Prevalence of Barrett's Esophagus in Bariatric Patients Undergoing Sleeve Gastrectomy. Obes Surg. 2016;26:710-714. [PMID: 25855575 DOI: 10.1007/s11695-015-1574-1]

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.

Impact of surgical technique on gastroesophageal reflux disease after laparoscopic sleeve gastrectomy: a nationwide observational study

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has gained increasing popularity worldwide, yet concerns persist regarding the development of gastroesophageal reflux disease (GERD) postoperatively.

OBJECTIVES

This study aimed to evaluate the influence of technical aspects of LSG, specifically bougie size and distance from the pylorus to resection line edge, on the risk of developing symptomatic GERD within 2years following surgery.

SETTING

Data from the Scandinavian Obesity Surgery Registry (SOReg) and the National Prescribed Drug Register were utilized for this analysis.

METHODS

A retrospective observational study was conducted encompassing all LSG patients in Sweden between 2012 and 2020 who did not receive preoperative proton pump inhibitor (PPI) prescriptions. Patients were categorized based on bougie size and pyloric distance. Regular PPI use, defined as a dispensed prescription of more than 300 tablets per year, was employed as a proxy measure of symptomatic GERD and was compared between the groups.

RESULTS

The study included 7,435 patients with complete data on dispensed PPI prescription both preoperatively and throughout the 2-year follow-up period. Information on bougie size and pyloric distance was available for 97.4% and 84.9%, respectively. Narrower bougie size and greater pyloric distance were associated with increased risk of regular PPI use postsurgery. Advanced age and female sex were independent risk factors for post-LSG regular PPI use, while initial body mass index (BMI), total weight loss (%TWL), and comorbidities showed no significant associations.

CONCLUSIONS

Using a narrow bougie and initiating resection at a greater distance from the pylorus were associated with higher risk of symptomatic de novo GERD following LSG.

Efficacy of combined sleeve gastrectomy and nissen fundoplication for weight loss and prevention of postoperative gastroesophageal reflux disease in patients with obesity: a systematic review and meta-analysis

The addition of a Nissen fundoplication to the sleeve gastrectomy (SG) has been recently proposed to reduce the incidence of postoperative gastroesophageal reflux disease (GERD). The aim of this study was to assess the effectiveness and safety of laparoscopic Nissen Sleeve (LNS). A systematic review using the Medline database was performed to identify original articles analyzing outcomes after LNS. Main outcomes included weight loss, improvement of GERD symptoms, esophagitis, proton pump inhibitor (PPI) usage, and pH monitoring. Postprocedural complications were included as secondary outcomes. A meta-analysis of proportions and paired preintervention and postintervention tests were used to assess the effect of the procedure on the different outcomes. A total of 5 studies comprising 246 patients undergoing LNS were included in the analysis. Mean age was 43.22 (40-46.2) years and 201 (85.12%) were females. The mean preoperative body mass index (BMI) of patients was 38.10 (33.9-40.4) kg/m2. After a mean follow up of 27 (12-60) months, there was a significant reduction in mean BMI (pre: 38.10 versus post: 29.36, P < .007) and a mean excess weight loss (EWL) of 59.10% (26%-82%). The proportion of patients with GERD symptoms (pre: 80.16% versus post: 11.22%, P = .001) were significantly reduced after the operation. The use of PPIs (pre: 69% versus post: 8.98%, P = .10) and presence of esophagitis (pre: 69.6% versus post: 18%, P = .05) also reduced after the procedure, but this was not statiscally significant. Overall morbidity rate was 4% (95% confidence interval [CI], 1%-11%), with a weighted pooled proportion of 2% (95% CI, 0%-6%) for leaks, 2% (95% CI, 1%-5%) for strictures, 1% (95% CI, 1%-3%) for bleeding, and 3% (95% CI, 1%-5%) for perforation. LNS seems to be a safe and effective operation with apparently better GERD-related outcomes than SG alone. Further studies with longer follow-up and objective measurement of reflux are needed to confirm the successful outcomes of the procedure.

Effect of sleeve gastrectomy on distal esophagus at 5 and 10 years

BACKGROUND

Sleeve gastrectomy (SG) is a primary surgical intervention for obesity management. However, several longitudinal studies have documented the emergence of long-term esophageal consequences, notably gastroesophageal reflux disease (GERD) and its associated complications. This study aimed to assess the occurrence of esophageal complications, including esophagitis and Barret's esophagus (BE), 5 and 10 years after SG, in one medical center.

METHODS

Two cohorts of consecutive patients who underwent SG were studied: patients who underwent a systematic upper gastro-intestinal endoscopy (UGIE) at five years or conversion to RYGB < 5 years (cohort n°1, n = 219), and patients who underwent UGIE at 10 years or converted to RYGB > 5 years (cohort n°2, n = 72). Patients with missing UGIE before or after SG were excluded.

RESULTS

In the cohort n°1, 62.7% of the patients had clinical GERD at the 5-years follow-up (vs. 21.8 before SG, p < 0.0001), 27.4% had esophagitis (vs. 14.2% before SG, p = 0.0006), and 8.3% had BE (vs. 1.8% before SG, p = 0.002) with metaplasia in 1.8%. De novo esophagitis and BE accounted for 19.6% and 7.8%, respectively. In the cohort n°2, at 10 years, 61.5% had clinical GERD (vs.12.5 before SG, p < 0.0001), 23.6% had esophagitis (vs. 9.7% before SG, p = 0.025) including 20.8% de novo, and 8.3% had de novo BE, with metaplasia in 5.6%. De novo esophagitis accounted for 20.8%. One patient developed esophageal adenocarcinoma 10 years after SG. Pre-operative esophagitis was significantly associated with BE on UGIE at 5 or 10 years, while active smoking and preoperative esophagitis were risk factors for esophagitis.

CONCLUSION

This study highlights a significant increase in esophageal complications 5 and 10 years after SG. Pre-operative esophagitis should be considered when choosing a surgical technique for obesity management.

Incidence of Barrett's Esophagus Following Sleeve Gastrectomy in Southeast Asian Population

Background: Variable incidences (up to 18.8%) of Barrett's esophagus (BE) have been reported following sleeve gastrectomy (SG), however, there is no published data from the Southeast Asian population. Objective: To determine the incidence of BE following SG in Southeast Asians. Materials and Methods: In this cross-sectional observational study from a tertiary-care center, all patients who had undergone SG from 2008 to 2021 and completed a minimum of 1-year follow-up were contacted to participate. Preoperative data were retrieved from a prospectively maintained database. On recruitment, all patients underwent barium swallow and upper gastrointestinal endoscopy, and weight parameters and reflux symptoms were recorded. Results: One hundred fourteen patients with no preoperative evidence of BE were included. The mean follow-up duration was 5.4 ± 3.1 years. On follow-up endoscopy, Barrett's was suspected in 4 patients. However, 3 patients had columnar-lined epithelium and only 1 patient (0.87%) had evidence of intestinal metaplasia without dysplasia on histology. Reflux esophagitis (grade LA-A) resolved in 9 out of 11 patients, while the rate of de novo esophagitis was reported in 22.3%. The mean reflux Symptom Severity score increased from 0.6 ± 1.8 to 2.6 ± 5.4 (P = .002). The mean body mass index reduced from 44.1 ± 7.1 to 33.6 ± 6.9 kg/m2 (P < .0001), however, 23.7% of the patients experienced significant weight recidivism. Conclusions: Southeast Asians might have a low incidence of BE following SG. Hence, endoscopic surveillance for the sole purpose of diagnosing BE may not be advisable for these patients.

GERD-screening before bariatric surgery: the predictive value of the GERD-HRQL questionnaire score compared with preoperative EGD findings

BACKGROUND

There is an ongoing debate on how to best identify patients with gastroesophageal reflux disease (GERD) before bariatric surgery. The value of routine preoperative esophagogastroduodenoscopy (EGD) is questioned, and patient reported symptoms are commonly used for screening. The goal of this study is to determine if patient reported symptoms using a validated questionnaire correlate with preoperative EGD findings.

METHODOLOGY

A prospective cohort study at a single institution was performed. Patients undergoing bariatric surgery between December 2020 and March 2023 were required to report symptoms of reflux by completing a preoperative GERD. Health-Related Quality of Life (GERD-HRQL) questionnaire and undergo a mandatory preoperative screening EGD. Patients were stratified into two cohorts: (group A) asymptomatic (score = 0) and (group B) symptomatic (score > 0). Statistical analysis was conducted using Pearson's chi-squared test and Wilcoxon rank-sum test in RStudio version 4.2.2. The predictive value of the GERD-HRQL score was analyzed using Areas Under the Curve (AUC; AUC = 0.5 not predictive, 0.5 < AUC ≥ 6 poor prediction & AUC > 0.9 excellent prediction) calculated from Receiver Operating Characteristic (ROC) curves.

RESULTS

200 patients were included; median age was 42.0 years (IQR 36.0 to 49.2). There were 79 patients (39.5%) in Group A and 121 patients (60.5%) in Group B. There was no difference in the frequency esophagitis (27.8% vs 32.2%, p = 0.61) or hiatal hernias (49.4% vs 47.1%, p = 0. 867) between group A and group B, respectively. ROC analysis revealed that the total GERD HRQL scores, heartburn only scores and regurgitation only scores, were poor predictors of esophagitis found on EGD (AUC 0.52, 0.53, 0.52), respectively. In asymptomatic patients, higher BMI was significantly associated with esophagitis (OR 1.15, 95% CI 1.06-1.27, p = 0.002).

CONCLUSION

Symptoms, identified through the GERD-HRQL questionnaire, are a poor indicator of esophagitis or its severity in patients undergoing workup for bariatric surgery. Therefore, liberal screening upper endoscopy is recommended for pre-bariatric surgery patients to guide appropriate procedure selection.

Long-Term Outcome of Laparoscopic Sleeve Gastrectomy (LSG) on Weight Loss in Patients with Obesity: a 5-Year and 11-Year Follow-Up Study

BACKGROUND

Bariatric surgery is the most efficient treatment for patients with clinically severe obesity who have failed to obtain satisfactory weight loss through lifestyle modification and medical treatments. This study aimed to present our long-term laparoscopic sleeve gastrectomy (LSG) efficacy in terms of weight loss and obesity-related complications resolution.

PATIENTS AND METHODS

This is a retrospective study that was based on prospectively collected data from patients undergoing LSG by the same surgeon from July 2011 to the end of August 2022. The LSG-associated short-term (at 3 months, 6 months, and 1 year postoperatively) and long-term (at 5 years and 11 years postoperatively) weight loss, and the short-term (6 months postoperatively) and long-term (5 and 11 years postoperatively) rates of obesity-related complications were assessed.

RESULTS

This study included 892 patients who underwent LSG over 11 years. At the 1-year follow-up, data on 860 patients were available, while at the 5-year and 11-year follow-ups, data on 193 patients and 48 patients, respectively, were available. The mean EBWL% was 84.57 ± 18.41%, 64.22 ± 15.53%, and 66.01 ± 8.66% at the 1-year, 5-year, and 11-year follow-ups, respectively.

CONCLUSION

This study adds new evidence concerning the short-term efficacy of LSG. The long-term assessment showed relatively sustainable weight loss and obesity-related complications resolution, with a regression of the short-term gains that was still far from the baseline burden.

Gastroesophageal reflux management after vertical sleeve gastrectomy

VSG is the most used surgical procedure in the world. Among the main complications linked to this procedure is GERD. It is apparent that endoscopic control protocols should be undertaken in all patients recovering from a VSG procedure. This is particularly key when taking into account the large number of patients suffering from GERD that show no symptoms, a situation that in many cases leads to severe esophagitis or even adenocarcinoma. Once the pertinent diagnostic tests have been carried out, the specialist should seek a conservative medical treatment including PPI. In the event that this treatment should fail, the next step to be considered should be a surgical procedure. In this case, the ideal procedure would be a reconversion to gastric bypass due to its low-risk and its results. There are other alternatives such as the Stretta, Linx or ARMS procedures; however, further research is necessary to prove their reliability.

Barrett's esophagus and esophageal cancer after sleeve gastrectomy. Myth or reality?

Sleeve gastrectomy has become the most performed bariatric surgery technique in the world. This bariatric technique has been related to the appearance of gastroesophageal reflux and recently with de novo Barrett's esophagus. It is not clear that this leads to an increased incidence of esophageal adenocarcinoma. In this review we analyze the current scientific literature to try to answer the true incidence of Barrett's esophagus and adenocarcinoma after sleeve gastrectomy, and whether these data should make us change the indications for this technique.

Possible technical aspects involved in the development of GERD after sleeve gastrectomy: Surgical technique considerations

Sleeve gastrectomy (SG) is the most common bariatric surgery worldwide and has shown to cause de novo or worsen symptoms of gastroesophageal reflux disease (GERD). Esophageal motility and physiology studies are mandatory in bariatric and foregut centers. The predisposing factors in post-SG patients are disruption of His angle, resection of gastric fold and gastric fundus, increased gastric pressure, resection of the gastric antrum, cutting of the sling fibers and pyloric spasm. There are symptomatic complications due to sleeve morphology as torsion, incisura angularis stenosis, kinking and dilated fundus. In this article, we present recommendations, surgical technique and patient selection flow diagram for SG and avoid de novo or worsening GERD.

Meta-analysis of Long-term De Novo Acid Reflux-Related Outcomes Following Sleeve Gastrectomy: Evidence Against the Need for Routine Postoperative Endoscopic Surveillance

OBJECTIVES

To evaluate the incidence of long-term de novo acid reflux-related complications following sleeve gastrectomy (SG) to determine whether routine postoperative surveillance endoscopy is necessary.

METHODS

A systematic search of Medline, Embase, CINAHL, CENTRAL, the Web of Science, and bibliographic reference lists was conducted. A proportion meta-analysis model was constructed to quantify the risk of the de novo gastro-oesophageal reflux disease (GORD), oesophagitis, and Barrett's oesophagus (BE) at least 4 years after SG. Random-effects modelling was applied to calculate pooled outcome data.

RESULTS

Thirty-two observational studies were included reporting a total of 7904 patients who underwent primary SG and were followed up for at least 4 years. The median follow-up period was 60 months (48-132). Preoperative acid-reflux symptoms existed in 19.1% ± 15.1% of the patients. The risk of development of de novo GORD, oesophagitis, and BE after SG was 24.8% (95% CI 18.6-31.0%), 27.9% (95% CI 17.7-38.1%), and 6.7% (95% CI 3.7-9.7%), respectively. The between-study heterogeneity was significant in all outcome syntheses. It was suspected that several of the included studies have not reported BE and oesophagitis because such events might not have happened in their cohorts.

CONCLUSIONS

Long-term risk of de novo GORD after SG seems to be comparable with those of the general population which questions the merit of surveillance endoscopy after SG in asymptomatic patients. De novo BE and oesophagitis after SG have not been reported by most of the available studies which may lead to overestimation of the rates of both outcomes in any evidence synthesis. We recommend endoscopic surveillance for symptomatic patients only.

Reflux and Barrett's esophagus after sleeve gastrectomy: analysis of a statewide database

BACKGROUND

Recent studies have suggested that sleeve gastrectomy (SG) is associated with the development of Barrett esophagus (BE) even in the absence of gastroesophageal reflux disease (GERD) symptoms.

OBJECTIVE

The aim of this study was to assess the rates of upper endoscopy and incidence of new BE diagnoses in patients undergoing SG.

SETTING

This was a claims-data study of patients who underwent SG between 2012 and 2017 while enrolled in a U.S. statewide database.

METHODS

Diagnostic claims data were used to identify pre- and postoperative rates of upper endoscopy, GERD, reflux esophagitis, and BE. Time-to-event analysis using a Kaplan-Meier approach was performed to estimate the cumulative postoperative incidence of these conditions.

RESULTS

We identified 5562 patients who underwent SG between 2012 and 2017. Of these, 1972 patients (35.5%) had at least 1 diagnostic record of upper endoscopy. The preoperative incidences of a diagnosis of GERD, esophagitis, and BE were 54.9%, 14.6%, and .9%, respectively. The predicted postoperative incidences of GERD, esophagitis, and BE, respectively, were 18%, 25.4%, and 1.6% at 2 years and 32.1%, 85.0%, and 6.4% at 5 years.

CONCLUSIONS

In this large statewide database, rates of esophagogastroduodenoscopy remained low after SG, but the incidence of a new postoperative esophagitis or BE diagnosis in patients who underwent esophagogastroduodenoscopy was higher than in the general population. Patients undergoing SG may have a disproportionately high risk of developing reflux complications including BE after surgery.

GERD as a Complication of Laparoscopic Sleeve Gastrectomy for the Treatment of Obesity: A Systematic Review and Meta-Analysis

INTRODUCTION

The incidence of obesity is increasing in developed societies, and surgical treatment is one treatment option. The most common surgical treatment for obesity is laparoscopic sleeve gastrectomy (LSG). Gastroesophageal reflux disease (GERD) is a complication of both obesity and the surgical treatment of obesity.

MATERIALS AND METHODS

In this study, the PubMed database was searched using the keywords "GERD" and "bariatric surgery", and 987 papers published between 1 July 2017 and 30 June 2022 were retrieved.

RESULTS

Nine papers met the inclusion criteria and were included in the meta-analysis. The articles were analyzed for the de novo occurrence of GERD after the treatment of its symptoms, the occurrence of erosive esophagitis, and Barrett's esophagus. In addition, interesting conclusions are presented from the papers that did not meet the inclusion criteria but shed light on the pathophysiology of GERD in obese patients undergoing LSG.

CONCLUSION

In conclusion, the authors draw attention to the need for endoscopic surveillance in patients undergoing LSG, even in the absence of clinical signs of GERD.

Insights into the Paradox of the Weak Association Between Sleeve Gastrectomy and Barrett's Esophagus

Sleeve gastrectomy (SG) is deemed a refluxogenic operation but with a low incidence of postoperative Barrett´s esophagus (BE). We aimed to shed some light on the potential paradox of the weak association between SG, BE and esophageal adenocarcinoma (EAC). The high incidence of GERD after SG is not followed by an increased rate of BE and EAC, as these rates are similar to the general population. We hypothesized that this paradox may occur due to a difference in the gastro-esophageal reflux composition secondary to a lower content of bile, to a decrease in inflammation due to weight loss and hormonal changes, and to acquisition of healthier habits such as exercise, smoking cessation, and better eating behavior.

Tubularized and Effaced Gastric Cardia Mimicking Barrett Esophagus following Sleeve Gastrectomy: Protocolized Endoscopic and Histological Assessment with High-Resolution Manometry Analysis

OBJECTIVE

To describe expected endoscopic and histological changes at gastro-esophageal junction (GEJ) and define diagnostic paradigms for Barrett esophagus (BE) post-sleeve gastrectomy (SG).

SUMMARY BACKGROUND DATA

De novo incidence of BE post-SG was reported as high as 18.8%. A confounding factor is the lack of standardized definition of BE post-SG, which may differ from the general population due to procedure-induced alterations of GEJ.

METHODS

Part 1 involved evaluating endoscopic changes of GEJ post-SG (N = 567) compared to pre-SG (N = 320), utilizing protocolized pre-operative screening, post-operative surveillance and synoptic reporting. Part 2 involved dedicated studies examining causes of altered anatomical and mucosal GEJ appearance using histopathology (N = 55) and high-resolution manometry (HRM) (N = 15).

RESULTS

Part 1 - A characteristic tubularized cardia segment projecting supra-diaphragmatically was identified and almost exclusive to post-SG (0.6%vs.26.6%, p < 0.001). True BE prevalence was low (4.1%pre-SG vs. 3.8%post-SG, p = 0.756), esophagitis was comparable (32.1%vs.25.9%, p = 0.056).Part 2 - Histologically-confirmed BE was found in 12/55 patients, but 70.8% had glandular-type gastric mucosa implying tubularized cardia herniation. HRM of tubularized cardia demonstrated concordance of supra-diaphragmatic cardia herniation between endoscopy and HRM (3cmvs.3.2 cm, p = 0.168), with frequent elevated isobaric intraluminal pressurizations in supra- and infra-diaphragmatic cardia compartments.

CONCLUSION

A novel appearance of tubularized cardia telescoping supra-diaphragmatically with flattening of gastric folds is common post-SG, likely associated with isobaric hyper-pressurization of proximal stomach. Incidence of true BE post-SG is low in short-intermediate term. These provided a clear framework for approaching endoscopic screening and surveillance, with correct anatomical and mucosal identifications, and clarified key issues of SG and BE.

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.

Predictive Factors for Developing GERD After Sleeve Gastrectomy: Is Preoperative Endoscopy Necessary?

INTRODUCTION

Sleeve gastrectomy (SG) is the most common bariatric procedure performed in the USA. There is a concern for new gastroesophageal reflux disease (GERD) and Barrett's esophagus after SG. Endoscopic screening before bariatric surgery is controversial. We sought to identify preoperative endoscopic factors that may predict the development of GERD after SG.

METHODS

We prospectively evaluated 217 patients undergoing primary robotic-assisted SG. All patients underwent endoscopy before SG and for-cause postoperatively. Patients were followed for the development of GERD, diagnosed by either biopsy-proven reflux esophagitis or a positive esophageal pH test. Patients were separated into 2 groups: Those who developed GERD after surgery (GERD group) and those who did not (No GERD group). Patients with a positive preoperative pH test, LA Grade B or greater esophagitis, or hiatal hernia > 5 cm on preoperative endoscopy were counseled to undergo gastric bypass and excluded.

RESULTS

There were more males in the No GERD group (25.6% vs. 8.1%; p = 0.02). More patients had preoperative heartburn symptoms in the GERD group (40.5% vs. 23.9%; p = 0.04). Endoscopically identified esophagitis was more common in the GERD group (29.7% vs. 13.3%; p = 0.01), as was biopsy-proven esophagitis (24.3% vs. 11.1%; p = 0.03). There was no significant difference in the incidence or size of hiatal hernia or in the rate of H. pylori infection between the groups. On multivariate analysis, the strongest predictors of GERD after SG were endoscopically identified esophagitis (odds ratio [OR] 2.79; 95% confidence interval [CI]1.17-6.69; p = 0.02) and biopsy-proven esophagitis (OR 2.80; 95% CI 1.06-7.37; p = 0.04). Male patients were less likely to develop GERD after SG (OR 0.23; 95% CI 0.06-0.85; p = 0.03).

CONCLUSION

Our findings strengthen the rationale for routine preoperative endoscopy and highlight critical clinical and endoscopic criteria that should prompt consideration of alternatives to SG for weight loss.

Assessment of the Role of Omentopexy in Laparoscopic Sleeve Gastrectomy: A Tertiary Center Experience

Background: Laparoscopic sleeve gastrectomy is one of the most common bariatric procedures due its high success and low complication rates. However, acid reflux and food intolerance remain drawbacks of the procedure, with high frequency of postoperative gastroesophageal reflux disease (GERD) and eating disorders reported by previous studies. Omentopexy is not a standard technique in laparoscopic sleeve gastrectomy and showed promising results in preventing these sequelae. The present study aimed to evaluate whether omentopexy would decrease the incidence of postoperative GERD, food intolerance, and gastric volvulus without increasing additional complications rates in comparison with laparoscopic sleeve gastrectomy (LSG) without omentopexy. Patients and Methods: Our study included all the patients undergoing laparoscopic sleeve gastrectomy in our bariatric unit, who were divided into two groups. Group II had the added step of omentopexy. Comparison between both groups was done regarding incidence of acid reflux, food tolerance, and postoperative complications. Results: Omentopexy decreased the incidence of acid reflux, gastric kink, volvulus, and intrathoracic migration. Moreover, food tolerance significantly improved in patients, which in turn led to higher compliance with the postoperative dietary plan and better outcome with regard to weight loss. In addition, omentopexy showed lower incidence of postoperative leakage. Conclusion: Omentopexy is a valuable step in laparoscopic sleeve gastrectomy, which should be considered a standard step in all cases.

Effect of laparoscopic sleeve gastrectomy vs laparoscopic sleeve + Rossetti fundoplication on weight loss and de novo GERD in patients affected by morbid obesity: a randomized clinical study

Purpose

To compare sleeve gastrectomy (SG) to SG associated with Rossetti fundoplication (SG + RF) in terms of de novo gastro-esophageal reflux disease (GERD) after surgery, weight loss, and postoperative complications.

Materials and methods

Patients affected by morbid obesity, without symptoms of GERD, who were never in therapy with proton pump inhibitors (PPIs), were randomized into two groups. One group underwent SG and the other SG + RF. The study was stopped on February 2020 due to the COVID pandemic.

Results

A total of 278 patients of the programmed number of 404 patients were enrolled (68.8%). De novo esophagitis was considered in those patients who had both pre- and postoperative gastroscopy (97/278, 34.9%). Two hundred fifty-one patients (90.3%) had completed clinical follow-up at 12 months. SG + RF resulted in an adequate weight loss, similar to classic SG at 12-month follow-up (%TWL = 35. 4 ± 7.2%) with a significantly better outcome in terms of GERD development. One year after surgery, PPIs were necessary in 4.3% SG + RF patients compared to 17.1% SG patients (p = 0.001). Esophagitis was present in 2.0% of SG + RF patients versus 23.4% SG patients (p = 0.002). The main complication after SG + RF was wrap perforation (4.3%), which improved with the surgeon’s learning curve.

Conclusion

SG + RF seemed to be an effective alternative to classic SG in preventing de novo GERD. More studies are needed to establish that an adequate learning curve decreases the higher percentage of short-term complications in the SG + RF group.

Graphical abstract

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.

Surgical Management of Gastroesophageal Reflux in Patients With Obesity

With the growing prevalence of obesity and its association with gastro-esophageal reflux disease (GERD), the thoracic, foregut, and bariatric surgeons will be ever more commonly facing the challenge to treat GERD in patients with obesity, albeit having the opportunity to treat GERD and obesity simultaneously. In this review, we outline the outcomes of laparoscopic antireflux surgery (LARS) in patients with Class 1, 2, and 3 obesity, as well as GERD outcomes of Roux-en-Y gastric bypass (LRYGB) and sleeve gastrectomy (LSG). We also discuss the revisional surgical options for patients with obesity and failed LARS, or with GERD after LRYGB and LSG.

Evaluation of reflux following sleeve gastrectomy and one anastomosis gastric bypass: 1-year results from a randomized open-label controlled trial

BACKGROUND

Recent reports have demonstrated that de novo reflux and worsening of pre-existing symptoms occur after SG; concerns are still expressed about the risk of symptomatic biliary reflux gastritis and oesophagitis. The aim of our study was to investigate and compare the rate of postoperative acid and non-acid reflux following Mini-/One anastomosis gastric bypass (MGB/OAGB) and laparoscopic sleeve gastrectomy (LSG).

STUDY DESIGN

A prospective randomized open-label, controlled trial registered on clinicaltrial.gov (NCT number: NCT02987673) has been carried out to evaluate esophagogastric junction exposure to reflux in the first year after MGB/OAGB and LSG using high impedance manometry, endoscopy, and a validated questionnaire.

RESULTS

A total of 58 individuals were eventually enrolled in this trial and represented the per-protocol population (n = 28 MGB/OAGB, n = 30 LSG). No difference was found between the two groups in terms of demographic characteristics, PAGI-SYM score, acid exposure time percent of the esophagus (AET%), esophagitis, and other HRiM and MII-pH data at baseline. Comparing MII-pH outcomes of the two groups, AET% resulted significantly higher after LSG at 12 months. Endoscopic findings showed a significant increase of esophagitis ≥ B in the LSG group after 1 year; postoperative esophagitis ≥ B resulted also significantly worsened after LSG when compared to MGB/OAGB.

CONCLUSION

Since AET% and rate of esophagitis are significantly higher after LSG when compared to MGB/OAGB, this procedure should be preferred in case of preoperative subclinical reflux or low grade (A) esophagitis.

Ten-Year Results of Laparoscopic Sleeve Gastrectomy: Retrospective Matched Comparison with Laparoscopic Adjustable Gastric Banding-Is There a Significant Difference in Long Term?

BACKGROUND

The laparoscopic sleeve gastrectomy (LSG) is the most common bariatric procedure performed worldwide while the laparoscopic adjustable gastric banding (LAGB) has been almost abandoned. Aim of this study was to retrospectively assess 10-year outcomes of LSG through a matched comparison with LAGB.

MATERIALS AND METHODS

Retrospective search of prospectively maintained database of our university was carried out to find all patients that underwent LSG before December 2010. Each subject with LSG was matched one-to-one with a patient that had undergone LAGB in the same period with correspondent preoperative age, BMI, and sex.

RESULTS

A total of 76 patients underwent LSG before 2010 and were all included in this study; a matched group of 76 out of 178 LAGB patients with 10-year follow-up was retrieved from our database. Comparison between the two groups showed better outcomes after LSG at 1 and 5 years but weight loss was comparable with the LAGB group at 10 years (%TWL 22.2 ± 13 vs 21.2 ± 16.1; p = 0.89). No significant difference was found in conversion/removal rate (15.8% vs 18.4%; p = 0.67).

CONCLUSION

LSG is an effective stand-alone bariatric procedure with better outcomes than LAGB in medium term, but results are comparable at 10 years. Subjects undergoing LSG should be informed that conversion to RYGB or OAGB may be necessary to achieve further weight loss or to treat reflux.

Effect of Concomitant Laparoscopic Sleeve Gastrectomy and Hiatal Hernia Repair on Gastroesophageal Reflux Disease in Patients with Obesity: a Systematic Review and Meta-analysis

BACKGROUND

Hiatal hernia repair (HHR) during sleeve gastrectomy (SG) is recommended when hiatal hernia (HH) is found intraoperatively. However, its effect on gastroesophageal reflux disease (GERD) remains controversial.

OBJECTIVE

To evaluate the effect of concomitant SG and HHR on GERD in patients with obesity.

METHODS

Web of Science, PubMed, Embase, the Cochrane Library, and ClinicalTrials.gov databases were searched for all studies reporting the efficacy of SG+HHR for patients with obesity and GERD up to March 2021.

RESULTS

A total of 18 studies totaling 937 patients met the inclusion criteria. The results of meta-analysis showed that after SG+HHR, there was a significant reduction in GERD symptoms (OR: 0.20; 95% CI: 0.10 to 0.41; P < 0.00001), improvement in esophagitis (OR: 0.12, 95% CI: 0.05 to 0.26, P < 0.001), and decrease in GERD-HRQL (MD: 19.13, 95% CI: -3.74 to 34.51; P=0.01). The incidence of GERD remission after SG+HHR was 68.0% (95% CI: 55.0-80.9%), de novo GERD was 12% (95% CI: 8-16%), and HH recurrence was 11% (95% CI: 4 to 19%). SG+HHR was superior to SG alone in GERD remission (OR: 2.97, 95% CI: 1.78 to 4.95, P < 0.0001). However, there was no significant difference in de novo GERD after SG+HHR compared with SG alone.

CONCLUSIONS

SG+HHR can positively affect weight loss, GERD resolution, esophagitis reduction, and GERD-HRQL improvement. SG+HHR seems to have a promising future in patients with obesity and GERD. However, further studies based on objective assessment are warranted to evaluate these results better.

Laparoscopic One Anastomosis Gastric Bypass Versus Laparoscopic Roux-en-Y Gastric Bypass Effects on Pre-existing Mild-to-Moderate Gastroesophageal Reflux Disease in Patients with Obesity: a Randomized Controlled Study

BACKGROUND

Patients with obesity having GERD usually undergo Roux-en-Y gastric bypass (RYGB) as the procedure of choice. However, the emergence of one anastomosis gastric bypass (OAGB) as a less time-consuming operation with fewer complications offers a potential option for these patients.

STUDY DESIGN

This randomized controlled trial included 80 patients (out of 457 screened) with mild-to-moderate GERD that were equally divided into two groups for OAGB and RYGB. GERD was diagnosed by 20-item questionnaire, upper endoscopy, 24-h pH monitoring, and manometry. Follow-up at 6 and 12 months was done.

RESULTS

No significant differences were found between the two groups regarding demographic data, comorbidities, and weight loss. OAGB had less operative time and fewer complications. Both procedures had comparable favorable effects in reducing the GERD symptoms evidenced by upper endoscopy, 24-h pH monitoring, and manometry.

CONCLUSION

OAGB is a promising bariatric procedure in weight loss for patients with obesity having mild-to-moderate GERD (up to grade B esophagitis by Los Angeles score). Furthermore, wide-scale studies and on more severe degrees of GERD are required to fully understand its benefits in GERD patients with obesity.

Outcomes of Conversion from Sleeve Gastrectomy to Roux-en-Y Gastric Bypass Due to GERD-a Retrospective Analysis of 35 Patients

BACKGROUND

Sleeve gastrectomy (SG) has become one of the most performed bariatric procedures worldwide. Its main weaknesses are weight regain and gastroesophageal reflux disease (GERD). Conversion to Roux-en-Y gastric bypass (RYGB) is considered the gold standard to manage GERD and related symptoms.

METHODS

Retrospective evaluation from a prospective bariatric surgery database of all our institution's patients converted from SG to RYGB due to GERD between January 2010 and December 2018. Clinical characteristics and workups before SG and before and after RYGB were analyzed.

RESULTS

During the study period, 35 patients needed a conversion to RYGB, due to GERD or GERD-related symptoms. Mean age was 48.6 years, 85.7% were women, and mean BMI was 31.4 kg/m². The interval between SG and RYGB was in a range 7 to 70 months (mean 33 months). All conversions were completed laparoscopically, associating a hiatoplasty in 45.7% of cases. A complete remission of symptoms was observed in 74% of patients, some improvement in 20%, and no relief in 6%. There were 3 cases of hiatal hernia persistence and 2 of recidivism. Only 1 patient presented pathological pHmetry, while moderate esophagitis was demonstrated in 2 patients.

CONCLUSIONS

Conversion to RYGB was effective in almost all patients. Pathological acid exposure and hiatal hernias seem to be the main findings prior to conversion, justifying an exhaustive examination and aggressive approach to the hiatus. Due to the insufficient correlation between symptoms and findings on morphological and functional tests, actively searching for signs of GERD is advisable.

The Nissen-Sleeve (N-Sleeve): Results of a Cohort Study

BACKGROUND

The Montpellier bariatric team has recently proposed some technical alternatives to decrease the rate of gastroesophageal reflux disease (GERD) after bariatric surgery and also to offer patients an alternative in case of contraindication to Roux-en-Y gastric bypass (RYGBP): the Nissen-Sleeve (N-Sleeve).

OBJECTIVES

We present here the results from a cohort of patients that underwent an operation with this newly designed anti-reflux bariatric procedure N-Sleeve: Nissen valve added to a standard SG.

METHODS

Data from a prospective, observational, and monocentric cohort. All consecutive patients presenting to the bariatric surgery department for a laparoscopic sleeve gastrectomy between 2016 and 2018 with GERD were included in the study. The fundus was stapled with a margin from the valve, and the valve was created with tissue at a distance from the greater curvature so as to avoid a double layer stapling of the stomach.

RESULTS

A total of 70 patients were included in the study. Ninety percent of the cohort presented with a hiatal hernia at the time of surgery. No mortality was observed during the follow-up period. Concerning GERD, 76% of all patients had preoperative esophageal syndromes, whereas 21% were asymptomatic with associated esophagitis. Grade A-C esophagitis was present in 99% of the cohort, but no Barrett's esophagus was present. Fifty-six (80%) patients used PPIs regularly. At 1 year of follow-up, one patient was still symptomatic.

CONCLUSIONS

Comparative trials remain necessary between N-Sleeve and standard bariatric procedures to refine the specific indications of each of them and determine the eventual role of the N-Sleeve.

Predictive Factors of Gastroesophageal Reflux Disease in Bariatric Surgery: a Controlled Trial Comparing Sleeve Gastrectomy with Gastric Bypass

OBJECTIVE

To evaluate the impact of laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB) on gastroesophageal reflux disease (GERD) in patients with obesity.

METHODS

Patients with class II or III obesity were treated with LSG or LRYGB. Procedure choice was based on patients and surgeon preferences. GERD symptoms, endoscopy, barium swallow X-ray, esophageal manometry, and 24-h pH monitoring were obtained before and 1 year after surgery.

RESULTS

Seventy-five patients underwent surgery (83% female, 39.3 ± 12.1 years, BMI of 41.5 ± 5.1 kg/m²): 35 (46.7%) had LSG and 40 (53.3%) LRYGB. LSG patients had lower BMI (40.3 ± 4.0 kg/m² vs. 42.7 ± 5.7 kg/m²; p = 0.041) and trend toward lower prevalence of GERD (20% vs. 40%; p = 0.061). One year after surgeries, GERD was more frequent in LSG patients (74% vs. 25%; p < 0.001) and all LSG patients with preoperative GERD continue to have GERD postoperatively. De novo GERD occurred in 19 of 28 (67.9%) of LSG patients and 4 of 24 (16.7%) patients treated with LRYGB (OR 10.6, 95%CI 2.78-40.1). Independent predictors for post-operative GERD were as follows: LSG (OR 12.3, 95%CI 2.9-52.5), preoperative esophagitis (OR 8.5, 95% CI 1.6-44.8), and age (OR 2.0, 95%CI 1.1-3.4).

CONCLUSIONS

One year after surgery, persistent or de novo GERD were substantially more frequent in patients treated with LSG compared with LRYGB. LSG was the strongest predictor for GERD in our trial. Preoperative counseling and choice of bariatric surgical options must include a detailed assessment and discussion of GERD-related surgical outcomes.

Systematic Review and Meta-Analysis of Randomised Controlled Trials Comparing Long-Term Outcomes of Roux-En-Y Gastric Bypass and Sleeve Gastrectomy

INTRODUCTION

Sleeve gastrectomy (SG) has overtaken Roux-En-Y gastric bypass (RYGB) as the most common bariatric procedure worldwide. However, there is little long-term data comparing the two procedures.

OBJECTIVES

We perform a systematic review and meta-analysis comparing 5-year outcomes of randomised controlled trials (RCTs) comparing RYGB and SG.

METHODS

Medline, Embase, The Cochrane Library, and NHS Evidence were searched for English language RCTs comparing RYGB with SG and assessed weight loss and/or comorbidity resolution at 5 years.

RESULTS

Five studies were included in the final analysis. Meta-analysis demonstrates a significantly greater percentage excess weight loss in patients undergoing RYGB compared with SG (65.7% vs 57.3%, p < 0.0001). Resolution of diabetes was seen in 37.4% and 27.5% after RYGB and SG respectively. There was no significant difference between RYGB and SG in rates of resolution or improvement of diabetes. Similarly, HbA1C levels were not significantly different between the two procedures. Resolution of dyslipidaemia was more common after RYGB (68.6% vs 55.2%, p = 0.0443). Remission of gastro-oesophageal reflux occurred in 60.4% in the RYGB group in contrast to 25.0% in the SG group (p = 0.002).

CONCLUSIONS

Both RYGB and SG result in sustained weight loss and comorbidity control at 5 years. RYGB resulted in greater %EWL, improved dyslipidaemia outcomes and a lower incidence of postoperative gastro-oesophageal reflux disease (GORD).

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.

ASMBS position statement on the rationale for performance of upper gastrointestinal endoscopy before and after metabolic and bariatric surgery

The following position statement is issued by the American Society for Metabolic and Bariatric Surgery in response to inquiries made to the Society by patients, physicians, society members, hospitals, health insurance payors, the media, and others regarding the need and possible strategies for screening endoscopic examination before metabolic and bariatric surgery (MBS), as well as the rationale, indications, and strategies for postoperative surveillance for mucosal abnormalities, including gastroesophageal reflux disease and associated esophageal mucosal injuries (erosive esophagitis and Barrett's esophagus) that may develop in the long term after MBS, specifically for patients undergoing sleeve gastrectomy or Roux-en-Y gastric bypass. The general principles described here may also apply to procedures such as biliopancreatic diversion (BPD) and BPD with duodenal switch (DS); however, the paucity of procedure-specific literature for BPD and DS limits the value of this statement to those procedures. In addition, children with obesity undergoing MBS may have unique considerations and are not specifically addressed in this position statement. This recommendation is based on current clinical knowledge, expert opinion, and published peer-reviewed scientific evidence available at this time. The statement is not intended to be and should not be construed as stating or establishing a local, regional, or national standard of care. The statement will be revised in the future as additional evidence becomes available.

Barrett's esophagus after sleeve gastrectomy: a systematic review and meta-analysis

BACKGROUND AND AIMS

Sleeve gastrectomy (SG) has become significantly more common in recent years. Gastroesophageal reflux disease (GERD) is a major concern in patients undergoing SG and is the major risk factor for Barrett's esophagus (BE). We aimed to assess the prevalence of BE in patients who had undergone SG.

METHODS

We searched the major search engines ending in July 2020. We included studies on patients who had undergone esophagogastroduodenoscopy (EGD) after SG. The primary outcome was the prevalence of BE in patients who had undergone SG. We assessed heterogeneity using I2 and Q statistics. We used funnel plots and the classic fail-safe test to assess for publication bias. We used random-effects modeling to report effect estimates.

RESULTS

Our final analysis included 10 studies that included 680 patients who had undergone EGD 6 months to 10 years after SG. The pooled prevalence of BE was 11.6% (95% confidence interval [CI], 8.1%-16.4%; P < .001; I2 = 28.7%). On logistic meta-regression analysis, there was no significant association between BE and the prevalence of postoperative GERD (β = 3.5; 95% CI, -18 to 25; P = .75). There was a linear relationship between the time of postoperative EGD and the rate of esophagitis (β = 0.13; 95% CI, 0.06-0.20; P = .0005); the risk of esophagitis increased by 13% each year after SG.

CONCLUSIONS

The prevalence of BE in patients who had EGD after SG appears to be high. There was no correlation with GERD symptoms. Most cases were observed after 3 years of follow-up. Screening for BE should be considered in patients after SG even in the absence of GERD symptoms postoperatively.

Gastroesophageal Reflux After Sleeve Gastrectomy

Sleeve gastrectomy continues to be the most commonly performed bariatric operation worldwide. Development or worsening of pre-existing GERD has been recognized as a significant issue postoperatively. There is a paucity of information concerning the most appropriate preoperative workup and the technical and anatomical factors that may or may not contribute to the occurrence of reflux symptoms. Contemporary data quality is deficient given the predominantly retrospective nature, limited follow-up time, and heterogeneous outcome measures across studies. This has produced mixed results regarding the postoperative incidence and severity of GERD. Ultimately, better-constructed investigations are needed in order to offer evidence-based recommendations that may guide preoperative workup and improved patient selection criteria.

Quality assessment for systematic reviews and meta-analyses of cohort studies

BACKGROUND AND AIMS

There is a growing need for valid, efficient, and easy scoring scales to rate the quality of cohort studies. We aimed to develop and validate a quality assessment score to be used for cohort studies.

METHODS

We followed a rigorous process to establish content, face, and construct validity. Most questions were scored at 0 or 1. Inter-rater reliability and test-retest reliability were assessed using the Spearman correlation coefficient (r_s) and Cohen's κ statistic. Internal consistency was measured using the Kuder-Richardson formula 20 (KR20).

RESULTS

The final tool consists of 9 questions with a maximum score of 10. The inter-rater reliability was high with the Spearman correlation coefficient (r_s = .66). Agreement for inclusion was 90%. Test-retest reliability was high. For rater 1, r_s = .91, κ = .38 for scores, and κ = 1 for inclusion. For rater 2, r = .94, 80% agreement for scores, and 100% agreement for inclusion. Internal consistency was reasonable based on 2 studies: KR20 = .21 and KR20 = .65. The novel scale rated highest in efficiency, understandably, ease of use, and ease of interpretation when compared with 3 other scales.

CONCLUSIONS

This novel scale has favorable performance characteristics, is efficient to conduct, and is easy to interpret and will be very helpful for physicians and researchers conducting systematic reviews and meta-analyses.

Barrett's Oesophagus and Bariatric/Metabolic Surgery-IFSO 2020 Position Statement

The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) has been playing an integral role in educating both the metabolic surgical and the medical community at large about the importance of surgical and/or endoscopic interventions in treating adiposity-based chronic diseases. The occurrence of chronic conditions following bariatric/metabolic surgery (BMS), such as gastro-oesophageal reflux disease (GERD) and columnar (intestinal) epithelial metaplasia of the distal oesophagus (also known as Barrett's oesophagus (BE)), has long been discussed in the metabolic surgical and medical community. Equally, the risk of neoplastic progression of Barrett's oesophagus to oesophageal adenocarcinoma (EAC) and the resulting requirement for surgery are the source of some concern for many involved in the care of these patients, as the surgical alteration of the gastrointestinal tract may lead to impaired reconstructive options. As such, there is a requirement for guidance of the community.The IFSO commissioned a task force to elucidate three aspects of the presenting problem: First, to determine what the estimated incidence of Barrett's oesophagus is in patients presenting for BMS; second, to determine the frequency at which Barrett's oesophagus may develop following BMS (with a particular focus on the laparoscopic sleeve gastrectomy (LSG)); and third, to determine if regression of Barrett's oesophagus may occur following BMS given the close relationship of obesity and the development of BE/EAC. Based on these findings, a position statement regarding the management of this pathology in the context of BMS was developed. The following position statement is issued by the IFSO Barrett's Oesophagus task force andapproved by the IFSO Scientific Committee and Executive Board. This statement is based on current clinical knowledge, expert opinion and published peer-reviewed scientific evidence. It will be reviewed regularly.

Long-term endoscopic follow-up after sleeve gastrectomy

BACKGROUND

Endoscopic follow-up after sleeve gastrectomy (SG) sometime reveals worrisome findings as the presence of major digestive lesions such as esophagitis, Barrett's esophagus (BE), and also esophageal cancer.

OBJECTIVES

The aim of this study was to investigate the frequency and severity of esophageal and gastric lesions after SG.

METHODS

Our team collected the results of esogastric endoscopies performed on patients who underwent SG up to five years before in our hospital, from April 2010 to August 2014. Summons were sent by mail to all patients operated on between those dates. The results were collected from January 2018 to June 2019.

RESULTS

Of the 765 patients who underwent SG up to five years before, only 78 (10.2%) agreed to undergo an upper digestive endoscopy. The average age before surgery was 51 years (range: 25-70 years). The mean preoperative body mass index (BMI) was 44.2±4.6kg/m². For 12 out of these 78 patients (15.4%) it was revisional surgery: 9 SG after gastric banding, and 3 revisional SG (Re-SG). With an average follow-up of 6.3±0.8 years, the endoscopic results of the 78 patients were found to be normal in 31 cases (39.7%): gastritis was found in 28 patients (35.9%), severe grade C or D esophagitis was found in 15 cases (19.2%), hiatal hernia in 18 cases (23.1%), a benign gastric polyp in 2 cases (2.6%). Of the 28 patients with gastritis, HelicobacterPylori was detected in 8 cases (28.6%). No cancer was diagnosed, and BE after SG was found in only one case (1.3%) (normal before surgery). Six of 15 patients with esophagitis (40%) had reflux symptoms. Fourteen of these patients (93.3%) developed de novo esophagitis.

CONCLUSION

Only 10.2% of operated patients agreed to a long-term esogastric endoscopy. The frequency and severity of endoscopic anomalies observed with an average follow-up of more than 6 years pleads for a policy of systematic upper endoscopies of long-term control after SG.

Revisional One-Anastomosis Gastric Bypass After Restrictive Index Surgery-a Metaanalysis and Comparison with Revisional Roux-en-Y Gastric Bypass

BACKGROUND

One-anastomosis gastric bypass (OAGB) was established as a recognized bariatric procedure in the 2018 International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) position statement. This study evaluates the outcomes of revisional OAGB (rOAGB) after a restrictive index procedure, and to compare it to revisional RYGB (rRYGB).

METHODS

A literature search was performed according to the PRISMA guidelines on papers published from inception till February 2020. Original studies involving patients who underwent rOAGB after a primary failed restrictive procedure were included. The primary outcome measured was postrOAGB weight loss. Secondary outcome measures include comorbidity resolution, operative duration, length of stay, morbidity, and mortality.

RESULTS

A total of 21 studies with 1377 patients were included. Five studies compared rOAGB versus rRYGB. Majority of the patients (76%) were female, with mean age of 43.5 years old. Mean body mass index (BMI) before revisional surgery was 41.6 kg/m². The most common biliopancreatic limb length was 200 cm. Percentage of excess weight loss after rOAGB increases to a maximum of 76.0% at 48 months postsurgery. rOAGB resulted in a pooled prevalence of diabetes, hypertension, hyperlipidemia, and obstructive sleep apnea resolution of 74.9%, 48.4%, 63.2%, and 75.7% respectively. When compared to rRYGB, rOAGB demonstrated greater weight loss, comparable metabolic syndrome resolution, but with a shorter operating time. Morbidity and mortality rates were low across all studies.

CONCLUSIONS

rOAGB has potential as an alternative revisional surgery, with weight loss profiles and rates of metabolic syndrome resolution that are comparable to rRYGB.

Should Sleeve Gastrectomy Be Considered Only as a First Step in Super Obese Patients? 5-Year Results From a Single Center

PURPOSE

Sleeve gastrectomy (SG) has been originally conceived as a first step procedure for super obese (SO) patients, but it is currently considered a stand-alone intervention. Medium-term to long-term studies have shown weight regain and risk of de novo gastroesophageal reflux (GERD). The aim of this study was to evaluate outcomes of SG in SO subjects.

MATERIALS AND METHODS

A retrospective analysis of a prospectively maintained database was carried out to find all SO patients who had undergone SG with a minimum follow-up of 5 years. Inclusion criteria were preoperative endoscopy negative for esophagitis and/or hiatal hernia, and no GERD or acid reduction medication before SG. Reflux symptoms were evaluated using a validated questionnaire and endoscopy. Remission rates from comorbidities and percentage of excess body mass index (BMI) loss were recorded.

RESULTS

A total of 66 (45 male/21 female) patients were included in our study. Mean preoperative BMI and age were 57.4±5.8 kg/m2 and 32.7±11.2 years, respectively. After 5 years, mean percentage of excess BMI loss was 56.42±27.8, and remission rates from hypertension, diabetes, and dyslipidemia were 33.3%, 5.3%, and 20%, respectively. After 5 years, new-onset GERD occurred in 66.7% of patients and 33.3% were taking acid reduction medication. Endoscopy revealed 12 (18.2%) cases of esophagitis ≥grade A.

CONCLUSIONS

After 5 years, weight loss in SO patients is satisfactory, but the vast majority of patients is still in class II obesity, and resolution of comorbidities is disappointing. High rates of de novo GERD and esophagitis may occur.