Moderating the Enthusiasm of Sleeve Gastrectomy: Up to Fifty Percent of Reflux Symptoms After Ten Years in a Consecutive Series of One Hundred Laparoscopic Sleeve Gastrectomies

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.

Bariatric surgery and relevant comorbidities: a systematic review and meta-analysis

BACKGROUND

Obesity is a growing epidemic in the United States, and with this, has come an increasing volume of metabolic surgery operations. The ideal management of obesity-associated medical conditions surrounding these operations is yet to be determined. This review sought to investigate the routine use of intraoperative cholangiogram (IOC) with cholecystectomy during or after a bypass-type operation, the ideal management of post-sleeve gastrectomy gastroesophageal reflux disease (GERD), and the optimal bariatric operation in patients with known inflammatory bowel disease (IBD).

METHODS

Using medical literature databases, searches were performed for randomized controlled trials (RCTs) and non-randomized comparative studies from 1990 to 2022. Each study was screened by two independent reviewers from the SAGES Guidelines Committee for eligibility. Data were extracted while assessing the risk of bias using the Cochrane Risk of Bias 2.0 Tool and the Newcastle-Ottawa Scale for RCTs and cohort studies, respectively. A meta-analysis was performed using random effects.

RESULTS

Routine use of IOC was associated with a significantly decreased rate of common bile duct injury and a trend towards decreased intraoperative complications, perioperative complications, and mortality. The rates of reoperation, postoperative pancreatitis, cholangitis, and choledocholithiasis were low in the routine use of the IOC group, but no non-routine use studies evaluated these outcomes. After sleeve gastrectomy, GERD-specific quality of life was significantly higher in the surgically treated group compared to the medically treated group. Bypass-type operations had worse outcomes of IBD sequelae than sleeve gastrectomy, including pain, patient perception, and fistula formation. Sleeve patients had lower mortality and fewer short- and long-term complications.

CONCLUSIONS

Low-quality data limited the conclusions that were drawn; however, trends were observed favoring the routine use of IOC during cholecystectomy for patients with bypass-type anatomy, surgical treatment of GERD post-sleeve gastrectomy, and sleeve gastrectomy in IBD patients. Future research proposals are suggested to further answer the questions posed.

Flap Valve-Preserving Vertical Sleeve Gastrectomy (INNOVATE-VSG): Clinical Trial Study Protocol

BACKGROUND

Conventional vertical sleeve gastrectomy (cVSG), the most commonly performed bariatric surgery, is associated with low complications, durable weight loss, and significant improvement of many obesity-related comorbidities. However, numerous studies have reported that patients who underwent the cVSG have worsening or new onset (de novo) gastroesophageal reflux disease (GERD) which could be related to a negative effect of the operative procedure on the geometry of the gastroesophageal junction impacting on the function of the native gastroesophageal valve. It is imperative to innovate the cVSG procedure because chronic GERD is a debilitating condition associated with increased risk for Barrett's esophagus and esophageal cancer. INNOVATE-VSG aims to test whether a modified flap valve-preserving VSG (fvpVSG), compared to cVSG, will be associated with improvement of preexisting GERD.

METHODS

The fvpVSG incorporates the following surgical modifications that strengthen the antireflux barrier: achieving 3 cm intrabdominal esophageal length; repair of the diaphragmatic crura; and preservation of 3 cm length of gastric fundus/cardia during the sleeve gastrectomy procedure which will be used to symmetrically wrap around the distal esophagus (120-160° wrap) to restore the naturally occurring gastroesophageal valve. A total of 44 obese patients (BMI 35-50 kg/m2) with pathologic GERD, confirmed by abnormal acid exposure time (AET), will be randomly assigned to cVSG or fvpVSG in this pilot randomized clinical trial at two academic sites. The primary outcome is the change in AET at 6-9 months after surgery. Secondary outcomes include changes in the lower esophageal sphincter pressure, compliance of the esophagogastric junction, weight loss, and quality of life.

DISCUSSION

Data generated from the INNOVATE-VSG trial will be used to design a larger multi-center randomized clinical trial to confirm the value of preserving a functioning gastroesophageal valve following sleeve gastrectomy.

Long-Term Follow-Up After Bariatric Surgery: Key to Successful Outcomes in Obesity Management

Background/Objectives: Bariatric surgery (BS) is considered one of the most effective interventions for the treatment of obesity. To achieve optimal long-term results, continuous follow-up (FU) within a multidisciplinary treatment team is essential to ensure patient compliance and maximize the benefits of BS. However, many patients find it difficult to maintain regular FU, which can affect the quality of care and lead to postoperative complications. This review aims to highlight factors that may hinder compliance with FU after BS, examine potential causes and consequences of inadequate FU, and identify strategies to improve patient participation in long-term FU. Methods: The literature search was conducted between October 2023 and June 2024 in Medline (PubMed) and the Cochrane Library datasets. Studies were selected for their relevance to adherence to FU, multidisciplinary approaches, and long-term bariatric outcomes. Results: The pre- and postoperative period is critical for educating patients and healthcare team members about the importance of FU, addressing potential barriers (e.g., logistical, psychological, and social challenges), and highlighting the risk of relapse to obesity after surgery. The lack of a standardized FU protocol leads to differences between medical centers, further impacting patient adherence. Conclusions: Tailored and regularly updated strategies are essential to address individual patient needs and improve adherence to FU. Further research is needed to identify the specific factors that influence variability in long-term BS outcomes, highlighting the need for a patient-centered approach to obesity treatment.

Do Abdominoplasties in Patients with Prior Sleeve Gastrectomy Impact De Novo Gastroesophageal Reflux Disorder and the Need for Conversion to Roux-en-Y Gastric Bypass?

Introduction: The sleeve gastrectomy (SG) often requires conversion to Roux-en-Y gastric bypass (RYGB) due to gastroesophageal reflux disorder (GERD). Many postbariatric patients seek body-contouring surgery such as abdominoplasty to remove unwanted skin and fat. Although the number of abdominoplasties performed in postbariatric patients is increasing each year, the number of conversion surgeries is increasing in accordance. This study evaluates the impact of abdominoplasties in patients with prior SG on the development of GERD and the need for conversion to RYGB. Methods: A retrospective study was conducted with 630 patients who underwent conversions from SG to RYGB at our institution between January 2014 and December 2023. Outcomes were stratified for comparison between patients with GERD as an indication for conversion and patients with inadequate weight loss as an indication for conversion. Between the two groups we compared the number of patients with post-SG abdominoplasty and the number of hiatal hernias (HH) seen during conversion surgery. A logistic regression analysis was performed to identify factors independently associated with GERD. Results: There was a statistically significant higher number of abdominoplasties in patients who underwent conversion to RYGB for GERD (29 patients, 8.6%) compared to inadequate weight loss (12 patients, 4.1%), P value .034. However, these patients also had statistically significantly more HH (98 patients, 28.9%) compared to patients with inadequate weight loss as an indication for conversion (46 patients, 15.8%), P value <.001. In the logistic regression comparing these two variables, only the presence of HH seen during surgery was found to be a significant predictor of GERD (odds ratio 2.7, confidence interval 1.7-4.1, P < .001). Conclusion: Our data shows that abdominoplasty surgery does not directly influence the development of GERD in post-SG patients. However, the presence of HH in this population significantly impacts the development of GERD, often necessitating conversion to RYGB.

Surgical treatment strategies for gastroesophageal reflux after laparoscopic sleeve gastrectomy

Bariatric surgery has emerged as an effective therapeutic approach for combating obesity. As the most commonly performed bariatric surgery, laparoscopic sleeve gastrectomy (LSG) has a long-term and effective outcome in weight reduction. However, studies have reported an increased incidence of gastroesophageal reflux disease (GERD) among patients after LSG. For those who fail to respond to conventional oral acid-suppressing medication, surgical intervention comes into consideration. The most commonly performed revisional surgery for sleeve gastrectomy is the Roux-en-Y gastric bypass, which can effectively alleviate the symptoms of reflux in patients and also continues to promote weight loss in patients who have not achieved satisfactory results or have experienced weight regain. In addition to this established procedure, innovative techniques such as laparoscopic magnetic sphincter augmentation (MSA) are being explored. MSA is less invasive, has good reflux treatment outcomes, and its safety and efficacy are supported by the literature, making it a promising tool for the future treatment of gastroesophageal reflux. This article also explores the role of endoscopic interventions for GERD treatment of post-sleeve gastrectomy patients. Although these methods have shown some therapeutic effect, their efficacy still requires further study due to a lack of support from more clinical data. For patients with preoperative hiatal hernia or gastroesophageal reflux symptoms, some experts now consider performing LSG combined with hiatal hernia repair or fundoplication to alleviate or prevent postoperative reflux symptoms. Both of these surgical approaches have demonstrated favorable outcomes; however, the addition of fundoplication requires further investigation regarding its long-term effects and potential postoperative complications. This article gathers and examines the current laparoscopic and endoscopic treatments for refractory gastroesophageal reflux following LSG, as well as the concurrent treatment of LSG in patients with preoperative gastroesophageal reflux or hiatal hernia.

Managing the Bariatric Surgery Patient: Presurgery and Postsurgery Considerations

Obesity has extensive health repercussions, and bariatric surgery remains a viable solution to address this issue. This article focuses on the preoperative and postoperative management strategies required to achieve successful and durable outcomes in bariatric surgery patients. Preoperative assessment includes appropriate patient selection, psychosocial evaluation, nutritional analysis, and behavioral/medical counseling. Postoperative assessment includes immediate perioperative care, diet transition, nutritional needs management, and handling of complications associated with bariatric surgery.

Obesity-related cancer and bariatric surgery: A comprehensive systematic review and meta-analysis protocol

INTRODUCTION

Obesity is a silent pandemic affecting all ages and is a component of metabolic syndrome. Its treatment is conducted by lifestyle and behavioral changes, pharmacological therapy, and when correctly indicated, bariatric surgery. In recent years, the procedures for weight loss have been investigated due to their relationship with the development of many types of cancer. Although many studies have shown that bariatric surgery decreases cancer risk, other researchers observed an increase in this association. Carcinogenesis is affected by many factors, such as age, sex, type of cancer, and the bariatric surgery performed on each patient. This systematic review and meta-analysis protocol aims to clarify the association between the different modalities of bariatric surgery and the risk of cancer development in adult patients with metabolic syndrome.

METHOD AND ANALYSIS

The proposed systematic review and meta-analysis will be reported conforming to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-P) guidelines. This research will include observational studies (case-control and cohort studies) about patients who undergo bariatric surgery due to metabolic syndrome. Will be accepted in any language and any year. Publications without peer review will be excluded from this review. Data will be entered into the Review Manager software (RevMan5.2.3). We extracted or calculated the OR and 95% CI for dichotomous outcomes for each study. In case of heterogeneity (I2>50%), the random-effects model will combine the studies to calculate the OR and 95% CI.

ETHICS AND DISSEMINATION

This study will review the published data; Thus, obtaining ethical approval is unnecessary. The findings of this systematic review will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42023432079.

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.

Post-bariatric pregnancy is associated with vitamin K1 deficiency, a case control study

BACKGROUND

Maternal obesity is associated with adverse outcome for pregnancy and childbirths. While bariatric surgery may improve fertility and reduce the risk of certain pregnancy-related complications such as hypertension and gestational diabetes mellitus, there is a lack of evidence on the optimal nutritional monitoring and supplementation strategies in pregnancy following bariatric surgery. We aimed to assess the impact of bariatric surgery on micronutrients in post-bariatric pregnancy and possible differences between gastric bypass surgery and sleeve gastrectomy.

METHODS

In this prospective case control study, we recruited 204 pregnant women (bariatric surgery n = 59 [gastric bypass surgery n = 26, sleeve gastrectomy n = 31, missing n = 2] and controls n = 145) from Akershus university hospital in Norway. Women with previous bariatric surgery were consecutively invited to study participation at referral to the clinic for morbid obesity and the controls were recruited from the routine ultrasound screening in gestational week 17-20. A clinical questionnaire was completed and blood samples were drawn at mean gestational week 20.4 (SD 4.5).

RESULTS

The women with bariatric surgery had a higher pre-pregnant BMI than controls (30.8 [SD 6.0] vs. 25.2 [5.4] kg/m2, p < 0.001). There were no differences between groups regarding maternal weight gain (bariatric surgery 13.3 kg (9.6) vs. control 14.8 kg (6.5), p = 0.228) or development of gestational diabetes (n = 3 [5%] vs. n = 7 [5%], p = 1.000). Mean levels of vitamin K1 was lower after bariatric surgery compared with controls (0.29 [0.35] vs. 0.61 [0.65] ng/mL, p < 0.001). Multiadjusted regression analyses revealed an inverse relationship between bariatric surgery and vitamin K1 (B -0.26 ng/mL [95% CI -0.51, -0.04], p = 0.047) with a fivefold increased risk of vitamin K1 deficiency in post-bariatric pregnancies compared with controls (OR 5.69 [1.05, 30.77] p = 0.044). Compared with sleeve gastrectomy, having a previous gastric bypass surgery was associated with higher risk of vitamin K1 deficiency (OR 17.1 [1.31, 223.3], p = 0.030).

CONCLUSION

Post-bariatric pregnancy is negatively associated with vitamin K1 with a higher risk of vitamin K1 deficiency in pregnancies after gastric bypass surgery compared with after sleeve gastrectomy. Vitamin K1 deficiency in post-bariatric pregnancy have potential risk of hypocoaguble state in mother and child and should be explored in future studies.

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.

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.

Conversion of Sleeve Gastrectomy to Roux-en-Y Gastric Bypass: Indications, Prevalence, and Safety

BACKGROUND

Sleeve gastrectomy (SG) frequently requires conversion to Roux-en-Y gastric bypass (RYGB) due to gastroesophageal reflux disease (GERD) or weight recurrence. Current evidence evaluating the safety of conversion from SG to RYGB and its indications is limited to single centers.

METHODS

The objective was to determine the rate of serious complications and mortality of conversion of SG to RYGB (SG-RYGB) compared to primary RYGB (P-RYGB). This was a retrospective analysis of the MBSAQIP database which includes 30-day outcomes. Individuals undergoing P-RYGB or SG-RYGB were included. Multivariable logistic regression was performed to determine if revisional surgery was an independent predictor of serious complications or mortality.

RESULTS

In 2020 and 2021, 84,543 (86.3%) patients underwent P-RYGB and 13,432 (13.7%) underwent SG-RYGB. SG-RYGB cohort had lower body mass index, lower rates of diabetes and hypertension, and higher rates of GERD. GERD was the most common indication for revision (55.3%) followed by weight regain (24.4%) and inadequate weight loss (12.7%). SG-RYGB had longer operative times (145 vs. 125 min, p < 0.001) and a higher rate of serious complications (7.2 vs. 5.0%, p < 0.001). This included higher rates of anastomotic leak (0.5 vs. 0.4%, p = 0.002), bleeding (2.0 vs. 1.6%, p < 0.001), and reoperation (3.0 vs. 1.9%, p < 0.001) but not death (0.1 vs. 0.1%, p = 0.385). On multivariable analysis, SG-RYGB was independently predictive of serious complications (OR 1.21, 95%CI 1.12 to 1.32, p < 0.001) but not mortality (p = 0.316).

CONCLUSIONS

While SG-RYGB is safe with a low complication rate, SG-RYGB was associated with a higher rate of serious complications compared to P-RYGB.

Multi-society consensus conference and guideline on the treatment of gastroesophageal reflux disease (GERD)

BACKGROUND

Gastroesophageal reflux disease (GERD) is one of the most common diseases in North America and globally. The aim of this guideline is to provide evidence-based recommendations regarding the most utilized and available endoscopic and surgical treatments for GERD.

METHODS

Systematic literature reviews were conducted for 4 key questions regarding the surgical and endoscopic treatments for GERD in adults: preoperative evaluation, endoscopic vs surgical or medical treatment, complete vs partial fundoplication, and treatment for obesity (body mass index [BMI] ≥ 35 kg/m2) and concomitant GERD. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Recommendations for future research were also proposed.

RESULTS

The consensus provided 13 recommendations. Through the development of these evidence-based recommendations, an algorithm was proposed for aid in the treatment of GERD. Patients with typical symptoms should undergo upper endoscopy, manometry, and pH-testing; additional testing may be required for patients with atypical or extra-esophageal symptoms. Patients with normal or abnormal findings on manometry should consider undergoing partial fundoplication. Magnetic sphincter augmentation or fundoplication are appropriate surgical procedures for adults with GERD. For patients who wish to avoid surgery, the Stretta procedure and transoral incisionless fundoplication (TIF 2.0) were found to have better outcomes than proton pump inhibitors alone. Patients with concomitant obesity were recommended to undergo either gastric bypass or fundoplication, although patients with severe comorbid disease or BMI > 50 should undergo Roux-en-Y gastric bypass for the additional benefits that follow weight loss.

CONCLUSION

Using the recommendations an algorithm was developed by this panel, so that physicians may better counsel their patients with GERD. There are certain patient factors that have been excluded from included studies/trials, and so these recommendations should not replace surgeon-patient decision making. Engaging in the identified research areas may improve future care for GERD patients.

Hiatal reconstruction is safe and effective for control of reflux after laparoscopic sleeve gastrectomy

Background

Gastroesophageal reflux is a known complication following laparoscopic sleeve gastrectomy (LSG) as anatomical changes predispose to reduced lower esophageal sphincter pressure and development of hiatus hernia. The mainstay of surgical management has been Roux-en-Y gastric bypass (RYGB) which is not without risk. Hiatus hernia repair (HHR) with surgical reattachment of the oesophagus to the crura, recreating the phreno-esophageal ligament is a simple procedure specifically targeting a number of anatomical changes responsible for reflux in this population.

Methods

We conducted a single centre retrospective analysis of adult patients with post-sleeve reflux refractory to medical treatment, managed with either HHR, RYGB or One-anastomosis Duodenal switch (OADS). PPI use and symptoms of reflux were assessed at early and mid-term time points via validated questionnaires.

Results

99 patients were included, of these the surgical procedure was HHR alone in 58, RYGB in 29 and OADS in 12. At early follow-up control of reflux symptoms was achieved in 72.4% after HHR, 82.1% after RYGB and 100% after OADS with no significant difference between groups (p = 0.09). At mid-term followup (median 10 months IQR 7–21) there was no significant difference in the presence of symptomatic reflux as determined by post-op Visick score nor a difference in PPI use. The GerdQ score was significantly lower after OADS as compared to HHR and RYGB (4.6 ± 2.3 vs 7.7 ± 2.2 vs 8.7 ± 3.5, p = 0.006).

Conclusion

HHR with reconstruction of the phreno-esophageal ligament is a safe and effective procedure for patients with reflux after LSG, that avoids more complex operations such as RYGB and OADS and their associated long-term sequelae.

Bariatric surgery outcomes following organ transplantation: A review study

Weight gain is a frequent postoperative complication following a solid organ transplant which can be solved by bariatric surgery. The outcomes of bariatric surgery among patients with an organ transplant history are always a challengeable subject for surgeons and surgery candidates. In this review article, we aim to investigate the existence literature about the rates of morbidity and mortality, frequent complications in terms of graft function, remission in diabetes, hypertension, pulmonary and cardiovascular disorders, hepatic and renal functions, and immunosuppressive stability, as well as the safety of bariatric surgery among patients.

Impact of hiatal hernia repair technique on patient-reported gastroesophageal reflux symptoms following laparoscopic sleeve gastrectomy

INTRODUCTION

Repairing a hiatal hernia at the time of laparoscopic sleeve gastrectomy (SG) can reduce or even prevent gastroesophageal reflux disease (GERD) symptoms in the post-operative period. Several different hiatal hernia repair techniques have been described but their impact on GERD symptoms after SG is unclear.

METHODS

Surgeons (n = 74) participating in a statewide quality collaborative were surveyed on their typical technique for repair of hiatal hernias during SG. Options included posterior repair with mesh (PRM), posterior repair (PR), and anterior repair (AR). Patients who underwent SG with concurrent hiatal hernia repair (n = 7883) were compared according to their surgeon's reported technique. Patient characteristics, baseline and 1-year GERD health-related quality of life surveys, weight loss and 30-day risk-adjusted complications were analyzed.

RESULTS

The most common technique reported by surgeons for hiatal hernia repair was PR (n = 64, 85.3%), followed by PRM (n = 7, 9.3%) and AR (n = 4, 5.3%). Patients who underwent SG by surgeons who perform AR had lower rates of baseline GERD diagnosis (AR 55.3%, PR 59.5%, PRM 64.8%, p < 0.01), but were more likely to experience worsening GERD symptoms at 1 year (AR 29.8%, PR 28.7%, PRM 28.2%, p < 0.0001), despite similar weight loss (AR 29.8%, PR 28.7%, PRM 28.2%, p = 0.08). Satisfaction with GERD symptoms at 1 year was high (AR 73.2%, PR 76.3%, PRM 75.7%, p = 0.43), and risk-adjusted 30-day outcomes were similar among all groups.

CONCLUSIONS

Patients undergoing SG with concurrent hiatal hernia repair by surgeons who typically perform an AR were more likely to report worsening GERD at 1 year despite excellent weight loss. Surgeons who typically performed an AR had nearly one-half of their patients report increased GERD severity after surgery despite similar weight loss. While GERD symptom control may be multifactorial, technical approach to hiatal hernia repair at the time of SG may play a role and a posterior repair is recommended.

The utility of endoscopy prior to bariatric surgery: an 11-year retrospective analysis of 885 patients

INTRODUCTION

Our aim was to evaluate the diagnostic yield of routine preoperative esophagogastroduodenoscopy (p-EGD) in patients undergoing bariatric surgery. Many medical problems that are common in patients with obesity, including gastroesophageal reflux disease (GERD) and hiatal hernias, have important implications for patients undergoing bariatric surgery. While p-EGD is considered standard of care prior to antireflux surgery, the role of p-EGD in bariatric surgery patients remains controversial.

METHODS AND PROCEDURES

We performed a retrospective chart review of 885 patients who underwent primary bariatric surgery at a university hospital-based bariatric surgery program between March 2011 and February 2022. Clinical history, demographics, and preoperative EGD reports were reviewed for abnormal findings.

RESULTS

Of the 885 patients evaluated in this study, one or more abnormal EGD findings were observed in 83.2% of patients. More than half of our patients (54.7%) presented with history of heartburn, reflux, or GERD. EGD findings demonstrated a hernia in 43.1% of patients [(Type I: 40.6%; Type II: 0.5%; Type III: 2.1%)]. 68.0% of patients were biopsied. Among patients who were biopsied, other findings included gastritis (32.4%), esophagitis (8.0%), eosinophilic esophagitis (4.7%), or duodenitis (2.7%). We found ulcers in 6.7% of patients. Pathology was consistent with H. pylori in 9.8% of biopsies taken and consistent with BE in 2.7%. Following routine p-EGD, 11.2% of patients were placed on PPI and 8.3% were recommended to stop NSAIDs.

CONCLUSION

Gastroesophageal reflux disease and associated pathology are common in the bariatric population. Preoperative EGD in patients undergoing bariatric surgery frequently identifies clinically significant UGI pathology. This may have important implications for medical and surgical management. Given the rate of abnormal preoperative endoscopic findings in obese patients, the work-up for bariatric surgery should align with the current recommendations for foregut surgery.

Gastroesophageal Reflux Disease as an Indication of Revisional Bariatric Surgery-Indication and Results-a Systematic Review and Metanalysis

This systematic review evaluates the indications and results of revisional bariatric surgery (RBS) in gastroesophageal reflux disease (GERD). A systematic literature search and meta-analysis was performed for articles published by April 1, 2021. After examining 722 papers involving 17,437 patients, 48 studies were included (n = 915 patients). RBS for GERD was mostly reported after sleeve gastrectomy (n = 796, 87%) and one anastomosis gastric bypass (n = 62, 6.8%) and was performed due to intractable GERD (71.6%), GERD and weight issues (16%), and biliary reflux (6.2%). Mean follow-up of the studies was 31.5 (3-84) months. Pooled estimation of a meta-analysis of studies reported 7% of GERD following primary surgery needing RBS, in which 99% of the patients experienced remission.

Omentopexy Effect on the Upper Gastrointestinal Symptoms and the Esophagogastroduodenoscopy Findings in Patients Undergoing Sleeve Gastrectomy

Background

Laparoscopic sleeve gastrectomy (LSG) has gained acceptance worldwide. However, SG has its own complications that need a specialized management. Omentopexy is a technique in which the sleeved part of the stomach is fixed to the greater omentum.

Aim of the Study

The present work aimed to investigate the potential effect of omentopexy on the upper GIT disturbances in patients with severe obesity and undergoing LSG.

Patients and Methods

This study included patients who were recruited for LSG in our institution from June 2019 to October 2020. Patients having no upper GIT symptoms, no esophagogastroduodenoscopy (EGD) GERD signs, and no hiatus hernia were eligible for the study. Patients were randomly enrolled into the omentopexy group (underwent LSG with omentopexy) and the non-omentopexy group (underwent LSG only). Patients were followed up 1 month, 3 months, and 1 year after the operation. EGD was performed at the 1-year follow-up.

Results

Forty-five patients constituted the omentopexy group and forty-six constituted the non-omentopexy group. Omentopexy was associated with significant reduction in the early post LSG upper GIT symptoms, and less EGD evident reflux esophagitis at the 1-year follow-up (statistically non-significant).

Conclusion

The current work adds a new evidence of the omentopexy benefits in patients undergoing sleeve gastrostomy, with an overall better outcome in regard to the upper GIT upset and GERD compared to LSG alone.

Graphical abstract

Outcome of Sleeve Gastrectomy Converted to Roux-en-Y Gastric Bypass and One-Anastomosis Gastric Bypass

Purpose

Sleeve gastrectomy (SG) is the commonest bariatric procedure worldwide but there is also a high conversion rate mainly due to weight regain and gastroesophageal reflux disease (GERD) reported in studies with long-term follow-up. The aim of this study is to highlight benefits and limitations of converting SG patients to Roux-en-Y gastric bypass (RYGB) and one-anastomosis gastric bypass (OAGB).

Setting

Retrospective cross-sectional-study, medical university clinic setting.

Methods

This study includes all patients converted from primary SG to RYGB or OAGB by 12/2018 at the Medical University of Vienna. Patients were examined using gastroscopy, esophageal manometry, 24-h pH-metry, and questionnaires.

Results

Fifty-eight patients were converted from SG to RYGB (n = 45) or OAGB (n = 13). Total weight loss of patients converted to RYGB and OAGB was 41.5% and 44.8%, respectively, at nadir. Six patients had Barrett’s esophagus (BE) after SG. In four out of these six patients, a complete remission of BE after conversion to RYGB was observed; nevertheless, two patients after RYGB and one after OABG newly developed BE. Clinical GERD improved at a higher rate after RYGB than after OAGB. Both revisional procedures improved associated medical problems.

Conclusion

Conversion to RYGB is probably the best option for patients with GERD after SG. OAGB has shown a low potential to cure patients from GERD symptoms after SG. In terms of additional weight loss and remission of associated medical problems, both procedures studied were equal. Surveillance gastroscopies every 5 years after SG revisions are recommended.

Graphical abstract

Guidelines for Perioperative Care in Bariatric Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations: A 2021 Update

Background

This is the second updated Enhanced Recovery After Surgery (ERAS®) Society guideline, presenting a consensus for optimal perioperative care in bariatric surgery and providing recommendations for each ERAS item within the ERAS® protocol.

Methods

A principal literature search was performed utilizing the Pubmed, EMBASE, Cochrane databases and ClinicalTrials.gov through December 2020, with particular attention paid to meta-analyses, randomized controlled trials and large prospective cohort studies. Selected studies were examined, reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. After critical appraisal of these studies, the group of authors reached consensus regarding recommendations.

Results

The quality of evidence for many ERAS interventions remains relatively low in a bariatric setting and evidence-based practices may need to be extrapolated from other surgeries.

Conclusion

A comprehensive, updated evidence-based consensus was reached and is presented in this review by the ERAS® Society.

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.

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.

Management of Postoperative Complications Following Bariatric and Metabolic Procedures

Bariatric and metabolic surgery is a safe and effective treatment of morbid obesity, a disease that continues to increase in prevalence in the United States and worldwide. The two most commonly performed operations are the sleeve gastrectomy and the gastric bypass. Early and late complications can occur, and although referral to a bariatric surgeon or center is ideal, emergency management of acute problems is relevant to all general surgeons. Bariatric surgery can have surgical and metabolic consequences. An understanding of the altered anatomy and physiology helps to guide management of morbidities. This article discusses surgical postoperative complications and metabolic complications.

GERD and Barrett's esophagus as indications for revisional surgery after sleeve gastrectomy: experience of a bariatric center of excellence IFSO-EC and narrative review

INTRODUCTION

Laparoscopic sleeve gastrectomy is the most commonly performed bariatric procedure worldwide; due to its extensive impact and analysis, multiple procedure-related early and late complications have been described. Gastroesophageal reflux and Barrett's esophagus are highly debated issues related to sleeve gastrectomy in long-term follow-up. This review aims to explore the association between sleeve gastrectomy and gastroesophageal reflux in terms of their occurrence, and to analyze the protective or affecting factors.

AREAS COVERED

Gastroesophageal reflux and Barrett's esophagus after laparoscopic sleeve gastrectomy.

EXPERT OPINION

Gastroesophageal reflux is the Achilles' heel of sleeve gastrectomy and is affected by multiple procedure-related functional or mechanical factors (intrathoracic migration, stenosis, lower esophageal sphincter incompetence). Its postoperative incidence is about 30% with significant variability among groups, especially in terms of preoperative workup (lack of routine upper gastro-intestinal endoscopy and symptom assessment). Strict patient selection and mandatory pre-operative endoscopy are the primary steps taken to prevent and reduce the incidence of post-operative severe gastroesophageal reflux. However, patients should also be informed of the possibility of the 'de novo gastroesophageal reflux disease' (incidence - 22-50%) and the need for surgical revision in selected cases (0.5-7%).

Single Anastomosis Duodenoileal Bypass or Roux-en-Y Gastric Bypass After Failed Sleeve Gastrectomy: Medium-Term Outcomes

Background

Although the sleeve gastrectomy (SG) has good short-term results, it comes with a significant number of patients requiring revisional surgery because of insufficient weight loss or functional complications.

Objective

To investigate the effectiveness of the single anastomosis duodenoileal bypass (SADI-S) versus the Roux-en-Y gastric bypass (RYGB) on health outcomes in (morbidly) obese patients who had previously undergone SG, with up to 5 years of follow-up.

Methods

Data from patients who underwent revisional SADI-S or RYGB after SG were retrospectively compared on indication of surgery, weight loss, quality of life, micronutrient deficiencies, and complications.

Results

From 2007 to 2017, 141 patients received revisional laparoscopic surgery after SG in three specialized Dutch bariatric hospitals (SADI-S n=63, RYGB n=78). Percentage total weight loss following revisional surgery at 1, 2, 3, 4, and 5 years was 22%, 24%, 22%, 18%, and 15% for SADI-S and 10%, 9%, 7%, 8%, and 2% for RYGB (P<.05 for 1–4 years). Patients who underwent RYGB surgery for functional complications experienced no persistent symptoms of GERD or dysphagia in 88% of cases. No statistical difference was found in longitudinal analysis of change in quality of life scores or cross-sectional analysis of complication rates and micronutrient deficiencies.

Conclusion

Conversion of SG to SADI-S leads to significantly more total weight loss compared to RYGB surgery with no difference in quality of life scores, complication rates, or micronutrient deficiencies. When GERD in sleeve patients has to be resolved, RYGB provides adequate outcomes.

Graphical abstract

When should we use mesh in laparoscopic hiatal hernia repair? A systematic review

The use of mesh in laparoscopic hiatal hernia repair (LHHR) remains controversial. The aim of this systematic review was to determine the usefulness of mesh in patients with large hiatal hernia (HH), obesity, recurrent HH, and complicated HH. We performed a systematic review of the current literature regarding the outcomes of LHHR with mesh reinforcement. All articles between 2000 and 2020 describing LHHR with primary suturing, mesh reinforcement, or those comparing both techniques were included. Symptom improvement, quality of life (QoL) improvement, and recurrence rates were evaluated in patients with large HH, obesity, recurrent HH, and complicated HH. Reported outcomes of the use of mesh in patients with large HH had wide variability and heterogeneity. Morbidly obese patients with HH should undergo a weight-loss procedure. However, the benefits of HH repair with mesh are unclear in these patients. Mesh reinforcement during redo LHHR may be beneficial in terms of QoL improvement and hernia recurrence. There is scarce evidence supporting the use of mesh in patients undergoing LHHR for complicated HH. Current data are heterogeneous and have failed to find significant differences when comparing primary suturing with mesh reinforcement. Further research is needed to determine in which patients undergoing LHHR mesh placement would be beneficial.

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.

Laryngopharyngeal Reflux Among Patients Undergoing Bariatric Surgery

PURPOSE

The effect of altered subsphincteric gastric volume and pressure after bariatric surgery on laryngopharyngeal reflux (LPR) remains largely unknown. This was a cross-sectional pilot study conducted between January 2018 and January 2019 to identify changes in LPR symptoms and signs in bariatric surgery patients presurgery and postsurgery.

MATERIALS AND METHODS

Thirty-four patients listed for bariatric surgery in a single tertiary referral center were recruited, where 31 (77.4% female, mean age 46.3 ± 8.9 years) fulfilled the eligibility criteria. Of the eligible patients, 54.8% and 45.2% underwent sleeve gastrectomy (SG) and gastric bypass (GB), respectively. LPR symptoms were assessed using the self-reported reflux symptom index (RSI). Video-recorded endolaryngeal signs were scored using the reflux finding score (RFS) by two blinded otolaryngologists. Patients' presurgical and 3-month postsurgical body mass index (BMI), RSI, and RFS were determined. Patients were deemed as having LPR when RSI > 13 or RFS > 7.

RESULTS

There was a significant correlation between the postsurgical RSI and RFS changes (Pearson's r = 0.474, p = 0.007). Of the 31 patients, 12.9% (RSI) and 6.4% (RFS) recovered from preexisting LPR, whereas 22.6% (RSI) and 3.2% (RFS) developed new de novo LPR postsurgery. The postsurgical mean RFS change improved significantly in the GB group compared with that of the SG group (p < 0.05).

CONCLUSION

LPR is best assessed clinically using a multimodal approach (RSI and RFS). Bariatric surgery may worsen or lead to de novo LPR. Recognizing the LPR outcomes in these patients is paramount for optimal voice, speech, and swallowing functions.

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.

Diagnostic Criteria for Gastro-esophageal Reflux Following Sleeve Gastrectomy

Background

Gastro-esophageal reflux disease (GERD) post-sleeve gastrectomy (SG) is a controversial issue and diagnostic dilemma. Strong heterogeneity exists in the assessment of reflux post-SG, and better diagnostic tools are needed to characterize symptomatic reflux. We aimed to determine the discriminant factors of symptomatic reflux and establish diagnostic thresholds for GERD following SG.

Materials and Methods

Patients post-SG were categorized into asymptomatic and symptomatic cohorts and completed validated symptom questionnaires. All patients underwent stationary esophageal manometry and 24-h ambulatory pH monitoring. Univariate and multivariate analyses were conducted to determine the strongest discriminant factors for GERD.

Results

Baseline characteristics of the asymptomatic cohort (n = 48) and symptomatic cohort (n = 76) were comparable. The median post-operative duration was 7.3 (14.1) vs 7.5 (10.7) months (p = 0.825). The symptomatic cohort was more female predominant (90.8 vs 72.9%, p = 0.008). Reflux scores were significantly higher in the symptomatic group (36.0 vs 10.5, p = 0.003). Stationary manometry parameters were similar, including hiatus hernia prevalence and impaired esophageal motility. The symptomatic cohort had significantly higher total acid exposure, especially while supine (11.3% vs 0.6%, p < 0.001). Univariate and multivariate regressions delineated reflux score and supine acid exposure as discriminant factors for symptomatic reflux. The thresholds for distinguishing symptomatic reflux are as follows: reflux score of 11.5 (sensitivity 84.0%, specificity 68.2%) and supine acid exposure of 2.65% (sensitivity 67.1%, specificity 70.8%).

Conclusion

A reflux score of 11.5 or more or supine acid exposure of 2.65% or more should be considered diagnostic in defining symptomatic reflux following SG.

Evaluation of Patient Reported Gastroesophageal Reflux Severity at Baseline and at One-Year after Bariatric Surgery

OBJECTIVE

To assess patient-reported gastroesophageal reflux disease (GERD) severity before and after sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB).

SUMMARY BACKGROUND DATA

Development of new-onset or worsening GERD symptoms following bariatric surgery varies by procedure, but there is a lack of patient-reported data to help guide decision-making.

METHODS

Retrospective cohort study of patients undergoing bariatric surgery in a statewide quality collaborative between 2013-2017. We used a validated GERD survey with symptom scores ranging from 0 (no symptoms) to 5 (severe daily symptoms) and included patients who completed surveys both at baseline and one-year after surgery (n = 10,451). We compared the rates of improved and worsened GERD symptoms after SG and RYGB.

RESULTS

Within our study cohort, 8,680 (83%) underwent SG and 1,771 (17%) underwent RYGB. Mean baseline score for all patients was 0.94. Patients undergoing SG experienced similar improvement in GERD symptoms when compared to RYGB (30.4% vs 30.8%, p = 0.7015). However, SG patients also reported higher rates of worsening symptoms (17.8% vs 7.5%, p < 0.0001) even though they were more likely to undergo concurrent hiatal hernia repair (35.1% vs 20.0%, p < 0.0001). More than half of patients (53.5%) did not report a change in their score.

CONCLUSIONS

Although SG patients reported higher rates of worsening GERD symptoms when compared to RYGB, the majority of patients (>80%) in this study experienced improvement or no change in GERD regardless of procedure. Using clinically relevant patient-reported outcomes can help guide decisions about procedure choice in bariatric surgery for patients with GERD.

Factors influencing the choice between laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass

BACKGROUND

While laparoscopic sleeve gastrectomy (LSG) continues to be the most commonly performed bariatric operation, several variables influence surgeons' practice patterns and patients' decision-making in the type of bariatric procedure to perform. The aim of this study was to evaluate patient factors that influence the decision between laparoscopic Roux-en-Y gastric bypass (LRYGB) versus LSG.

METHODS

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was queried for patients undergoing LSG and LRYGB between 2015 and 2017. Univariate analysis and multivariate logistic regression were used to evaluate factors associated with performing LRYGB compared to LSG.

RESULTS

A total of 252,117 (72.3%) LSG and 96,677 (27.7%) LRYGB cases were identified. Patients undergoing LSG were younger (44.3 ± 12.0 vs 45.2 ± 11.8 years; p < 0.01) and had a lower body mass index (BMI; 45.1 ± 7.8 vs 46.2 ± 8.1 kg/m²; p < 0.01). Most of the patients were females (79.4%), white (73.0%), with an American Society of Anesthesiology (ASA) class ≤ 3 (96.4%). The factors associated with undergoing LRYGB compared to LSG were diabetes mellitus, gastroesophageal reflux disease, BMI ≥ 50 kg/m², ASA class > 3, obstructive sleep apnea, hypertension, and hyperlipidemia. However, patients with kidney disease, black race, chronic steroid use, age ≥ 60 years, recent smoking history, chronic obstructive pulmonary disease, and coronary artery disease were more likely to undergo LSG.

CONCLUSIONS

The decision to perform LRYGB is primarily driven by obesity-associated comorbidities and higher BMI, whereas LSG is more likely to be performed in higher risk patients.

Outcomes in Bariatric and Metabolic Surgery: an Updated 5-Year Review

PURPOSE OF REVIEW

Knowledge regarding postoperative outcomes after bariatric and metabolic surgery continues to evolve. This review highlights key findings in outcomes research over the last 5 years related to weight loss, remission of obesity-related disease, reflux, revisional surgery, robotic-assisted surgical platforms, and adolescent populations.

RECENT FINDINGS

Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) produce similar weight loss patterns at 5 years, while duodenal switch (BPD/DS) and related procedures are associated with maximal weight loss overall and optimal resolution of obesity-related comorbidities. Remission of type 2 diabetes mellitus (T2DM) following surgery is more likely in patients who are not insulin dependent prior to surgery. Bariatric and metabolic surgery offers a significant protective effect against coronary artery disease (CAD) and associated interventions in both diabetic and nondiabetic patients, as well as heart failure (HF). Gastroesophageal reflux disease (GERD) and dysphagia following SG are common, and routine endoscopic surveillance for Barrett's esophagus may be of significant utility. Robotic-assisted laparoscopic platforms concur similar outcomes to laparoscopic intervention, with a potential benefit in high BMI patients. Revisional surgery is most commonly performed for weight regain and/or inadequate weight loss following an index procedure, or reflux, and generally characterized by higher postoperative complication rates and longer inpatient lengths of stay (LOS). Surgical intervention in adolescent populations has similar weight loss and postoperative complication profiles to those seen in adult populations, with improved outcomes related to T2DM. Bariatric and metabolic surgery continues to evolve as a treatment for obesity and obesity-related comorbidities. While effective for weight loss and remission of obesity-related disease, SG is associated with high rates of postoperative GERD.

Magnetic sphincter augmentation versus fundoplication for gastroesophageal reflux disease: pros and cons

PURPOSE OF REVIEW

The purpose of this magnetic sphincter augmentation (MSA) year in review article is to provide a clear understanding for the current state of MSA literature in 2019, and contrast MSA outcomes with traditional fundoplication.

RECENT FINDINGS

Continued work was performed in 2019 to expand patient populations eligible for MSA including those with hiatal hernia, post-bariatric patients, patients necessitating a thoracic approach, and patients with esophageal intestinal metaplasia. Additionally, a large systematic review reinforced earlier findings comparing laparoscopic fundoplication to MSA. This study demonstrated equivalency over many different operative outcomes, with MSA patients having less bloating while also retaining the ability to belch and vomit. Furthermore, independent research teams found a modest cost savings for MSA over laparoscopic fundoplication with budget analysis.

SUMMARY

MSA is a safe and efficacious procedure originally approved for patients with medically refractory, uncomplicated gastroesophageal reflux disease. The accumulating body of evidence suggests patients with intestinal metaplasia or hiatal hernias can safely and effectively undergo MSA, whereas further research will be required before MSA is widely used for post-bariatric patients or for patients requiring a transthoracic surgical approach. MSA is equivalent or superior to laparoscopic fundoplication in all surgical outcomes measured thus far.

Gastroesophageal reflux disease complicating laparoscopic sleeve gastrectomy: current knowledge and surgical therapies

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is currently the most commonly performed bariatric procedure worldwide. However, the incidence of gastroesophageal reflux disease (GERD) after LSG is high.

OBJECTIVES

The aim of this systematic review was to identify the optimal surgical strategy for treating GERD after LSG.

SETTING

West China Hospital, Sichuan University, Chengdu, China.

METHODS

A systematic literature search was performed to identify studies on surgical treatments for GERD after LSG. The effectiveness and safety profile of surgical management on GERD after LSG were analyzed.

RESULTS

A total of 40 articles enrolling 2049 patients were included in this review. Surgical strategies to prevent GERD after LSG were mainly of 2 types: concomitant LSG + antireflux procedures (hiatal hernia repair or fundoplication) and secondary procedures (conversion to Roux-en-Y gastric bypass [RYGB] or repeat sleeve gastrectomy). The short-term remission or improvement rate of GERD was 34.6%-100% after concomitant LSG + antireflux procedures. The postoperative complication rate was the same (3.0%) for both LSG + antireflux procedures and LSG alone. The remission or improvement rate of GERD was 57.1%-100% after conversion to RYGB and 100% after repeat sleeve gastrectomy.

CONCLUSIONS

The effectiveness and safety profile of concomitant LSG + antireflux procedures is uncertain. However, secondary operations after LSG, such as conversion to RYGB, appear to provide good results. The data overall are heterogeneous, with imprecise methods of documenting and defining GERD complicating LSG. More cohort studies or RCT studies of high quality with long-term follow-up are needed in the future.

Quality of Life 10 Years After Bariatric Surgery

PURPOSE

Improvement of the quality of life after bariatric surgery is an important outcome of the treatment. Assessing the long-term QoL results provides better insights into the effectiveness of bariatric surgery.

MATERIALS AND METHODS

This is a cohort study including patients who underwent bariatric surgery between June 2009 and May 2010 in one academic center. Patients underwent either laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB). Overall, 34 patients underwent LSG (52.3%) and 31 patients underwent LRYGB (47.7%). Preoperatively, and after 1 and 10 years, QoL was assessed using two standardized questionnaires: SF-36 and MA-QoLII. After 10 years, 72% of patients filled out these questionnaires.

RESULTS

The global QoL score before surgery was 48.3 ± 20.6. At the 1-year follow-up, the global total QoL score was 79.7 ± 9.8. At the 10-year follow-up, the global total QoL score was 65.1 ± 21.4. There was a significant increase in total QoL between measurements before the operation and 10 years after surgery in the whole study group (p = 0.001) and for patients who underwent LSG (p = 0.001). There was no significant difference between total QoL prior to surgery and 10 years after for patients who underwent LRYGB (p = 0.450).

CONCLUSION

LSG led to significant improvement in QoL.

Gastroesophageal Reflux and Laparoscopic Sleeve Gastrectomy: Results of the First International Consensus Conference

BACKGROUND

Gastroesophageal reflux disease (GERD) is probably the main drawback of laparoscopic sleeve gastrectomy (LSG). Herein, we critically discuss the issue and report the results of the first international consensus conference held in Montpellier, France, during June 2019.

METHODS

Fifty international bariatric experts from 25 countries convened for 2 days for interactive discussions, and to formulate the most relevant questions by electronically submitting 55 preliminary questions to panelists. Following the meeting, a final drafted questionnaire comprised of 41 questions was sent to all experts via e-mail.

RESULTS

Forty-six experts responded (92%). Esophago-gastro-duodenoscopy was considered mandatory before (92%) and after (78%) surgery. No consensus was achieved as to time intervals after surgery and the role of specialized tests for GERD. Higher degrees of erosive esophagitis (94%) and Barrett's esophagus (96%) were viewed as contra-indications for LSG. Roux-en-Y gastric bypass was recommended in postoperative patients with uncontrolled GERD and insufficient (84%) or sufficient (76%) weight loss and Barrett's esophagus (78%). Hiatal hernia (HH) repair was deemed necessary even in asymptomatic patients without GERD (80% for large and 67% for small HH). LSG with fundoplication in patients with GERD was considered by 77.3% of panelists.

CONCLUSIONS

The importance of pre- and postoperative endoscopy has been emphasized. The role of specialized tests for GERD and the exact surveillance programs need to be further defined. LSG is viewed as contra-indicated in higher degrees of endoscopic and clinical GERD. LSG with anti-reflux fundoplication emerges as a new valid option in patients with GERD.