Sleeve gastrectomy and development of "de novo" gastroesophageal reflux. Obes Surg. 2014;24:71-77. [PMID: 24249251 DOI: 10.1007/s11695-013-1046-4]

Impact of Sleeve Gastrectomy and Roux-en-Y Gastric Bypass on Esophageal Physiology and Gastroesophageal Reflux Disease: A Prospective Study

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) are the most commonly performed bariatric surgical procedures. The effectiveness of these operations on weight control is well established; however, their impact on esophageal physiology is still under evaluation. The aim of this study is to evaluate the consequences of LSG and LRYGB on esophageal physiology, especially concerning reflux.

METHODS

This prospective study involved 30 patients with severe obesity; 15 underwent LSG, and 15 had LRYGB. Conducted between 2021 and 2023 in Turin, Italy, the study employed preoperative and 1-year postoperative assessments of esophageal function using conventional esophageal manometry, 24-h multichannel intraluminal impedance-pH (MII-pH), upper gastrointestinal series, upper endoscopy, and a validated questionnaire to assess outcomes related to esophageal and lower esophageal sphincter (LES) functions and reflux.

RESULTS

Both groups experienced significant reductions in weight and body mass index, with p-values < 0.001 for both measures. The LRYGB group achieved a significantly higher percentage of excess weight loss compared to the LSG group, with a p-value of < 0.001. In the LSG group, GERD symptoms remained unchanged postoperatively (p = 0.687), with 26.7% using proton pump inhibitors (PPIs) before and after surgery, while in the LRYGB group, GERD symptoms and PPIs use significantly decreased from 53.3 to 6.7% (p = 0.016). Quality of life improved significantly in both groups, with a p-value of 0.001. In the LRYGB group only, esophagitis significantly decreased from 53.3 to 6.7% (p = 0.007), and barium studies showed a significant reduction in reflux signs from 66.7% preoperatively to none postoperatively (p = 0.002). Multichannel intraluminal impedance-pH monitoring revealed significant reductions in reflux metrics for LRYGB group only: total refluxes decreased from 29.0 to 15.0, acidic refluxes from 12.0 to 8.0, and the DeMeester score from 4.70 to 3.70 (p = 0.026, 0.033, and 0.029, respectively). Regarding the manometric parameters, significant changes were observed in the LSG group: total LES length decreased from 34.0 to 31.33 mm (p = 0.027) and residual pressure increased from 2.0 to 4.0 mmHg (p = 0.012), also peristaltic wave amplitude decreased from 98.20 to 52.93 mmHg (p < 0.001), while in the LRYGB group, only the LES residual pressure significantly increased from 2.0 to 4.0 mmHg (p = 0.006).

CONCLUSIONS

LSG and LRYGB are effective for weight loss and improving quality of life. Sleeve gastrectomy controls reflux, with new cases being rare. Advanced diagnostics are key when standard tests are insufficient.

Long-term effect of Roux-en-Y gastric bypass versus sleeve gastrectomy on reflux and Barrett's oesophagus: a randomized controlled trial

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is a potentially refluxogenic operation while Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) is regarded as an anti-reflux procedure. The aim of this study is to compare long-term incidence of Barrett's Oesophagus (BO) and gastroesophageal reflux disease (GORD) following LSG and LRYGB.

METHODS

Participants of a double-blinded randomized controlled trial comparing banded LRYGB and LSG for remission of type 2 diabetes were contacted to take part. A gastroscopy was performed. Primary outcome was endoscopic and histologic evidence of BO. Secondary outcomes included reflux and regurgitation scores, presence of oesophagitis, proton-pump inhibitor (PPI) usage, Body Mass Index (BMI), and percentage excess weight loss (%EWL).

RESULTS

Forty-eight of 109 patients were enrolled into the study (LSG 26 vs. LRYGB 22). Mean follow-up was 7.5 years for the LSG group, and 7.4 years for the RYGB group (P = 0.22). 8 LSG patients had BO while 3 LRYGB patients had BO (30.8%vs13.6%, P = 0.19). There was no significant difference in the mean reflux (8.1 ± 9.4(0-36) vs. 9.3 ± 8.8(0-34), P = 0.47) and regurgitation scores (7.7 ± 6.9(0-22) vs. 11.5 ± 10.5(0-44), P = 0.23) for LSG versus LRYGB patients or between those with and without BO. PPI usage before and after surgery was 6/26 (23.1%) versus 13/26 (50.0%) and 8/22 (36.4%) versus 12/22 (54.5%) for LSG and LRYGB patients respectively. PPI usage in patients with and without BO was 7/11 versus 18/37. EWL was significantly greater (P = 0.0013) in the LRYGB group (74.8 ± 28.1%) compared to LSG group (49.7 ± 18.7%).

CONCLUSIONS

Long-term incidence of BO trended towards but was not significantly higher for LSG compared to LRYGB group. We support routine endoscopic surveillance for bariatric patients.

Retrospective Cohort Study of Gastric Bypass Versus Sleeve Gastrectomy in Gastroesophageal Reflux Disease Patients: Procedure Use and Racial Disparity

BACKGROUND

Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) are common bariatric procedures, with GERD being a frequent obesity-associated disease among individuals undergoing these surgeries. RYGB is recommended for patients with GERD due to the increased control of GERD symptoms. This study examines RYGB and SG use in this population and factors influencing procedure choice.

METHODS

This study analyzed 2016-2022 data from the MBSAQIP database comprising patients with GERD who underwent SG or RYGB. Statistical analysis included univariate and multivariable logistic regression to identify factors associated with procedure receipt.

RESULTS

RYGB rates are rising annually but remain lower than SG for GERD. Compared to White individuals, Hispanics are 14% less likely, and African Americans are 19% less likely, to receive RYGB.

CONCLUSIONS

The study notes a research gap in choosing RYGB or SG for patients with GERD, despite consensus favoring RYGB. It highlights a disparity between recommendations and practice, with GERD predicting the use of RYGB but SG being more prevalent in this population overall. The analysis links race to procedure choice, showing African American and Hispanic patients are less likely to undergo RYGB, indicating potential disparities in access and decision-making.

Magnetic Sphincter Augmentation for Gastroesophageal Reflux After Sleeve Gastrectomy: A Systematic Review

This systematic review aims to evaluate the current evidence regarding safety and efficacy of magnetic sphincter augmentation (MSA) for the treatment of gastroesophageal reflux disease (GERD) after laparoscopic sleeve gastrectomy (LSG). Conversion to Roux-en-Y gastric bypass (RYGB) carries the risk of surgical and metabolic complications and may be contraindicated in patients with normalized or near-normalized body mass index. The LINX™ procedure aims to restore LES competency and to repair the crura. We included 109 patients (14 studies) undergoing LINX™ implant after LSG. Median follow-up was 18.9 months (range 0.3-63). Both the GERD-HRQL (38 ± 13 vs. 10 ± 11; p = 0.0078) and daily PPI use (97.4% vs. 25.3%; p < 0.0001) were significantly improved. Overall, 31.8% of the patients experienced device-related adverse events, mainly self-limiting. LINX™ explant for esophageal erosion occurred in 0.9% of the patients.

The effect of laparoscopic vertical sleeve gastrectomy and laparoscopic roux-en-Y gastric bypass on gastroesophageal reflux disease: An updated meta-analysis and systematic review of 5-year post-operative data from randomized controlled trials

BACKGROUND

To evaluate 5-year effect of laparoscopic vertical sleeve gastrectomy (LVSG) versus laparoscopic roux-en-Y gastric bypass (LRYGB) on gastroesophageal reflux disease (GERD) solely based on randomized controlled trials (RCTs).

METHODS

A systematic review and meta-analysis of 5-year postoperative GERD data comparing LVSG and LRYGB in adults were undertaken. Electronic databases were searched from January 2015 to March 2024 for publications meeting inclusion criteria. The Hartung-Knapp-Sidik-Jonkman random effects model was applied to estimate pooled odds ratio where meta-analysis was possible. Bias and certainty of evidence were assessed using the Cochrane Risk of Bias Tool 2 and GRADE.

RESULTS

Five RCTs were analysed (LVSG n = 554, LRYGB n = 539). LVSG was associated with increased adverse GERD outcomes compared to LRYGB at 5 years. The odds for revisional surgery to treat GERD in LVSG patients were 11 times higher compared to LRYGB (OR 11.47, 95% CI 1.83 to 71.69; p = 0.02; I2 = 0% High level of certainty). Similarly pharmacological management for increasing GERD was significantly more frequent in LVSG patients compared to LRYGB (OR 3.89, 95% CI 2.31 to 6.55; p ≤ 0.01; I2 = 0% Moderate level of certainty). Overall, LVSG was associated with significantly more interventions (both medical and surgical) for either worsening GERD and/or development of de novo GERD compared to LRYGB (OR 5.98, 95% CI 3.48 to 10.29; p ≤ 0.01; I2 = 0%) Moderate level of certainty).

CONCLUSIONS

The development and worsening of GERD symptoms are frequently associated with LVSG compared to LRYGB at 5 years postoperatively requiring either initiation or increase of pharmacotherapy or failing that revisional bariatric surgery. Appropriate patient/surgical selection is crucial to reduce these postoperative risks of GERD.

3dct Conduit and Oesophageal Metrics, a Valuable Method to Diagnose Post Sleeve Gastrectomy Abnormalities

PURPOSE

Reflux after laparoscopic sleeve gastrectomy (LSG) may result from anatomical and functional anomalies in the gastric conduit. Three-dimensional CT scans (3DCT) offer a comprehensive view of gastric anatomy. This study aims to establish specific measurements associated with sleeve abnormalities to standardise the reporting of 3DCT which may help in management of LSG complications.

MATERIALS AND METHODS

This retrospective study analysed 64 post-LSG patients who underwent gastric 3DCT. Data included clinical demographics, pre-LSG BMI, BMI at 3DCT, and the duration between surgery and examination. Symptomatology prompts the scan and other concurrent investigations. Various 3DCT measurements were taken, including angularis angle (AA), surface area (ASA), conduit length (CL), proximal maximal surface area (PMSA), and distal maximal surface area (DMSA) of the gastric conduit. Patients were categorised based on endoscopy findings and symptomatology. Outcomes post-revisional surgery were assessed and analysed.

RESULTS

20.3% were male. Pre-LSG BMI and BMI at 3DCT were 45.57 (± 8.3) and 36.3 (± 8.7), respectively. Mean surgery-to-scan period was 6.2 years. 71.8% of patients presented with reflux, regurgitation, or dysphagia, whilst the remainder primarily exhibited weight regain. Patients with endoscopic evidence of stenosis/reflux demonstrated significantly lower gastric volume, ASA, and DMSA (p = 0.002 and p = 0.007, respectively). Oesophageal diameter above the conduit and an ASA to DMSA ratio ≤ 0.5 were negatively associated with AA (p = 0.008 and p = 0.08, respectively). Patients with improved outcomes after revisional bypass and gastrogastrostomy displayed a negative correlation with ASA and positive correlation with the ASA to PMSA ratio (≤ 0.5).

CONCLUSION

3DCT measurements have a potential role in defining post-LSG stenosis and predicting outcomes of revisional surgery. Patients with anatomic abnormalities that are shown on CT appear to improve with anatomic correction.

Full esophageal mobilization during hiatal hernia repair with concomitant sleeve gastrectomy improves postoperative reflux symptoms for patients with preexisting reflux

BACKGROUND

Hiatal hernia repair (HHR) performed concurrently with vertical sleeve gastrectomy (VSG) has been shown to improve postoperative gastroesophageal reflux disease (GERD). However, data on the optimal extent of esophageal mobilization during repair are lacking. Mobilization techniques for HHR during VSG include partial (PM) or full (FM) mobilization of the esophagus. We hypothesize that patients who undergo full mobilization will be less likely to develop postoperative reflux.

METHODS

A single-institution retrospective review of all patients who underwent a VSG with a HHR between 2014 and 2021 was conducted. The primary outcome was postoperative reflux symptoms defined by diagnosis in the medical record, utilization of anti-reflux medications, and GERD health-related quality of life (GERD-HRQL) scores obtained via patient surveys.

RESULTS

There were 190 patients included with 80 patients (42.1%) undergoing PM and 110 (57.9%) undergoing FM. Rates of preoperative reflux were similar between the two groups (47.5% vs. 51.8%; p = 0.55). During the GERD-HRQL survey, there were 114 patients (60.0%) contacted with a participation rate of 91.2% (104 patients). Patients with preoperative reflux who underwent PM were found to have a higher rate of reported postoperative reflux (90.0% vs. 62.5%; p = 0.03) and higher GERD-HRQL scores (16.40 ± 9.95 vs. 10.84 ± 9.01; p = 0.04). Patients without preoperative reflux did not have a significant difference in reported reflux (55.0% vs. 51.7%; p = 0.82) or GERD-HRQL scores (12.35 ± 14.14 vs. 9.93 ± 9.46; p = 0.25).

CONCLUSION

Our study found that postoperative GERD was higher in patients with preexisting reflux who underwent partial esophageal mobilization during concurrent hiatal hernia repair with vertical sleeve gastrectomy. In patients without preoperative GERD, our data suggest that postoperative reflux symptoms are not dependent on the extent of esophageal mobilization during hiatal hernia repair with vertical sleeve gastrectomy.

Significant and distinct impacts of sleeve gastrectomy and Roux-en-Y gastric bypass on esophageal acid exposure, esophageal motility, and endoscopic findings: a systematic review and meta-analysis

BACKGROUND

The lack of standardized objective assessment of esophageal physiology and anatomy contributes to controversies regarding the effects of sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) on gastroesophageal reflux disease. This study aimed to investigate esophageal acid exposure, esophageal motility, and endoscopic findings before and after SG and RYGB.

METHODS

This was a systematic review and meta-analysis of studies reporting at least 1 objective measure of esophageal physiology and/or esophagogastroduodenoscopy (EGD) at baseline and after SG or RYGB. The changes in pH test, manometry, and EGD parameters were summarized.

RESULTS

Acid exposure time (AET) and DeMeester score (DMS) significantly increased after SG (mean difference [MD]: 2.1 [95% CI, 0.3-3.9] and 8.6 [95% CI, 2.0-15.2], respectively). After RYGB, both AET and DMS significantly decreased (MD: -4.2 [95% CI, -6.1 to -2.3] and -16.6 [95% CI, -25.4 to -7.8], respectively). Lower esophageal sphincter resting pressure and length significantly decreased after SG (MD: -2.8 [95% CI, -4.6 to -1.1] and -0.1 [95% CI, -0.2 to -0.02], respectively). There were no significant changes in esophageal manometry after RYGB. The relative risks of erosive esophagitis were 2.3 (95% CI, 1.5-3.5) after SG and 0.4 (95% CI, 0.2-0.8) after RYGB. The prevalence rates of Barrett esophagus changed from 0% to 3.6% after SG and from 2.7% to 1.4% after RYGB.

CONCLUSION

SG resulted in the worsening of all objective parameters, whereas RYGB resulted in the improvement in AET, DMS, and EGD findings. Determining the risk factors associated with these outcomes can help in surgical choice.

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.

Management of Gastroesophageal Reflux Disease after Sleeve Gastrectomy: Effectiveness of Medical, Endoscopic, and Surgical Therapies

Introduction: Sleeve gastrectomy (SG) has become the most frequently performed bariatric operation in the United States. One of the main disadvantages of this procedure is the risk of developing gastroesophageal reflux disease (GERD) after the operation. We aimed to analyze different approaches for the treatment of GERD after SG. Methods: A literature review was performed to identify all possible treatment options for post-SG GERD. All the studies were assessed for full eligibility by manual assessment of their aims, methodology, results, and conclusions. Records were individually reviewed by the authors comparing outcomes and complications between procedures. Results: Although some studies have shown improvement or even resolution of GERD symptoms after SG, most patients develop or worsen symptoms. Lifestyle modifications along with medical therapy should be started on patients with GERD after SG. For those who are refractory to medication, endoscopic and surgical therapies can be offered. Conversion to Roux-en-Y gastric bypass (RYGB) is consistently effective in treatment of GERD and is the ideal therapy in patients with associated insufficient weight loss. Endoscopic and alternative surgical procedures are also available and have shown acceptable short-term outcomes. Conclusions: Several treatment options exist for the treatment of GERD after SG. Although conversion to RYGB remains the most effective therapy, other emerging endoscopic and surgical procedures could avoid the potential morbidity of this procedure and should be further evaluated. An evidence-based algorithm for the management of GERD after SG is proposed to guide decision making.

Oesophageal fluoroscopy in adults-when and why?

Oesophageal fluoroscopy is a radiological procedure that uses dynamic recording of the swallowing process to evaluate morphology and function simultaneously, a characteristic not found in other clinical tests. It enables a comprehensive evaluation of the entire upper gastrointestinal tract, from the oropharynx to oesophagogastric bolus transport. The number of fluoroscopies of the oesophagus and the oropharynx has increased in recent decades, while the overall use of gastrointestinal fluoroscopic examinations has declined. Radiologists performing fluoroscopies need a good understanding of the appropriate clinical questions and the methodological advantages and limitations to adjust the examination to the patient's symptoms and clinical situation. This review provides an overview of the indications for oesophageal fluoroscopy and the various pathologies it can identify, ranging from motility disorders to structural abnormalities and assessment in the pre- and postoperative care. The strengths and weaknesses of this modality and its future role within different clinical scenarios in the adult population are discussed. We conclude that oesophageal fluoroscopy remains a valuable tool in diagnostic radiology for the evaluation of oesophageal disorders.

Physiological Archetypes of de novo Gastroesophageal Reflux Disease After Laparoscopic Sleeve Gastrectomy

Laparoscopic Sleeve Gastrectomy (LSG) is the most common bariatric surgery in the world. While clinically effective, recent studies have shown increasingly higher rates of gastroesophageal reflux disease (GERD) and esophageal motility disorders. We reviewed all the literature and unraveled the underlying mechanism of post-LSG GERD. Finally, we propose a new classification to help us understand the disease and guide work-up, treatment, and future refinements in the surgical technique.

Use of Preoperative Endoscopic Capsule-Based pH Testing Before Bariatric Surgery

BACKGROUND

Vertical sleeve gastrectomy is the most performed bariatric operation in the US; however, a significant number of patients suffer from persistent or new-onset reflux. No consensus for objective preoperative evaluation in these patients exists. We compared capsule-based pH testing vs GERD symptom scoring to determine extent of preoperative GERD to aid in procedure selection for bariatric surgery.

STUDY DESIGN

An IRB-approved retrospective review of consecutive patients at a single institution was performed from April 2021 to December 2022. During initial consultation for bariatric surgery, a validated GERD symptom subjective survey was administered. All patients demonstrating interest in sleeve gastrectomy or had a history of reflux underwent upper endoscopy with capsule-based pH testing.

RESULTS

Sixty-two patients underwent preoperative endoscopy with capsule-based pH testing and completed GERD symptom assessment survey(s). Median BMI was 43.4 kg/m 2 and 66.1% of patients were not taking a proton-pump inhibitor before performance of pH testing. There was negligible linear association between the objective DeMeester score obtained by capsule-based pH probe and GERD symptom survey scores. Median GERD symptom survey scores did not differ between patients with and without a diagnosis of GERD based on pH testing (all p values >0.11).

CONCLUSIONS

An objective method for identifying severe GERD in the preoperative assessment may aid in the decision tree for procedure selection and informed consent process. Patients with significant preoperative GERD may be at higher risk for future GERD-related sleeve complications. Capsule-based pH testing may prove to be superior to subjective symptom scoring systems in this patient population.

Gastroesophageal reflux disease following laparoscopic vertical sleeve gastrectomy and laparoscopic roux-en-Y gastric bypass: meta-analysis and systematic review of 5-year data

To compare 5-year gastroesophageal reflux outcomes following Laparoscopic Vertical Sleeve Gastrectomy (LVSG) and Laparoscopic Roux-en-Y gastric bypass (LRYGB) based on high quality randomized controlled trials (RCTs). We conducted a sub-analysis of our systematic review and meta-analysis of RCTs of primary LVSG and LRYGB procedures in adults for 5-year post-operative complications (PROSPERO CRD42018112054). Electronic databases were searched from January 2015 to July 2021 for publications meeting inclusion criteria. The Hartung-Knapp-Sidik-Jonkman random effects model was utilized to estimate weighted mean differences where meta-analysis was possible. Bias and certainty of evidence was assessed using the Cochrane Risk of Bias Tool 2 and GRADE. Four RCTs were included (LVSG n = 266, LRYGB n = 259). An increase in adverse GERD outcomes were observed at 5 years postoperatively in LVSG compared to LRYGB in all outcomes considered: Overall worsened GERD, including the development de novo GERD, occurred more commonly following LVSG compared to LRYGB (OR 5.34, 95% CI 1.67 to 17.05; p = 0.02; I2 = 0%; (Moderate level of certainty); Reoperations to treat severe GERD (OR 7.22, 95% CI 0.82 to 63.63; p = 0.06; I2 = 0%; High level of certainty) and non-surgical management for worsened GERD (OR 3.42, 95% CI 1.16 to 10.05; p = 0.04; I2 = 0%; Low level of certainty) was more common in LVSG patients. LVSG is associated with the development and worsening of GERD symptoms compared to LRYGB at 5 years postoperatively leading to either introduction/increased pharmacological requirement or further surgical treatment. Appropriate patient/surgical selection is critical to minimize these postoperative risks.

Investigation of the Relationship Between Laparoscopic Sleeve Gastrectomy and Gastroesophageal Reflux Disease Using 24-hour Multichannel Intraluminal Impedance With pH Testing According to Current Consensus

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is a popular weight loss procedure with potential effects on gastroesophageal reflux disease (GERD). However, research on the association between LSG and GERD using objective evaluation criteria, such as multichannel intraluminal impedance combined with pH testing (MII-pH), is limited. This study aimed to investigate the impact of LSG on GERD using MII-pH and current consensus guidelines.

MATERIALS AND METHODS

It was conducted as a prospective clinical study on 33 patients who underwent LSG between January 2022 and August 2022. MII-pH and high-resolution manometry were performed preoperatively and 3 to 6 months postoperatively. GERD diagnosis was based on MII-pH results using the Lyon and Update Porto consensus guidelines.

RESULTS

Postoperative MII-pH analysis revealed a significant increase in acid reflux time, acid exposure time, reflux index, esophageal clearance, total reflux time, and longest reflux period. Weak acid reflux episodes decreased, while Demeester score and alkaline reflux showed nonsignificant increases. Pathologic reflux significantly increased postoperatively based on MII-pH diagnosis. High-resolution manometry showed a significant increase in unsuccessful motility.

CONCLUSION

Although the Demeester score calculation consists of 6 metrics, including acid exposure time, the acid exposure time is more specific in detecting pathologic reflux. Pathologic GERD increases significantly with LSG in the early period. Therefore, preoperative and postoperative endoscopy and MII-pH can provide valuable information regarding the need for closer follow-up after LSG.

Laparoscopic Sleeve Gastrectomy Lacks Intrasurgeon and Intersurgeon Agreement in Technical Key Points That May Affect Gastroesophageal Reflux Disease After the Procedure

PURPOSE

Gastroesophageal reflux disease (GERD) after sleeve gastrectomy (SG) may be related to surgical technique. The fact that there is a lack of technical standardization may explain large differences in GERD incidence. The aim of this study is to evaluate auto- and hetero-agreement for SG technical key points based on recorded videos.

METHODS

Ten experienced (minimum of 5 years performing bariatric surgery, minimum of 30 SG per year) bariatric surgeons (9 (90%) males) were selected. Participants were invited to send an unedited video with a typical laparoscopic SG (first round of the Delphi process). Videos were cropped into small clips comprising 11 key points of the technique. All anonymized clips (including their own) were returned to all surgeons. Individuals were asked to agree or not with the technique demonstrated (second round). The percentage of agreement was presented to the entire group that was asked for a second vote (third round).

RESULTS

Agreement was poor/fair for all points except hiatal repair that had a very good agreement in the second round. For the third round, there was a slight increase in agreement for distance esophagogastric junction/proximal stapling and gastric mobilization for stapling and a slight decrease in agreement for gastric tube final shape. Only 1 (10%) surgeon recognized that he evaluated his own video. Five (50%) surgeons disagreed with themselves on 1 or more points.

CONCLUSION

SG lacks intrasurgeon and intersurgeon agreement in technical key points that may justify significant differences in GERD incidence after the procedure.

Revisional bariatric surgery for gastroesophageal reflux disease: characterizing patient and procedural factors and 30-day outcomes for a retrospective cohort of 4412 patients

INTRODUCTION

Gastroesophageal reflux disease (GERD) is a well-established potential consequence of bariatric surgery and can require revisional surgery. Our understanding of the population requiring revision is limited. In this study, we aim to characterize patients requiring revisional surgery for GERD to understand their perioperative risks and identify strategies to improve their outcomes.

METHODS

Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) registry, a retrospective cohort of patients who required revisional surgery for GERD in 2020 was identified. Multivariable logistic regression modelling was used to assess correlations between baseline characteristics and morbidity.

RESULTS

4412 patients required revisional surgery for GERD, encompassing 24% of all conversion procedures. In most cases, patients underwent sleeve gastrectomy (SG) as their original surgery (n = 3535, 80.1%). The revisional surgery for most patients was a Roux-en-Y gastric bypass (RYGB) (n = 3722, 84.4%). Major complications occurred in 527 patients (11.9%) and 10 patients (0.23%) died within 30 days of revisional surgery. Major complications included anastomotic leak in 31 patients (0.70%) and gastrointestinal bleeding in 38 patients (0.86%). Multivariable analyses revealed that operative length, pre-operative antacid use, and RYGB were predictors of major complications.

CONCLUSION

GERD is the second most common indication for revisional surgery in patients who have undergone bariatric surgery. Patients who underwent SG as their initial procedure were the primary group who required revisional surgery for GERD; most underwent revision via RYGB. Further inquiry is needed to tailor operative approaches and pre-operative optimization for revisional surgery patients.

Revisional Bariatric Surgery due to Complications: Indications and Outcomes

BACKGROUND

The increasing prevalence of bariatric procedures has led to a surge in revisional surgeries. Failure of bariatric surgery can be attributed to inadequate weight loss or complications necessitating revisional surgery. In this study, we investigated the indications and outcomes of revisional surgery due to complications following primary bariatric surgery.

MATERIALS AND METHODS

A retrospective study was conducted using data from the Tehran Obesity Treatment Study, which included patients who underwent revisional bariatric surgery between March 2013 and September 2021 due to complications following primary bariatric surgery.

RESULTS

Of the 5382 patients who underwent primary bariatric surgery (sleeve gastrectomy, one-anastomosis gastric bypass, and Roux-en-Y gastric bypass), 203 (3.70%) required revisional surgery, with 37 cases performed due to surgical complications. The indications of revisional operations were gastroesophageal reflux disease (GERD) (n=17, 45.9%), protein-calorie malnutrition (PCM) (n=14, 37.8%), unexplained abdominal pain (n=5, 13.5%), and phytobezoar (n=1, 0.03%). In the postoperative follow-up, most patients exhibited improvement in signs and symptoms related to underlying causes. However, eight patients experienced early or late complications of grade III or higher according to the Clavien-Dindo classification, with one death resulting from liver failure.

CONCLUSION

Revisional bariatric surgery may effectively address complications from primary bariatric surgery, with the majority of patients experiencing improvements in symptoms. While the overall incidence of revisional surgery due to complications is relatively low, our findings suggest that GERD and PCM are the most common indications for revisional surgery.

Postoperative outcomes for sleeve gastrectomy patients with positive pH-defined GERD

BACKGROUND

Gastroesophageal reflux disease (GERD) is a possible side effect of sleeve gastrectomy (SG). However, procedure selection for patients with GERD and risk factors for morbidity after bypass surgeries is complex. For patients with a preoperative GERD diagnosis, literature related to worsening postoperative symptoms is discordant.

OBJECTIVE

This study evaluated the effects of SG on patients with pre-operative GERD confirmed through pH testing.

SETTING

University Hospital, United States.

METHODS

This was a single-center case-series. SG patients with preoperative pH testing were compared based on DeMeester scoring. Preoperative demographics, endoscopy results, need for conversion surgery, and changes in gastrointestinal quality of life (GIQLI) scores were compared. Two-sample independent t-tests assuming unequal variances were used for statistical analysis.

RESULTS

Twenty SG patients had preoperative pH testing. Nine patients were GERD positive; median DeMeester score 26.7 (22.1-31.15). Eleven patients were GERD negative, with a median DeMeester score of 9.0 (4.5-13.1). The two groups had similar median BMI, preoperative endoscopic findings and use of GERD medications. Concurrent hiatal hernia repair was performed in 22% of GERD positive vs. 36% of GERD negative patients, (p = 0.512). Two patients in the GERD positive cohort required conversion to gastric bypass (22%), while none in the GERD negative cohort did. No significant postoperative differences were noted in GIQLI, heartburn, or regurgitation symptoms.

CONCLUSION

Objective pH testing may allow the differentiation of patients who would be higher risk for need for conversion to gastric bypass. For patients with mild symptoms, but negative pH testing, SG may represent a durable option.

Changes in Oesophageal Transit, Macro-Reflux Events, and Gastric Emptying Correlate with Improvements in Gastro-Intestinal Symptoms and Food Tolerance Early Post Sleeve Gastrectomy

PURPOSE

There are significant alterations in gastro-intestinal function, food tolerance, and symptoms following sleeve gastrectomy (SG). These substantially change over the first year, but it is unclear what the underlying physiological basis for these changes is. We examined changes in oesophageal transit and gastric emptying and how these correlate with changes in gastro-intestinal symptoms and food tolerance.

MATERIAL AND METHODS

Post-SG patients undertook protocolised nuclear scintigraphy imaging along with a clinical questionnaire at 6 weeks, 6 months, and 12 months.

RESULTS

Thirteen patients were studied: mean age (44.8 ± 8.5 years), 76.9% females, pre-operative BMI (46.9 ± 6.7 kg/m2). Post-operative %TWL was 11.9 ± 5.1% (6 weeks) and 32.2 ± 10.1% (12 months), p-value < 0.0001. There was a substantial increase of meal within the proximal stomach; 22.3% (IQR 12%) (6 weeks) vs. 34.2% (IQR 19.7%) (12 months), p = 0.038. Hyper-accelerated transit into the small bowel decreased from 6 weeks 49.6% (IQR 10.8%) to 42.7% (IQR 20.5%) 12 months, p = 0.022. Gastric emptying half-time increased from 6 weeks 19 (IQR 8.5) to 12 months 27 (IQR 11.5) min, p = 0.027. The incidence of deglutitive reflux of semi-solids decreased over time; 46.2% (6 weeks) vs. 18.2% (12 months), p-value < 0.0001. Reflux score of 10.6 ± 7.6 at 6 weeks vs. 3.5 ± 4.4 at 12 months, (p = 0.049) and regurgitation score of 9.9 ± 3.3 at 6 weeks vs. 6.5 ± 1.7, p = 0.021 significantly reduced.

CONCLUSIONS

These data demonstrate that there is an increase in the capacity of the proximal gastric sleeve to accommodate substrate over the first year. Gastric emptying remains rapid but reduce over time, correlating with improved food tolerance and reduced reflux symptoms. This is likely the physiological basis for the changes in symptoms and food tolerance observed early post-SG.

Turnkey algorithmic approach for the evaluation of gastroesophageal reflux disease after bariatric surgery

Bariatric surgeries are often complicated by de-novo gastroesophageal reflux disease (GERD) or worsening of pre-existing GERD. The growing rates of obesity and bariatric surgeries worldwide are paralleled by an increase in the number of patients requiring post-surgical GERD evaluation. However, there is currently no standardized approach for the assessment of GERD in these patients. In this review, we delineate the relationship between GERD and the most common bariatric surgeries: sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), with a focus on pathophysiology, objective assessment, and underlying anatomical and motility disturbances. We suggest a stepwise algorithm to help diagnose GERD after SG and RYGB, determine the underlying cause, and guide the management and treatment.

Clinical influence of conversion of laparoscopic sleeve gastrectomy to one anastomosis gastric bypass on gastroesophageal reflux disease

PURPOSE

Assess the subjective impact of gastro-esophageal reflux disease (GERD) symptoms on patients undergoing revision from laparoscopic sleeve gastrectomy (LSG) to one-anastomosis gastric bypass (OAGB) using the Reflux Disease Questionnaire for GERD (RDQ) and the GERD-health related quality of life score (GERD-HRQL), prior to- and following conversion.

METHODS

Patients undergoing revision from LSG to OAGB were prospectively followed between May 2015 and December 2020. Data retrieved included demographics, anthropometrics, previous bariatric history, time interval between LSG and OAGB, weight loss, and co-morbidities. Pre- and post-OAGB RDQ and GERD-HRQL questionnaires were obtained. In the case of sleeve dilatation, sleeve resizing was performed.

RESULTS

During the study period, 37 patients underwent revision from LSG to OAGB. Mean ages at LSG and pre-OAGB were 38 ± 11.74 and 46 ± 12.75, respectively. Median follow-up time was 21.5 months (range 3-65). All patients underwent sleeve resizing. RDQ and GERD-HRQL scores were obtained at a median of 14 months (range 3-51) between pre- and post-OAGB. Median RDQ score pre-OAGB vs post-OAGB was significantly reduced (30 (range 12-72) vs 14 (range 12-60), p = 0.007). All 3 parts of the GERD- HRQL questionnaires were significantly reduced between pre-OAGB and post-OAGB: Symptoms (20; 62.5% vs 10; 31.3%, p = 0.012), overall score (15 (0-39) vs 7 (0-28), p = 0.04) and subjective improvement (10; 31% vs 20; 62.5%, p = 0.025).

CONCLUSION

Conversion of LSG to OAGB showed subjective improvement of GERD symptoms both in RDQ and in GERD-HRQL.

Quantifying physiologic parameters of the gastroesophageal junction during robotic sleeve gastrectomy and identifying predictors of post-sleeve gastroesophageal reflux disease

BACKGROUND

Sleeve gastrectomy is among the most commonly-performed procedures for morbid obesity. However, patients occasionally develop post-sleeve gastroesophageal reflux disease (GERD). Identifying patients most at risk for this complication remains difficult. We aimed to correlate intra-operative physiologic measurements of the lower esophageal sphincter (LES) at the gastroesophageal junction (GEJ) during robotic sleeve gastrectomy in an attempt to identify predictors of post-sleeve GERD symptoms.

METHODS

A retrospective chart review of a prospectively maintained database identified 28 patients in whom robotic sleeve gastrectomy was performed utilizing EndoFLIP™ technology between January and September 2021. Intraoperative LES measurements at the GEJ including cross-sectional area (CSA), distensibility index (DI), intra-balloon pressure, and high-pressure zone (HPZ length) were correlated with post-operative GERD.

RESULTS

GEJ CSA, pressure, and DI increased over the course of the surgery (CSA pre-op: 31 (IQR 19.3-39.5) mm² vs. post-op: 67 (IQR 40.8-95.8) mm², p < 0.001; pressure: 25.8 (IQR 20.2-33.1) mmHg vs. 31.5 (IQR 28.9-37.0) mmHg, p = 0.007; DI 1.1 (IQR 0.8-1.8) mm²/mmHg vs. 2.0 (IQR 1.2-3.0) mm²/mmHg, p =  < 0.001), whereas HPZ length decreased (2.5 (IQR 2.5-3) cm vs. 2.0 (IQR 1.3-2.5) cm, p = 0.022). Twenty-three patients (82.1%) completed a post-operative GERD questionnaire. Fifteen (65.2%) had no GERD symptoms before or after surgery; 5 (21.7%) reported new post-sleeve GERD symptoms; 3 (13.0%) reported exacerbation of pre-existing GERD symptoms. Patients with new or worsening GERD symptoms had higher post-sleeve DIs (3.2 (IQR 1.9-4.5) mm²/mmHg vs. 1.5 (IQR 1.2-2.4) mm²/mmHg, p = 0.024) and lower post-sleeve LES pressures (29.9 (IQR 26.3-32.9) mmHg vs. 35.2 (IQR 31.0-38.0) mmHg, p = 0.023) than those without.

CONCLUSIONS

An increase in GEJ CSA, pressure, and DI, and a decrease in GEJ length can be expected during robotic sleeve gastrectomy. Patients with new or worsening post-sleeve GERD symptoms have higher post-sleeve DI and lower post-sleeve LES pressure than their asymptomatic counterparts.

Incidence of Abnormalities of the Gastric Tube Following Sleeve Gastrectomy and Its Role on Esophagitis Progression

PURPOSE

The purpose of this study is to determine the incidence of gastric tube abnormalities after SG and its relationship with esophagitis progression.

METHODS

Retrospective study which included 459 patients in the postoperative period of SG who underwent an esophagogastroduodenoscopy in both pre- and postoperative periods. The main studied variables were presence of gastric tube abnormalities (dilation, neofundus, twist, and hiatal hernia) and esophagitis progression.

RESULTS

Among the 459 patients who underwent SG, 393 (85.6%) were women, and 66 (14.4%) men, with mean age of 40.4 years. Mean preoperative BMI was 39.70 kg/m². In total, 20.3% of the sample presented progression of esophagitis after surgery. Among the whole sample, 130 (28.3%) presented with an abnormality of the remnant gastric tube. The most common alteration was gastric dilation, which occurred in 16.1% of the patients, followed by gastric twist (10.7%), neofundus (7.4%), and hiatal hernia (0.2%). Patients who presented with any abnormality of the gastric tube were significantly prone to presenting esophagitis progression (p = 0.013). When analyzing each morphological abnormality isolated, there was no statistically significant correlation.

CONCLUSION

Abnormalities of the gastric tube are not uncommon after SG and seems to contribute partially to the relevant rates of GERD and esophagitis after this surgery.

Post Sleeve Reflux: indicators and impact on outcomes

INTRODUCTION

Post-operative gastroesophageal reflux disease (GERD) remains a significant morbidity following sleeve gastrectomy (SG). We aim to evaluate the incidence and impact within a single center experience.

MATERIALS AND METHODS

A retrospective review of a prospectively maintained database was performed identifying laparoscopic or robotic SG patients. Primary outcomes included weight loss, rates of post-operative GERD (de-novo or aggravated), and re-intervention. Subgroup analysis was performed between patients with (Group 1) and without (Group 2) post-operative GERD. De-novo GERD and aggravated was defined as persistent GERD complaints or new/increased PPI usage in GERD naive or prior GERD patients, respectively.

RESULTS

392 patients were identified between 2014 and 2019. Average demographics: age 42.3 (18-84) years, Charlson Comorbidity Index (CCI) 1.12 (0-10), and body mass index (BMI) 47.7 (28-100). 98% were performed laparoscopically. Average excess weight loss (EWL) was 51.0% and 46.4% at 1 and 2 years post-operatively. Average follow up was 516 (6-2694) days. 69 (17%) patients developed post operative de-novo or aggravated GERD. Group 1 had significantly higher EWL at 9 months (57% vs 47%, p 0.003). 13 (3%) patients required operative re-intervention for GERD and other morbidities: 4 RYGB conversions, 4 diagnostic laparoscopies, 3 HHR, 1 MSA placement. Group 1 had higher rates of post-operative intervention (14% vs 1%, p 0.0001). Subanalysis demonstrated that Group 1 had elevated preoperative DeMeester scores on pH testing (34.8 vs 18.9, p 0.03). De-novo GERD had an elevated post-operative total acid exposure when compared to aggravated GERD (12.7% vs 7.0% p 0.03). No significant differences were found between preoperative endoscopy findings, pre and postoperative total acid exposure, post-operative DeMeester scores, and high-resolution manometry values regarding de-novo/aggravated GERD development.

CONCLUSION

Preoperative DeMeester scores may serve as risk indicators regarding post-operative GERD. Outcomes such as reintervention remain elevated in post-operative GERD patients.

Staple Line Intrathoracic Migration After Sleeve Gastrectomy: Correlation between Symptoms, CT Three-Dimensional Stomach Analysis, and 24-h pH Monitoring

PURPOSE

Migration of the staple line is the definition of sliding hiatus hernia in sleeve gastrectomy patients. The main aim was to determine the frequency and measurement of intrathoracic staple line migration and its correlation with GERD symptoms and pH monitoring.

MATERIALS AND METHODS

This was a prospective clinical trial including all patients who underwent sleeve gastrectomy more than 1 year previously. All the patients underwent computed tomography (CT) imaging, and migration of the proximal end of the suture above the level of the hiatus was measured in mm. All the patients with symptoms suggestive of GERD were assessed using the GERD impact scale (GIS), and wireless 24-h esophageal pH and symptom association monitoring (SAP) were carried out. Analysis of risk factors for postoperative staple line migration was performed.

RESULTS

Between March 2018 and December 2018, 194 patients were evaluated (mean age 45.1 ± 11.2 years; 161 females); 88/194 (45.4%) presented an average intrathoracic migration of 16.2 ± 6.9 mm. Thirty-eight of 194 (19.5%) patients presented symptoms suggestive of gastroesophageal reflux. There was a significant relationship between staple line intrathoracic migration and postsleeve GERD symptomatology (p = 0.0004, OR = 4.25 [1.92-9.39]). However, there was no significant correlation between positive 24-h pH monitoring and intrathoracic migration of the staple line (p = 0.1).

CONCLUSION

A migration greater than 17 mm was strongly correlated with postsleeve GERD symptoms but not with positive 24-h pH monitoring.

The new onset of GERD after sleeve gastrectomy: A systematic review

BACKGROUND

The main adverse effect is gastroesophageal reflux disease (GERD), with concern on the development of Barrett's esophagus and esophageal adenocarcinoma in the long term. However, the relationship between SG and GERD is complex. The aim of this study is to systematically evaluate all published data existing in the literature to evaluate the effect of sleeve gastrectomy on GERD, esophagitis, BE in order to clarify the long-term clinical sequelae of this procedure.

MATERIALS AND METHODS

This systematic review was conducted in accordance with the guidelines for Preferred Reporting Items for Systematic Review. The work has been reported in line with the PRISMA criteria [19]. We evaluated the quality and risk of bias of this Systematic Review using AMSTAR 2 checklist [20]. Published studies that contained outcome data for primary sleeve gastrectomy associated with the primary and secondary outcomes listed below were included. The UIN for ClinicalTrial.gov Protocol Registration and Results System is: NCT05178446 for the Organization UFoggia.

RESULTS

49 articles were eligible for inclusion that met the following criteria: publications dealing with patients undergoing laparoscopic SG, publications describing pre- and postoperative GERD symptoms and/or esophageal function tests, articles in English, human studies and text complete available.

CONCLUSIONS

We have controversial data on LSG and GERD in the literature as there is a multifactorial relationship between LSG and GERD. The most recent studies have shown satisfactory control of postoperative reflux in most patients and low rates of de novo GERD. These data are leading to wider acceptance of LSG as a bariatric procedure even in obese patients with GERD.

The Protective Effect of Transit Bipartition and Its Modification Against Sleeve Gastrectomy-Related Esophagitis in a Rodent Model

BACKGROUND

The protective effect of transit bipartition against esophagitis has not yet been proven. Thus, we investigate and compare the bariatric outcomes and esophagus' histological changes of sleeve gastrectomy (SG), SG with transit bipartition (SG-TB), and the proximal SG-TB (SG-PTB) in a rodent model.

METHODS

This study included 45 diabetic Sprague-Dawley rats assigned to one of the four groups, SG-PTB (n = 15), SG-TB (n = 12), SG (n = 10), and SHAM (n = 8). Eight surviving rats from each group were included for further investigation. Histological analysis of the gastroesophageal junction was performed. Body weight, food intake, glucose control, and hormonal changes (glucagon-like peptide-1 and insulin) were assessed before and after surgery in all groups.

RESULTS

Preoperatively, no significant differences were observed in food intake, body weight, and fasting blood glucose levels among the groups. Postoperatively, the SG-PTB and SG-TB groups showed significantly superior glucose control compared to the SG group following the gavage of glucose (p < 0.05). Postoperatively, the SG-PTB and SG-TB groups had higher postoperative GLP-1 levels than postoperative SG and SHAM groups. More severe esophageal hyperpapillomatosis (EHP) of the esophageal section was observed in the SG group. The mucosal height of the SG group was significantly higher than that of the SG-PTB, SG-TB, and SHAM groups (p < 0.05).

CONCLUSION

The transit bipartition procedure may protect the distal esophagus from histological changes associated with esophagitis. Clinical studies are needed to confirm the anti-reflux effects of transit bipartition.

The Impact of Sleeve Gastrectomy on Gastroesophageal Reflux Disease in Patients with Morbid Obesity

INTRODUCTION

The impact of laparoscopic sleeve gastrectomy (LSG) on gastroesophageal reflux disease (GERD) has not been widely quantified, and the data in the literature remain controversial.

MATERIALS AND METHODS

Candidates for LSG underwent barium swallow, esophageal manometry, ambulatory 24-h esophageal pH monitoring (APM), and gastric emptying scintigraphy before and after surgery (1 and 18 months). Symptoms were evaluated using a gastroesophageal reflux disease questionnaire (GERDq). Esophagogastroduodenoscopy was performed preoperatively in all patients and at 18 months postoperatively in patients who had suffered from preoperative esophagitis.

RESULTS

Fifty-two patients were included in the study (64.4% women and 34.6% men) with a median age of 46 years (25-63 years) and BMI of 45.0 ± 5.6 kg/m². The follow-up rates at 1 and 18 months were 82.7% and 80.8%. At 18 months, the percentage of weight loss (%TWL) was 33.6 ± 10.4% and the percentage of excess BMI loss (%EBMIL) was 77.6 ± 25%. Postoperatively, a significant increase in accelerated gastric emptying and impaired esophageal body motility occurred at 1 and 18 months. A significant worsening of all the values obtained at both 1 and 18 months postoperatively becomes evident when comparing the results of the APM. After surgery, 76.4% of patients had developed "de novo" GERD at 1 month and 41% at 18 months. No improvement was found in patients with symptomatic GERD.

CONCLUSION

Based on the results of this study, LSG led to a considerable rate of postoperative "de novo" GERD. In addition, no improvement was found in patients with symptomatic GERD.

Relationship between gastroesophageal reflux disease and laparoscopic sleeve gastrectomy: a narrative review

This paper aims to revisit the relationship between gastroesophageal reflux disease and laparoscopic sleeve gastrectomy in obese patients by reviewing the recent available literature, in the form of a narrative review. The interpretation of the current evidence is challenged by the fact that published data are contradictory and comparison between studies is difficult. Most studies investigate the presence of gastroesophageal reflux disease by assessing only the symptoms reported by patients. A few studies have objectively investigated gastroesophageal reflux disease by functional tests and endoscopic evaluation. Also, the surgical technique of laparoscopic sleeve gastrectomy plays an important role in the incidence of postoperative gastroesophageal reflux disease. In conclusion, surgeons must be aware of the existence of gastroesophageal reflux disease and, at the same time, patients should be informed regarding the possible effect of laparoscopic sleeve gastrectomy on gastroesophageal reflux disease.

Does Sleeve Gastrectomy Worsen Gastroesophageal Reflux Disease in Obese Patients? A Prospective Study

BACKGROUND

To evaluate the impact of laparoscopic sleeve gastrectomy (LSG) and gastric bypass (LGB) on gastroesophageal reflux disease (GERD).

METHODS

GERD was evaluated by the Modified Italian Gastroesophageal reflux disease-Health-Related Quality of Life (MI-GERD-HRQL) questionnaire, pH-manometry, endoscopy, and Rx-esophagogram, before and 12 months after surgery. Based on these exams, patients without GERD underwent LSG, and patients with GERD underwent LGB.

RESULTS

Thirteen and six patients underwent LSG and LGB, respectively. After LSG, the only statistically significant difference observed at pH-manometry was the median DeMeester score, from 5.7 to 22.7 (P = .0026). De novo GERD occurred in 6 patients (46.2%), with erosive esophagitis in one. The median MI-GERD-HRQL score improved from 3 to 0. Overall, nine patients underwent LGB, but three were lost to follow-up. Preoperative pH-manometry changed the surgical indication from LSG to LGB in 7 out of 9 patients (77.8%). Six patients who underwent LGB completed the study, and at pH-manometry, statistically significant differences were observed in the percentage of total acid exposure time, with the number of reflux episodes lasting >5 minutes and DeMeester score (P = .009). The median MI-GERD-HRQL score improved from 6.5 to 0. Statistically significant differences were not observed at endoscopy and Rx-esophagogram findings in both groups.

CONCLUSIONS

LSG has a negative impact on GERD, even in patients without preoperative GERD. LGB confirmed to be the intervention of choice in patients with GERD. Preoperative pH-manometry may identify patients with silent GERD, to candidate them to LGB rather than LSG. pH-manometry should be used more liberally to establish the correct surgical indication on objective grounds.

Manometric and pH-monitoring changes after laparoscopic sleeve gastrectomy: a systematic review

PURPOSE

Aim of this systematic review is to assess the changes in esophageal motility and acid exposure of the esophagus through esophageal manometry and 24-hours pH-monitoring before and after laparoscopic sleeve gastrectomy (LSG).

METHODS

Articles in which all patients included underwent manometry and/or 24-hours pH-metry or both, before and after LSG, were included. The search was carried out in the PubMed, Embase, Cochrane, and Web of Science databases, revealing overall 13,769 articles. Of these, 9702 were eliminated because they have been found more than once between the searches. Of the remaining 4067 articles, further 4030 were excluded after screening the title and abstract because they did not meet the inclusion criteria. Thirty-seven articles were fully analyzed, and of these, 21 further articles were excluded, finally including 16 articles.

RESULTS

Fourteen and twelve studies reported manometric and pH-metric data from 402 and 547 patients, respectively. At manometry, a decrease of the lower esophageal sphincter resting pressure after surgery was observed in six articles. At 24-hours pH-metry, a worsening of the DeMeester score and/or of the acid exposure time was observed in nine articles and the de novo gastroesophageal reflux disease (GERD) rate that ranged between 17.8 and 69%. A meta-analysis was not performed due to the heterogeneity of data.

CONCLUSIONS

After LSG a worsening of GERD evaluated by instrumental exams was observed such as high prevalence of de novo GERD. However, to understand the clinical impact of LSG and the burden of GERD over time further long-term studies are necessary.

Effects of Obesity Surgery on GERD and Esophageal Motility

With the rising prevalence of obesity, bariatric surgery has become an increasingly popular treatment option. However, bariatric surgery can contribute to esophageal dysmotility and lead to worsening or development of GERD, two conditions that are already frequently seen in the obese population. We review the effects of the various types of bariatric surgeries on the esophagus, specifically focusing on sleeve gastrectomy, Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding.

Gastroesophageal Reflux Disease, Esophagitis, and Barrett's Esophagus 3 to 4 Years Post Sleeve Gastrectomy

BACKGROUND

Sleeve gastrectomy (SG) has become the most popular bariatric procedure worldwide. However, SG is associated with de novo gastroesophageal reflux (GERD) and esophagitis, with concerns for progression into Barrett's esophagus (BE). The purpose of this study is to assess the clinical and endoscopic progression of GERD, esophagitis, and BE 3 to 4 years after SG.

METHODS

Fifty-eight patients (pts) were assessed with endoscopy preoperative and at 3 to 4 years post SG, representing 44.9% follow-up. Endoscopy was offered to all SG pts regardless of symptoms. Outcomes including percent total weight loss (%TWL), PPI use, esophagitis progression, de novo reflux, and BE formation.

RESULTS

At post-op follow-up, the %TWL was 23%. The average BMI dropped from 49.07 to 37.5. De novo reflux developed in 13 pts (30.9%). Of the 16 pts with GERD pre-op, 37.5% improved, 25% had stable disease, and 37.5% had worsening symptoms. The rate of esophagitis nearly doubled from 37.9% pre-op to 70.6% post-op. A majority of post-op pts had mild esophagitis (87.8%), with 12.1% with LA classes C and D. Asymptomatic esophagitis was found in 68.2% of post-op pts. The incidence of BE was 12.7% post-op, with de novo BE developing in 4 pts, representing 7.2%.

CONCLUSION

SG is associated with increased rates of asymptomatic esophagitis and de novo reflux at 3 to 4 years post-op. De novo BE was detected as well, highlighting the importance of post-op screening. The majority of pts with GERD pre-op have stable disease or improve.

Assessment and management of gastroesophageal reflux disease following bariatric surgery

Gastroesophageal reflux disease (GERD) is a common disease in patients with obesity. The incidence of de novo GERD and the effect of bariatric surgery on patients with pre-existing GERD remain controversial. Management of GERD following bariatric surgery is complicated and can range from medical therapy to non-invasive endoscopic options to invasive surgical options. To address these issues, we performed a systematic review of the literature on the incidence of GERD and the various modalities of managing GERD in patients following bariatric surgery. Given the increased number of laparoscopic sleeve gastrectomy (LSG) procedures being performed and the high incidence of GERD following LSG, bariatric surgeons should be familiar with the options available to manage GERD following LSG as well as other bariatric procedures.

Excess Body Weight and Gastroesophageal Reflux Disease

Background

Gastroesophageal reflux disease (GERD) is strongly associated with excess body weight.

Summary

GERD is characterized by typical symptoms with or without mucosal damage because of retrograde flow of gastric content into the esophagus. An ineffective esophagogastric junction (EGJ) combined with anatomical abnormalities is considered to be causative. The incidence of GERD is strongly associated with excess body weight, reflecting the pathophysiological relevance of the abdominothoracic pressure gradient.

Key Message

Weight loss has been demonstrated to be an effective therapy for GERD combined with obesity. In cases in which surgical therapy is indicated, traditional antireflux surgery has led to equivocal results, advocating a proximal Roux-en-Y gastric bypass in these patients to correct both GERD and excess body weight.

Morphological alterations in gastrointestinal organs of western-diet obese rats submitted to vertical sleeve gastrectomy or Roux-en-Y gastric bypass

To assess the effect of vertical sleeve gastrectomy (VSG) and Roux-en-Y gastric bypass (RYGB) on the esophageal and intestinal morphology of western diet (WD)-obese rats and to characterize the stomach histopathology of WD rats submitted to VSG. Male Wistar rats received WD from 2-4 months of age, to induce obesity, before randomly submitting them to pseudo (WD-SHAM), VSG (WD-VSG) or RYGB (WD-RYGB) surgeries. Gastrointestinal histomorphometry was performed at 3-months post-surgery. The upper esophagus of VSG and RYGB rats increased luminal area, while reductions in the keratin layer of the mucosa and the tunica muscularis were observed only in the RYGB animals. In the lower esophagus, both surgeries increased keratin layer thickness, but reduced the mucosal mucus content, while RYGB increased the thickness of the tunica mucosa and muscularis. The glandular region of the stomach of WD-VSG rats exhibited hypotrophy, epithelial erosion, fibrosis and moderate inflammatory infiltration. VSG and RYGB increased the villi height in the ileum, and the thickness of the tunica muscularis in the jejunum and ileum of WD rats; furthermore, RYGB augmented the ileal villi height. Thus both approaches induced histomorphological alterations in the esophagus and intestine and VSG damaged the gastric mucosa, even over the long-term.

Impact of bariatric surgery on gastroesophageal reflux disease and esophageal motility

PURPOSE OF REVIEW

Obesity is rapidly increasing in prevalence, and bariatric surgery has become a popular treatment option that can improve all-cause mortality in obese individuals. Gastroesophageal reflux disease (GERD) and esophageal motility disorders are common in the obese population, and the effects of bariatric surgery on these conditions differ depending on the type of bariatric surgery performed.

RECENT FINDINGS

Laparoscopic adjustable gastric banding has declined in popularity due to its contributions to worsening GERD symptoms and the development of esophageal dysmotility. Although laparoscopic sleeve gastrectomy (LSG) is the most popular type of bariatric surgery, a comprehensive assessment for acid reflux should be performed as LSG has been linked with worsening GERD. Novel methods to address GERD due to LSG include magnetic sphincter augmentation and concomitant fundoplication. Due to the decreased incidence of postoperative GERD and dysmotility compared to other types of bariatric surgeries, Roux-en-Y gastric bypass should be considered for obese patients with GERD and esophageal dysmotility.

SUMMARY

Bariatric surgery can affect esophageal motility and contribute to worsening or development of GERD. A thorough workup of gastrointestinal symptoms before bariatric surgery should be performed with consideration for formal testing with high-resolution manometry and pH testing. Based on these results, the choice of bariatric surgery technique should be tailored accordingly to improve clinical outcomes.

Expected Values of Esophageal Transit and Gastric Emptying Scintigraphy Post-uncomplicated Sleeve Gastrectomy

PURPOSE

Sleeve gastrectomy (SG) results in significant anatomical and physiological alterations of the esophagus and stomach, including food tolerance. Currently, there is no consensus on the parameters of abnormal esophageal transit and gastric emptying in this population. We describe standardized esophageal transit and gastric emptying protocols, and define expected values following an uncomplicated SG.

MATERIALS AND METHODS

In 43 asymptomatic post-SG patients with optimal weight loss, a standardized liquid and semi-solid (oatmeal) esophageal transit study, plus a 90-min semi-solid gastric emptying study with dynamic 5-s image acquisition to assess gastroesophageal reflux, was performed. Gastric emptying half-time and retention rate was calculated. Esophageal transit and reflux were graded by visual inspection of images.

RESULTS

Thirty-one female and 12 male patients participated: mean age 49.0±10.7 years, pre-operative BMI 47.6±7.0 kg/m², excess weight loss 58.8±26.0% at median follow-up of 7.4 months. The standardized semi-solid meal and liquid preparations were well tolerated. Delays in esophageal transit of liquid and semi-solid boluses were infrequent (7.0% and 16.3% respectively). Deglutitive reflux of both semi-solids and liquids was common (48.8% and 32.6%). The median semi-solid gastric emptying half-time was 21.0 min. A large proportion of substrate transited into the small bowel on initial image acquisition (median 39.1%). Reflux events during gastric emptying were common (median 5.0 events, 12.7% of image acquisition time).

CONCLUSIONS

Rapid gastric emptying with asymptomatic deglutitive and post-prandial gastroesophageal reflux events are common following SG. We have defined the expected values of standardized esophageal transit and gastric emptying scintigraphy specifically tailored to SG patients.

Sleeve gastrectomy versus Roux-en-Y gastric bypass in patients Aged ≥65 years: a comparison of short-term outcomes

BACKGROUND

Bariatric surgery in the elderly population has been reported as feasible and safe. Sleeve gastrectomy (SG) seems to have fewer complications than Roux-en-Y gastric bypass (RYGB) even in the 65 years of age population. We analyzed the difference in weight loss between SG and RYGB in patients age 65 years.

OBJECTIVES

To analyze and compare outcomes between SG and RYGB in patients 65 years of age and older.

SETTING

Academic hospital, United States.

METHODS

After internal review board approval, we retrospectively reviewed 2486 patients who underwent either SG or RYGB between 2005 and 2018 at our institution. Basic demographics, preoperative body mass index (BMI), and co-morbidities were described. We identified all patients age ≥65 years and subsequently divided them into 2 groups based on type of bariatric procedure performed. Analysis and comparison of outcomes between these groups were completed. Postoperative BMI was reviewed at 6, 12, and 24 months and percent excess BMI loss (%EBMIL, as defined by the ASMBS clinical committee) was calculated accordingly. The t test and χ² analysis were performed for nominal and categorical variables, respectively.

RESULTS

From 2486 patients reviewed, 22.7% (n = 565) were aged ≥65 years. From these, 43.1% (n = 244) underwent SG and 56.8% (n = 321) underwent RYGB. White and female patients were predominant in both groups. Mean age was similar for both populations (SG: 71.1 ± 4.0, RYGB: 71.7 ± 4.5; P = .12). Pre-procedure mean BMI for both groups was close in value, but the difference was statistically significant (40.5 ± 5.5 for SG versus 43.7 ± 7.2 for RYGB; P < .0001). Postoperative follow-up rates were similar in both groups at 12 and 24 months (SG: 51.2% and 31.6%; RYGB: 48.3% and 34.3%; P = .49 and P = .5). The %EBMIL at 6, 12, and 24 months was higher for the RYGB group than the SG group (59.3 ± 27.9, 72.1 ± 29.5, 77.4 ± 26.1 versus 50.2 ± 21.9, 55.2 ± 25.6, 43.9 ± 32.2; P < .01, P < .01, and P < .01, respectively). Complication rates were significantly higher in RYGB versus SG (27.7% versus 9.4%; P < .01). We observed significantly higher anastomotic ulcer and stricture rates for RYGB versus SG (7.2% and 5.9 versus 0% and 0%; P < .01 and P < .01, respectively). RYGB had a higher rate for gastrointestinal obstruction requiring intervention (2.2% versus .4%; P = .07). A similar de novo gastroesophageal reflux disease rate was noted in both procedures (3.7% versus 3.7%; P = .98). No leaks were reported in either group.

CONCLUSIONS

Both SG and RYGB are effective weight loss procedures for patients aged ≥65 years. RYGB seems to have higher %EBMIL at 1 and 2 years; however, when compared with SG, complication rates appear to be almost 3 times higher.

Sleeve Gastrectomy and Anterior Fundoplication (D-SLEEVE) Prevents Gastroesophageal Reflux in Symptomatic GERD

BACKGROUND

A worrying increase of gastroesophageal reflux disease (GERD) and Barrett esophagus has been reported after sleeve gastrectomy (SG). Recent reports on combined fundoplication and SG seem to accomplish initial favorable results. However, no study included manometry or pH monitoring to evaluate the impact of fundoplication in SG on esophageal physiology.

METHOD

In this study, 32 consecutive bariatric patients with GERD and/or esophagitis had high-resolution impedance manometry (HRiM) and combined 24-h pH and multichannel intraluminal impedance (MII-pH) before and after laparoscopic sleeve gastrectomy associated to anterior fundoplication (D-SLEEVE). The following parameters were calculated at HRiM: lower esophageal sphincter pressure and relaxation, peristalsis, and mean total bolus transit time. The acid and non-acid GER episodes were assessed by MII-pH, symptom index association (SI), and symptom-association probability (SAP) were also analyzed.

RESULTS

At a median follow-up of 14 months, HRiM showed an increased LES function, and MII-pH showed an excellent control of both acid exposure of the esophagus and number of reflux events. Bariatric outcomes (BMI and EWL%) were also comparable to regular SG (p = NS).

CONCLUSION

D-SLEEVE is an effective restrictive procedure, which recreates a functional LES pressure able to control and/or prevent mild GERD at 1-year follow-up.

Impact of Laparoscopic Sleeve Gastrectomy on Gastroesophageal Reflux Disease and Risk Factors Associated with Its Occurrence Based Upon Quality of Life

BACKGROUND

To assess the impact of laparoscopic sleeve gastrectomy (LSG) on gastroesophageal reflux disease (GERD) symptoms and to determine factors associated with the occurrence of post-LSG GERD symptoms.

MATERIAL AND METHODS

This is a retrospective study that included all obese patients who underwent LSG in Aseer Central Hospital, during the period from August 2017 to August 2019. GERD-Health-Related Quality of Life questionnaire was used to assess the patients' pre- and postoperative GERD symptoms and their satisfaction toward their general health.

RESULTS

The study included 326 patients (195 males and 131 females) with a mean age of 39.43 ± 11.17 years. Postoperatively, GERD symptoms newly developed in 105 patients (32.2%), while 25 patients out of 127 with preoperative GERD symptoms (19.69%) showed resolution of symptoms. There were significant associations (p < 0.001) between the old age, smoking and existence of comorbidities, and the occurrence of postoperative heartburn and regurgitation symptoms. Postoperatively, excess weight loss (EWL) was significantly associated with postoperative regurgitation (p = 0.045) and patients showed significant improvement in their satisfaction toward their health condition even those who developed GERD symptoms.

CONCLUSIONS

After LSG, GERD symptoms developed in about one-third of the patients while symptoms improved in only one-fifth of patients. Older patients, smokers, patients with comorbidities, and patients with more EWL had significantly worse GERD symptoms postoperatively. Weight loss rather than GERD symptoms significantly influenced patients' satisfaction toward their general health. Further prospective studies are needed to determine the relationship between weight loss and other factors associated with post-LSG reflux and overall quality of life.