Long-Term Implications of GERD After Sleeve Gastrectomy

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

Aims

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

Materials and methods

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

Results

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

Conclusions

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

SAGES guidelines for the management of comorbidities relevant to metabolic and bariatric surgery

BACKGROUND

Patients who are under consideration for or have undergone metabolic and bariatric surgery frequently have comorbid medical conditions that may make their perioperative care more complex. These recommendations address routine intraoperative cholangiography in patients with bypass-type anatomy, the management of reflux disease after sleeve gastrectomy, and the optimal bariatric procedure for patients with comorbid inflammatory bowel disease.

METHODS

A systematic review was conducted including studies published from 1990 to 2022 to address these questions. These results were then presented to a panel of bariatric surgeons who formulated recommendations based on the best available evidence or utilized expert opinion when the evidence base was lacking.

RESULTS

Conditional recommendations were made in favor of routine intraoperative cholangiography in patients with bypass-type anatomy undergoing laparoscopic cholecystectomy, trialing medical management prior to surgical management in patients with reflux after sleeve gastrectomy, and sleeve gastrectomy rather than Roux en Y gastric bypass in patients with inflammatory bowel disease. The strength of these recommendations was limited by the quality of evidence available. Recommendations for future research were made for all questions.

CONCLUSIONS

These recommendations should provide guidance regarding management of these comorbidities in patients who are under consideration for or have undergone metabolic and bariatric surgery. These recommendations also identify important areas where the future research should focus to strengthen the evidence base.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Quality of Life in Patients Undergoing Revisional Bariatric Surgery: From Sleeve Gastrectomy to Roux-en-Y Gastric Bypass

Sleeve gastrectomy (SG) is the most performed bariatric surgery worldwide. However, this surgery may be associated with long-term weight regain and severe gastroesophageal reflux disease (GERD), sometimes necessitating conversion to Roux-en-Y gastric bypass (RYGB) to improve quality of life (QoL). We conducted a systematic review on QoL measures following the conversion of SG to RYGB. We searched various databases for studies conducted between January 2005 and September 2023. Four studies, involving 196 participants in total, met the inclusion criteria. Different assessment methods were used to evaluate QoL following the conversion. In the included studies, we observed that GERD symptoms and proton pump inhibitor (PPI) use both decreased following conversion to RYGB. Excess weight loss (EWL) was also observed in all studies.

Long-term impact of gastropexy on use of acid-reducing medication, second operations for gastroesophageal reflux and subjective reflux symptoms after sleeve gastrectomy

We investigated whether adding gastropexy to sleeve gastrectomy (SG) reduced gastroesophageal reflux disease (GERD) in patients operated for severe obesity, assessed mainly by use of anti-reflux medication (ARM) and second operations due to GERD worsening. In a prospective non-randomized study, patients undergoing SG at two Norwegian hospitals were included from 2011 to 2015 and followed for 7 years. GERD was defined by regular use of ARM, and epigastric pain and heartburn were measured by the Rome II questionnaire. Gastropexy was done by suturing the gastrocolic ligament to the staple line. Patients undergoing SG only, mainly before gastropexia was introduced in 2013, were compared to those with additional gastropexy from 2013 onwards. Of 376 included patients (75% females, mean age 42.6 years and BMI 42.9 kg/m2 ), 350 (93%) and 232 (62%) were available for evaluation after 1 and 7 years, respectively. Baseline characteristics in the no-gastropexy (n = 235) and gastropexy groups (n = 141) were similar. In patients without ARM use before surgery, the use increased and in those that used ARM at baseline, the proportion decreased, with no difference in the no-gastropexy and gastropexy groups. With a combined endpoint of ARM use and/or second operation for GERD, there was no difference during follow-up between the two groups. With time, adding gastropexy did not reduce symptoms of GERD significantly. In this population, adding gastropexy to SG did not reduce use of ARM and/or second operation for uncontrolled GERD, epigastric pain or heartburn during the first 7 postoperative years.

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.

Computational evaluation of laparoscopic sleeve gastrectomy

LSG is one of the most performed bariatric procedures worldwide. It is a safe and effective operation with a low complication rate. Unsatisfactory weight loss/regain may occur, suggesting that the operation design could be improved. A bioengineering approach might significantly help in avoiding the most common complications. Computational models of the sleeved stomach after LSG were developed according to bougie size (range 27-54 Fr). The endoluminal pressure and the basal volume were computed at different intragastric pressures. At an inner pressure of 22.5 mmHg, the basal volume of the 54 Fr configuration was approximately 6 times greater than that of the 27 Fr configuration (57.92 ml vs 9.70 ml). Moreover, the elongation distribution of the gastric wall was assessed to quantify the effect on mechanoreceptors impacting satiety by differencing regions and layers. An increasing trend in elongation strain with increasing bougie size was observed in all cases. The most stressed region and layer were the antrum (approximately 25% higher stress than that in the corpus at 37.5 mmHg) and mucosa layer (approximately 7% higher stress than that in the muscularis layer at 22.5 mmHg), respectively. In addition, the pressure-volume behaviors were reported. Computational models and bioengineering methods can help to quantitatively identify some critical aspects of the "design" of bariatric operations to plan interventions, and predict and increase the success rate. Moreover, computational tools can support the development of innovative bariatric procedures, potentially skipping invasive approaches.

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.