIV or AIDS
ISSN : 2374-0094
Launched : 2013
Journal of Endocrinology, Diabetes and Obesity
ISSN : 2333-6692
Launched : 2013
Journal of Substance Abuse and Alcoholism
ISSN : 2373-9363
Launched : 2013
JSM Neurosurgery and Spine
ISSN : 2373-9479
Launched : 2013
Journal of Liver and Clinical Research
ISSN : 2379-0830
Launched : 2014
Journal of Drug Design and Research
ISSN : 2379-089X
Launched : 2014
JSM Clinical Oncology and Research
ISSN : 2373-938X
Launched : 2013
JSM Bioinformatics, Genomics and Proteomics
ISSN : 2576-1102
Launched : 2014
JSM Chemistry
ISSN : 2334-1831
Launched : 2013
Journal of Trauma and Care
ISSN : 2573-1246
Launched : 2014
JSM Surgical Oncology and Research
ISSN : 2578-3688
Launched : 2016
Annals of Food Processing and Preservation
ISSN : 2573-1033
Launched : 2016
Journal of Radiology and Radiation Therapy
ISSN : 2333-7095
Launched : 2013
JSM Physical Medicine and Rehabilitation
ISSN : 2578-3572
Launched : 2016
Annals of Clinical Pathology
ISSN : 2373-9282
Launched : 2013
Annals of Cardiovascular Diseases
ISSN : 2641-7731
Launched : 2016
Journal of Behavior
ISSN : 2576-0076
Launched : 2016
Annals of Clinical and Experimental Metabolism
ISSN : 2572-2492
Launched : 2016
Clinical Research in Infectious Diseases
ISSN : 2379-0636
Launched : 2013
JSM Microbiology
ISSN : 2333-6455
Launched : 2013
Journal of Urology and Research
ISSN : 2379-951X
Launched : 2014
Journal of Family Medicine and Community Health
ISSN : 2379-0547
Launched : 2013
Annals of Pregnancy and Care
ISSN : 2578-336X
Launched : 2017
JSM Cell and Developmental Biology
ISSN : 2379-061X
Launched : 2013
Annals of Aquaculture and Research
ISSN : 2379-0881
Launched : 2014
Clinical Research in Pulmonology
ISSN : 2333-6625
Launched : 2013
Journal of Immunology and Clinical Research
ISSN : 2333-6714
Launched : 2013
Annals of Forensic Research and Analysis
ISSN : 2378-9476
Launched : 2014
JSM Biochemistry and Molecular Biology
ISSN : 2333-7109
Launched : 2013
Annals of Breast Cancer Research
ISSN : 2641-7685
Launched : 2016
Annals of Gerontology and Geriatric Research
ISSN : 2378-9409
Launched : 2014
Journal of Sleep Medicine and Disorders
ISSN : 2379-0822
Launched : 2014
JSM Burns and Trauma
ISSN : 2475-9406
Launched : 2016
Chemical Engineering and Process Techniques
ISSN : 2333-6633
Launched : 2013
Annals of Clinical Cytology and Pathology
ISSN : 2475-9430
Launched : 2014
JSM Allergy and Asthma
ISSN : 2573-1254
Launched : 2016
Journal of Neurological Disorders and Stroke
ISSN : 2334-2307
Launched : 2013
Annals of Sports Medicine and Research
ISSN : 2379-0571
Launched : 2014
JSM Sexual Medicine
ISSN : 2578-3718
Launched : 2016
Annals of Vascular Medicine and Research
ISSN : 2378-9344
Launched : 2014
JSM Biotechnology and Biomedical Engineering
ISSN : 2333-7117
Launched : 2013
Journal of Hematology and Transfusion
ISSN : 2333-6684
Launched : 2013
JSM Environmental Science and Ecology
ISSN : 2333-7141
Launched : 2013
Journal of Cardiology and Clinical Research
ISSN : 2333-6676
Launched : 2013
JSM Nanotechnology and Nanomedicine
ISSN : 2334-1815
Launched : 2013
Journal of Ear, Nose and Throat Disorders
ISSN : 2475-9473
Launched : 2016
JSM Ophthalmology
ISSN : 2333-6447
Launched : 2013
Journal of Pharmacology and Clinical Toxicology
ISSN : 2333-7079
Launched : 2013
Annals of Psychiatry and Mental Health
ISSN : 2374-0124
Launched : 2013
Medical Journal of Obstetrics and Gynecology
ISSN : 2333-6439
Launched : 2013
Annals of Pediatrics and Child Health
ISSN : 2373-9312
Launched : 2013
JSM Clinical Pharmaceutics
ISSN : 2379-9498
Launched : 2014
JSM Foot and Ankle
ISSN : 2475-9112
Launched : 2016
JSM Alzheimer's Disease and Related Dementia
ISSN : 2378-9565
Launched : 2014
Journal of Addiction Medicine and Therapy
ISSN : 2333-665X
Launched : 2013
Journal of Veterinary Medicine and Research
ISSN : 2378-931X
Launched : 2013
Annals of Public Health and Research
ISSN : 2378-9328
Launched : 2014
Annals of Orthopedics and Rheumatology
ISSN : 2373-9290
Launched : 2013
Journal of Clinical Nephrology and Research
ISSN : 2379-0652
Launched : 2014
Annals of Community Medicine and Practice
ISSN : 2475-9465
Launched : 2014
Annals of Biometrics and Biostatistics
ISSN : 2374-0116
Launched : 2013
JSM Clinical Case Reports
ISSN : 2373-9819
Launched : 2013
Journal of Cancer Biology and Research
ISSN : 2373-9436
Launched : 2013
Journal of Dermatology and Clinical Research
ISSN : 2373-9371
Launched : 2013
JSM Gastroenterology and Hepatology
ISSN : 2373-9487
Launched : 2013
TEST Journal of Dentistry
ISSN : 1234-5678
Launched : 2014
Annals of Nursing and Practice
ISSN : 2379-9501
Launched : 2014
JSM Dentistry
ISSN : 2333-7133
Launched : 2013
Author Information X