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Abstract & Commentary
Synopsis: Cholecystectomy is associated with increased risk of adenocarcinoma of the esophagus, perhaps as a consequence of increased duodenogastric-esophageal reflux of biliary contents.
Source: Freedman J, et al. Gastroenterology. 2001;121:548-553.
Cholecystectomy is known to be associated with more reflux of biliary and pancreatic juices from the duodenum into the stomach (DGER). Also, there is an apparent relationship between cholecystectomy and subsequent gastroesophageal reflux disease (GERD). Barrett’s esophagus has been associated with "bile reflux." The aim of this study was to test the hypothesis that DGER may be a risk factor for adenocarcinoma of the esophagus. A large number of patients with cholelithiasis were identified, and 101,156 patients with no cholecystectomy (658,641 patient-years at risk) were compared to 66,489 patients who underwent cholecystectomy (3,151,494 person-years at risk). Adenocarcinoma of the esophagus was found is 53 patients who had undergone cholecystectomy compared to 38 cases in both the age-matched general Swedish population. No excess adenocarcinoma was identified in the patients with gallstones who did not undergo cholecystectomy. No associations were found for squamous cell cancer of the esophagus. Obesity did not appear to be a separate risk factor for esophageal cancer.
Comment by Malcolm Robinson, MD, FACP, FACG
The known 3-to-10-fold increase in bile acids in the stomach after cholecystectomy may well be the culprit in the causation of esophageal adenocarcinoma, a finding confirmed in animal models. Adenocarcinoma of the esophagus is still sufficiently rare—it is not yet a major issue in terms of planning cholecystectomy. However, this study does provide one more reason not to undertake cholecystectomy with inadequate clinical indications. The general issue of bile reflux and its implications for GERD treatment remains controversial.
Dr. Robinson, Medical Director, Oklahoma Foundation for Digestive Research; Clinical Professor of Medicine, University of Oklahoma College of Medicine, Oklahoma City, is Associate Editor of Internal Medicine Alert.