Obesity Surgery (2018) 28:1441–1444

https://doi.org/10.1007/s11695-018-3156-5

REVIEW ARTICLE

One Anastomosis Gastric Bypass and Risk of Cancer

1
Ahmed Guirat 1,2 & Hassan Majed Addossari

Published online: 8 March 2018

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

Abstract
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-
Methods
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
ahmedguirat@yahoo.fr prompted surgeons to lengthen the gastric tube and keep the
afferent loop higher than the efferent to avoid the risk of
1
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
2
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
such as epigastric pain, nausea, belching, abdominal bloating,
nasopharyngeal and/or pulmonary signs… All of these symp-
toms should require UGI endoscopy to look for gastritis and/
or esophagitis with evidence of bile in the gastric tube and/or
esophagus. In case of persistent doubt, impedancemetry [5]
and hepato-biliary scintigraphy [6] are two very sensitive and
specific tests to confirm the diagnosis.
The incidence of symptomatic biliary reflux is low and
does not exceed 2% in the largest series with a medium-term
follow-up (Table 1). This is an acceptable rate but it is consid-
ered by some to be underestimated given the number of cases
of asymptomatic biliary reflux and the lack of longer-term
follow-up. In cases of refractory biliary reflux, it is reasonable
to convert the procedure into BBraun jejunojejunostomy^ or
better into BRoux-en-Y gastric bypass.^ The conversion is
generally simple and safe.
OAGB and Asymptomatic Biliary Reflux
Asymptomatic biliary reflux after OAGB is theoretically pos-
sible but difficult to document. Only one study detected this
reflux postoperatively after OAGB. Tolone et al. [12] studied
the effect of this procedure on the gastroesophageal junction on
15 patients by clinical examination, UGI endoscopy, manome-
try, and impedancemetry before and 1 year after OAGB. No
patient developed postoperative reflux symptoms. Endoscopy
revealed neither gastritis nor esophagitis. No pathological bili-
ary reflux was observed. However, it is a series with a low
number of cases and short follow-up (12 months). Thus, no
conclusion can be reached and it seems reasonable to perform
periodically an endoscopic control after OAGB, even in the
absence of symptoms of biliary reflux. Endoscopy should be
indicated periodically (every 2 to 3 years) in all patients to
screen asymptomatic biliary reflux. If confirmed, it is indicated
to convert the OAGB into Braun jejunojejunostomy or better
into Roux-en-Y gastric bypass.
OAGB and Cancer
In a literature review published in 2013, Scozzari et al. [13]
reported 33 cases of gastroesophageal cancers after bariatric sur-
gery. Among them, four cases of gastric cancers were reported
after surgery using the Bloop gastric bypass^ technique,
Bancestor^ of the OAGB [14]. Three cases were carcinoma of
the excluded stomach and one case was a gastric stump carcino-
ma (GSC) which occurred 26 years after surgery. After OAGB,
only one case of gastric cancer has been published in the litera-
ture [15] and developed on the remnant stomach, occurring
9 years after surgery in a 41-year-old woman operated on
in 2003. The HP profile has not been specified.
Many hypotheses have been made in favor of or against the
risk of degeneration after OAGB. Many surgeons are con-
vinced about the risk of degeneration after OAGB, because:
– First: It has been demonstrated that bilio-pancreatic reflux
is directly responsible for esophageal adenocarcinoma in
the animal model [16].
– Second: According to some authors, excessive biliary re-
flux can lead to intestinal metaplasia, Barrett’s esophagus,
and gastric/esophageal cancer in humans [17, 18].
– Third: One randomized prospective study (non-bariatric),
comparing the BBillroth II^ technique to the Roux-en-Y
technique in 75 patients having antrectomy with selective
bivagotomy [19], found a significant increase in intestinal
metaplasia (24 versus 3%, P < 0.0001) and chronic atro-
phic gastritis (39 versus 10%, P < 0.008) after Billroth II
compared with the Roux-en-Y reconstruction after a
mean follow-up of 15 years.
Conversely, many authors are convinced that there is no
causal link between OAGB and cancer [4, 8], and are based
on these arguments:
– First: The implication of other factors in the genesis of
gastric cancer (food habits, tobacco, Helicobacter pylori
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
– Second: The reported cases of cancer occurring on the
remnant stomach after RYGB (14 cases) and vertical-
banded gastroplasty (n = 9) [13, 21].
– Third: No published cases of esophagus cancer or on the
remnant stomach after OAGB since 1997.
– Fourth: The results of the study by Bassily et al. [22] who
did not show a significant risk of gastric or/and esopha-
geal cancer in 569 patients who had antrectomy for a
peptic ulcer and gastrojejunal anastomosis of the
Billroth II type (assembly similar to OAGB) between
1957 and 1976 and after a mean follow-up of 17 years.
However, when analyzing these results, we should be
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-
ation that OAGB is a recent procedure developed since 1997
(21 years), and on the other hand, the GSC has long evolution
which often can reach more than 20 years after surgery to
occur.
– Fifth: Recently, Carbajo et al. evaluated a cohort of pa-
tients who underwent OAGB and reported that none had
reflux symptoms postoperatively [23]. They studied re-
flux with 24-h pH and manometry in conjunction with
endoscopy at 12 and 18 months after surgery, with normal
findings in all. However, this study presents some limita-
tions; because only patients with no symptoms were stud-
ied, the results can only be applied to asymptomatic pa-
tients and are hardly applicable to other groups of
patients.
Regarding all these arguments, it seems that there is a the-
oretical relationship between OAGB and cancer, which still
needs Btime^ (more follow-up) to be confirmed or disproved.
Conclusion
Actually, OAGB is becoming popular within the bariatric com-
munity and despite its excellent and promising results in terms
of weight loss and resolution of comorbidities, the theoretical
risk of asymptomatic chronic biliary reflux after OAGB still
exists and may be responsible for gastroesophageal cancer.
The duration of gastroesophageal mucosa exposure to the bile
is a main determinant in the pathogenesis of degeneration as
intestinal metaplasia may take several years to develop in
humans. To confirm or disprove the role of OAGB in the gen-
esis of gastric/esophageal cancer, more follow-up is needed as
GSC can take more than 20 years to appear after surgery. By
advocating a prudential attitude, it is reasonable to indicate
OAGB for patients over 50 years of age. Otherwise, it is justi-
fied to perform UGI endoscopy periodically (every 2 to 3 years)
1443
in all patients after OAGB, to screen for asymptomatic biliary
reflux and thus to convert the procedure before the occurrence
of intestinal metaplasia and/or Barrett’s esophagus.
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflict of
interest.
Informed Consent Informed consent was obtained from all individual
participants included in the study.
Human and Animal Rights This article does not contain any studies
with human participants or animals performed by any of the authors.
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