In the eye of the beholder: surgeon variation in intra-operative perceptions of hiatal hernia and reflux outcomes after sleeve gastrectomy

Assessing academic impact through a bibliometrics analysis: Gastroesophageal reflux disease in the context of obesity treatment and bariatric surgery

Aims

The global rise in obesity rates has led to increased use of bariatric surgery, which can potentially exacerbate or induce gastroesophageal reflux disease. This study aimed to assess the academic impact and trends in research on gastroesophageal reflux disease in the context of obesity treatment and bariatric surgery through a comprehensive bibliometric analysis.

Materials and methods

A bibliometric analysis was conducted using data from Web of Science and Scopus databases, covering publications from 1993 to 2024. The study utilized the Bibliometrix R package to analyze publication trends, collaborative networks, and research topics.

Results

The analysis encompassed 257 documents from 82 sources, with 6192 total citations and an 8.2% annual growth rate in publications. The United States emerged as the leading contributor with 90 publications. Key research topics included bariatric surgery, sleeve gastrectomy, and gastroesophageal reflux disease, with increasing focus on complications and revisional bariatric surgery in recent years. Two main research clusters were identified: one focusing on general health aspects and demographics, and another on specialized bariatric procedures and outcomes. However, the analysis is constrained by its reliance on data from only two bibliographic databases, which may not encompass all pertinent studies, and by a geographic bias toward high-income countries. Moreover, our deep literature reviews highlighted that obesity is a known risk factor for gastroesophageal reflux disease, and while Roux-en-Y gastric bypass often reduces gastroesophageal reflux disease symptoms, sleeve gastrectomy may exacerbate or cause de novo gastroesophageal reflux disease postoperatively.

Conclusions

This bibliometric study reveals a significant increase in research activity on gastroesophageal reflux disease in relation to obesity treatment and bariatric surgery, particularly since 2017. The findings highlight the growing importance of this field and the need for continued international research efforts to optimize surgical protocols and improve patient outcomes.

Prognosis of Reflux Symptom Resolution After Bariatric Surgery: How Can Preoperative Esophageal Testing Help?

PURPOSE

The incidence of unresolved postoperative reflux after bariatric surgery varies considerably. Consistent perioperative patient characteristics predictive of unresolved reflux remain unknown. We leverage our institution's comprehensive preoperative esophageal testing to identify predictors of postoperative reflux.

MATERIALS AND METHODS

We performed a single-center retrospective review of adult patients with preoperative reflux symptoms who underwent either vertical sleeve gastrectomy (VSG) or Roux-en-Y gastric bypass (RYGB) from 2015 to 2021. All patients had pH and high-resolution manometry preoperatively. Predictors of postoperative unresolved reflux at 1 year were explored via Fisher's exact test, Kruskal Wallis test, and univariate logistic regression.

RESULTS

Unresolved reflux was higher in patients undergoing VSG (n = 60/129,46.5%) vs. RYGB (n = 19/98, 19.4%). Median DeMeester scores were higher (22 vs. 13, p = .07) along with rates of ineffective esophageal motility (IEM) (31.6 vs. 8.9%, p = .01) in the 19 (19.3%) patients with unresolved postoperative reflux after RYGB compared to the resolved RYGB reflux cohort. Sixty (46.5%) of VSG patients had unresolved postoperative reflux. The VSG unresolved reflux cohort had similar median DeMeester and IEM incidence to the resolved VSG group but more preoperative dysphagia (13.3% vs. 2.9%, p = .04) and higher preoperative PPI use (56.7 vs. 39.1%, p = .05). In univariate analysis, only IEM was predictive of unresolved reflux after RYGB (OR 4.74, 95% CI 1.37, 16.4).

CONCLUSION

Unresolved reflux was higher after VSG. Preoperative IEM predicted unresolved reflux symptoms after RYGB. In VSG patients, preoperative dysphagia symptoms and PPI use predicted unresolved reflux though lack of correlation to objective testing highlights the subjective nature of symptoms and the challenges in predicting postoperative symptomatology.

Comparison of safety and healthcare utilization following sleeve gastrectomy or gastric bypass among medicare beneficiaries using sex as a biologic variable

BACKGROUND

Bariatric surgery is a common operation, but differences in outcomes between males and females are unknown.

OBJECTIVES

To compare the risk of mortality, complications, reintervention, and healthcare utilization after sleeve gastrectomy or gastric bypass using sex as a biologic variable.

SETTING

United States.

METHODS

Retrospective cohort study of adults undergoing sleeve gastrectomy or gastric bypass from January 1, 2012 to December 31, 2018 using Medicare claims data. We performed a heterogeneity of treatment effect analysis to determine the impact of sleeve gastrectomy versus gastric bypass comparing males to females. The primary outcome was safety (mortality, complications, and reinterventions) up to 5 years after surgery. The secondary outcome was healthcare utilization (hospitalization and emergency department use).

RESULTS

Among 95,405 patients the majority (n = 71,348; 74.8%) were female and most (n = 57,008; 59.8%) underwent sleeve gastrectomy. For all patients, compared to gastric bypass, sleeve gastrectomy was associated with a lower risk of complications and reintervention but a higher risk of revision. Compared to gastric bypass, sleeve gastrectomy was associated with a lower risk of mortality for females (adjusted hazard ratio .86, 95% CI .75-.96) but not males. We found no difference in procedure treatment effect by sex for mortality, hospitalization, emergency department use, or overall reintervention when comparing sleeve to gastric bypass.

CONCLUSIONS

Females and males have similar outcomes following bariatric surgery. Females have a lower risk of complications but a higher risk of reintervention. Decisions surrounding treatment for this common procedure should be tailored to include a discussion of sex-specific differences in treatment outcome.

Comparison of upper gastrointestinal series and symptom questionnaires with intraoperative diagnosis of hiatal hernia during sleeve gastrectomy

BACKGROUND

Hiatal hernias are common in bariatric surgery patients, but the utility of preoperative hiatal hernia diagnosis prior to sleeve gastrectomy (SG) is debated.

OBJECTIVE

This study compared preoperative and intraoperative hiatal hernia detection rates in patients undergoing laparoscopic SG.

SETTING

University hospital, United States.

METHODS

As part of a randomized trial evaluating the role of routine crural inspection during SG, an initial cohort was prospectively studied to assess the correlation between preoperative upper gastrointestinal (UGI) series, reflux and dysphagia symptoms, and intraoperative hiatal hernia diagnosis. Preoperatively, patients completed the Gastroesophageal Reflux Disease Questionnaire (GerdQ), the Brief Esophageal Dysphagia Questionnaire (BEDQ), and a UGI series. Intraoperatively, patients with an anteriorly visible defect underwent hiatal hernia repair followed by SG. All others were randomized to standalone SG or posterior crural inspection with repair of any hiatal hernia identified prior to SG.

RESULTS

Between November 2019 and June 2020, 100 patients (72 female patients) were enrolled. Preoperative UGI series identified hiatal hernia in 28% (26 of 93) of patients. Intraoperatively, hiatal hernia was diagnosed during initial inspection in 35 patients. Diagnosis was associated with older age, lower body mass index, and Black race but did not correlate with GerdQ or BEDQ. Using the standard conservative approach, compared with intraoperative diagnosis, sensitivity and specificity of the UGI series were 35.3% and 80.7%, respectively. Hiatal hernia was identified in an additional 34% (10 of 29) of patients randomized to posterior crural inspection.

CONCLUSION

Hiatal hernias are highly prevalent in SG patients. However, GerdQ, BEDQ, and a UGI series unreliably identify hiatal hernia in the preoperative setting and should not influence intraoperative evaluation of the hiatus during SG.

Impact of concurrent hiatal hernia repair during laparoscopic sleeve gastrectomy on patient-reported gastroesophageal reflux symptoms: a state-wide analysis

BACKGROUND

Concurrent hiatal hernia repair (HHR) during laparoscopic sleeve gastrectomy (LSG) may improve gastroesophageal reflux disease (GERD) symptoms. However, patient-reported outcomes are limited, and the influence of surgeon technique remains unclear.

OBJECTIVES

To assess patient-reported GERD severity before and after LSG with and without concomitant HHR.

SETTING

Teaching and non-teaching hospitals participating in a state-wide quality improvement collaborative.

METHODS

Using a state-wide bariatric-specific data registry, all patients who underwent a primary LSG between 2015 and 2019 who completed a baseline and 1 year validated GERD health related quality of life (GERD-HRQL) survey were identified (n = 11,742). GERD severity at 1 year as well as 30-day risk-adjusted adverse events was compared between patients who underwent LSG with or without HHR. Results were also stratified by anterior versus posterior HHR.

RESULTS

A total of 4015 patients underwent a LSG-HHR (34%). Compared to patients who underwent LSG without HHR, LSG-HHR patients were older (47.8 yr versus 44.6 yr; P < .0001), had a lower preoperative body mass index (BMI) (45.8 kg/m² versus 48 kg/m²; P < .0001) and more likely to be female (85.2% versus 77.6%, P < .0001). Patients who underwent a posterior HHR (n = 3205) experienced higher rates of symptom improvement (69.5% versus 64.0%, P = .0014) and lower rates of new onset symptoms at 1 year (28.2% versus 30.2%, P = .0500). Patients who underwent an anterior HHR (n = 496) experienced higher rates of hemorrhage and readmissions with no significant difference in symptom improvement.

CONCLUSIONS

Concurrent posterior hiatal HHR at the time of sleeve gastrectomy can improve reflux symptoms. Patients undergoing anterior repair derive no benefit and should be avoided.

Independent association of preoperative Hill grade with gastroesophageal reflux disease 2 years after sleeve gastrectomy

BACKGROUND

The sleeve gastrectomy (SG) is associated with postoperative gastroesophageal reflux disease (GERD). Higher endoscopic Hill grade has been linked to GERD in patients without metabolic surgery. How preoperative Hill grade relates to GERD after SG is unknown.

OBJECTIVE

To explore the relationship between preoperative Hill grade and GERD outcomes 2 years after SG.

SETTING

Academic hospital, United States.

METHODS

All patients (n = 882) undergoing SG performed by 5 surgeons at a single academic institution from January 2015 to December 2019 were included. Complete data sets were available for 360 patients, which were incorporated in analyses. GERD was defined as the presence of a diagnosis in the medical record accompanied by pharmacotherapy. Patients with GERD postoperatively (n = 193) were compared with those without (n = 167). Univariable and multivariable analyses were conducted to explore independent associations between preoperative factors and GERD outcomes.

RESULTS

The presence of any GERD increased at the postoperative follow-up of 25.2 (3.9) months compared with preoperative values (53.6% versus 41.1%; P = .0001). Secondary GERD outcomes at follow-up included de novo (41.0%), persistent (33.1%), resolved (28.4%), worsened (26.4%), and improved (12.2%) disease. Postoperative endoscopy and reoperation for GERD occurred in 26.4% and 6.7% of the sample. Patients with GERD postoperatively showed higher prevalence of Hill grade III-IV (32.6% versus 19.8%; P = .0062) and any hiatal hernia (HH) (36.3% versus 25.1%; P = .0222) compared with patients without postoperative GERD. Frequencies of gastritis, esophagitis A or B, duodenitis, and peptic ulcer disease were similar between groups. Higher prevalence of preoperative GERD (54.9% versus 25.1%; P < .0001), obstructive sleep apnea (66.8% versus 54.5%; P = .0171), and anxiety (25.4% versus 15.6%; P = .0226) was observed in patients with postoperative GERD compared with those without it. Baseline demographics, weight, other obesity-associated diseases, whether an HH was repaired at index SG, and follow-up length were statistically similar between groups. After adjusting for collinearity, preoperative GERD (odds ratio [OR] = 3.6; 95% confidence interval [CI], 2.2-5.7; P < .0001) and Hill grade III-IV (OR [95% CI]: 1.9 [1.1-3.1]; P = .0174) were independently associated with the presence of any GERD postoperatively. The preoperative presence of an HH >2 cm and whether an HH was repaired at index SG showed no independent association with GERD at follow-up.

CONCLUSIONS

More than 50% of patients experienced GERD 2 years after SG. Preoperative GERD confers the highest risk for GERD postoperatively. Hill grade III-IV is independently associated with GERD after SG. Whether a hiatal hernia repair was performed did not influence GERD outcomes. Preoperative esophagogastroduodenoscopy should be obtained before SG and Hill grade routinely captured and used to counsel patients about the risk of postoperative GERD after this procedure. Hill grade may help guide the choice of metabolic operation.

A protocol for developing core outcome sets for laparoscopic hiatal hernia repair

Background

Hiatal hernias negatively damage patients’ health and life quality. Laparoscopic hiatal hernia repair is currently the gold standard for the treatment of hiatal hernia (LHHR). Numerous clinical trials on laparoscopic hiatal hernia repair have been done, but the published findings are highly variable due to the lack of unique outcome sets. Basic outcome sets have ever been established over the previous decade for a few procedures, but not for hiatal hernia repair yet. This protocol outlines the procedure to develop a core outcome set for laparoscopic hiatal hernia repair COS-LHHR). COS-LHHR will provide a unique criteria for clinical investigations.

Methods

This study will be conducted in four phases: (1) scoping reviews of existing qualitative studies and outcome reporting in randomized controlled trials to develop a list of potential outcome domains; (2) qualitative interviews with patients to explore the impact of laparoscopic hiatal hernia repair and the outcomes that they care most; (3) a multi-round e-Delphi study to achieve preliminary consensus on the core outcome set; and (4) an evidence-based consensus on a core outcome set will be achieved through a structured group consensus meeting, recommending best assessment outcome sets.

Discussion

The development the COS-LHHR will guide clinical research of laparoscopic hiatal hernia repair with unique outcome assessment. This would improve comparative analyses among studies.

Female Patient Perceptions on Financial Incentives to Promote Follow-Up After Bariatric Surgery

INTRODUCTION

Financial incentives to promote recommended behaviors have been applied in many healthcare settings, but to our knowledge, have never been tested as a strategy to improve patient follow-up after bariatric surgery. Given that females make up majority of bariatric surgery patients, our goal was to explore female patient perceptions on the effects of a financial incentive program designed to increase follow-up after bariatric surgery.

METHODS

This was an exploratory qualitative study of patient participants in a pilot program investigating financial incentives. We performed qualitative interviews with female patients to include personal experiences with bariatric surgery, progress toward goals, and concerns related to post-surgical behaviors. The data was analyzed iteratively through inductive thematic analysis.

RESULTS

Twenty-one female patients who had undergone bariatric surgery and enrolled in the financial incentive program participated in this study. Participants had generally positive impressions of the financial incentive program. Participants described the utility of the program in helping to pay for expenses associated with bariatric surgery; feeling that participation was their way of demonstrating that they were compliant with post-surgical recommendations; and that it provided additional motivation. All patients stated that even without the financial incentive they would have continued to follow-up.

CONCLUSIONS

While financial incentives can provide additional motivation for patients following bariatric surgery, they are not the primary reason that patients choose to follow-up. Understanding the motivation of patients who choose to follow-up (or not) may better inform investigations intended to improve follow-up rates after bariatric surgery.

Do we understand the pathophysiology of GERD after sleeve gastrectomy?

Gastroesophageal reflux disease (GERD), a prevalent problem among obese individuals, is strongly associated with obesity and weight loss. Hence, bariatric surgery effectively improves GERD for many patients. Depending on the type of bariatric procedure, however, surgery can also worsen or even cause a new onset of GERD. As a consequence, GERD remains a relevant problem for many bariatric patients, and especially those who have undergone sleeve gastrectomy (SG). Affected patients report not only a decrease in physical functioning but also suffer from mental and emotional problems, resulting in poorer social functioning. The pathomechanism of GERD after SG is most likely multifactorial and triggered by the interaction of anatomical, physiological, and physical factors. Contributing factors include the shape of the sleeve, the extent of injury to the lower esophageal sphincter, and the presence of hiatal hernia. In order to successfully treat post-sleeve gastrectomy GERD, the cause of the problem must first be identified. Therapeutic approaches include lifestyle changes, medication, interventional treatment, and/or revisional surgery.