Radiologic, endoscopic, and functional patterns in patients with symptomatic gastroesophageal reflux disease after Roux-en-Y gastric bypass

Mechanisms of Gastroesophageal Reflux Post-Roux-en-Y Gastric Bypass: Universal Alteration of the Antireflux Barrier is the Culprit

INTRODUCTION

Gastroesophageal reflux disease (GERD) symptoms and the use of proton pump inhibitors (PPIs) remain prevalent after Roux-en-Y Gastric Bypass (RYGB), despite it being known to alleviate reflux. The physiological changes behind long-term GERD and hiatal hernia (HH) prevalence post-RYGB are not commonly investigated.

METHODS

In this consecutive cohort study, we examined patients who underwent RYGB and subsequent upper endoscopy, conducted by an expert bariatric endoscopist. The primary focus was on pouch endoscopic retrosflexion to evaluate the antireflux barrier (ARB). We gathered data encompassing patient demographics, anthropometrics, comorbidities, and findings from esophagogastroduodenoscopy (EGD) at the time of surgery and during follow-up EGD.

RESULTS

Our study included a total of 42 patients, predominantly female (97.5%) and White (100%), with an average age of 53.6±10.6 years and a body mass index (BMI) of 32.9±9.4 kg/m2. In our findings, all EGDs revealed the presence of a HH of varying sizes. The average HH size was 2.07±0.87 cm. The esophagogastric junction (EGJ) flap was also effaced in all patients with the majority (90.4%, 38 patients) classified as Hill grade IV and a smaller proportion (9.6%, 4 patients) as Hill grade III. Notably, PPI usage increased from the time of surgery to the time of EGD (69.0% vs. 42.9%, P=0.06).

CONCLUSION

This research highlights the high incidence of HH and EGJ flap effacement in patients after RYGB, potentially elucidating the persistence of reflux symptoms, including weakly acidic or alkaline reflux, post-RYGB.

Persistent Gastroesophageal Reflux Disease After RYGB: What Shall we do Next?

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is considered the weight loss procedure of choice for obese patients with gastroesophageal reflux disease (GORD). The long-term prevalence of GORD after RYGB for obesity is underestimated as many post-RYGB patients can still complain of severe reflux symptoms, refractory to medications.

METHODS

This is a narrative review using the patient, intervention, comparison, outcome and study strategy. The literature search was undertaken using PubMed, Medline, and Google Scholar databases with the following MeSH terms: Gastroesophageal reflux disease, GORD, Obesity, Gastric bypass, Roux-en-Y gastric bypass, complication, and fundoplication.

RESULTS

Twelve original papers and case report studies on 57 patients who met the inclusion criteria were suitable for the present review. Reporting styles on successful treatment outcomes were heterogeneous. Treatment options for these patients are limited but include further surgical or endoscopic interventions. Careful follow-up and appropriate management are paramount for this population.

CONCLUSION

There is significant paucity in the available evidence on managing GORD after RYGB. This narrative review provides a detailed overview of the underlying causes, discusses the various endoscopic and surgical therapy options, and suggests strategies to provide tailored and appropriate therapy for this complex group of patients.

Laparoscopic Toupet-Sleeve gastrectomy in morbid obese patients with preoperative gastro-esophageal reflux: a 4-year follow-up cohort study

AIM

To assess the 4-year outcomes after Toupet-Sleeve (TS) gastrectomy in morbid obese patients with concomitant preoperative gastro-esophageal reflux disease (GERD).

MATERIAL AND METHODS

The study group consisted of 19 consecutive patients operated on between August 2017 and February 2019. There were 5 men and 14 women with a mean body mass index (BMI) of 43 ± 5 kg/m2 and a mean age of 42 ± 15 years. A retrospective analysis of database and telephone interview of patients who defaulted clinic follow-up was conducted. The main study end-points were weight loss and success of surgery, defined as no need for conversion and %EWL > 50%. Resolution of GERD was a secondary end-point.

RESULTS

No patient was lost for follow-up. Nadir weight loss was reached after a follow-up of one year: mean BMI was 32 ± 5 kg/m2, %EWL 61 ± 21% and %TWL 24 ± 7%. Thereafter, we observed a progressive weight regain over time. With a mean follow-up of 51 ± 6 months, mean BMI was 36 ± 8 kg/m2, %EWL 43 ± 35% and %TWL 16 ± 12%. Two patients were converted to another bariatric procedure because of dysphagia and fundus dilatation or because of insufficient weight loss. The overall surgical success rate was 32% (6/19). Resolution of GERD without any PPI treatment was noted in 88% (15/17) of the non-converted patients.

CONCLUSION

In our experience, with a 4-year follow-up, TS is associated with a significant risk of conversion, a moderate weight loss and a poor surgical success rate.

Effect of anti-reflux suture on gastroesophageal reflux symptoms after one anastomosis gastric bypass: a randomized controlled trial

PURPOSE

Gastroesophageal reflux disease (GERD) is an issue after one anastomosis gastric bypass (OAGB) and modification of OAGB with adding an anti-reflux system may decrease the incidence of postoperative GERD. This study aimed to compare the efficacy of the anti-reflux mechanism to treat preoperative GERD and prevent de novo GERD.

METHODS

A prospective randomized clinical trial study was conducted on patients with a body mass index of 40 and more from August 2020 to February 2022. Patients undergoing one anastomosis gastric bypass with and without anti-reflux sutures (groups A and B, respectively). These patients had follow-ups for one year after the surgery. GERD symptoms were assessed in all the patients using the GERD symptom questionnaire.

RESULTS

The mean age was 39.5 ± 9.8 years and 40.7 ± 10.2 years in groups A and B respectively. GERD symptoms remission occurred in 76.5% and 68.4% of patients in groups A and B, respectively. The incidence of de novo GERD symptoms was lower in group A, compared to group B (6.2% and 16.1% in groups A and B respectively), without any statistically significant difference (p-value: 0.239).

CONCLUSION

GERD symptoms and de novo GERD after OAGB seems to be under-reported after OAGB. This study suggests that applying an anti-reflux suture can decrease de novo GERD symptoms.

Hiatal hernia repair after previous laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Symptomatic hiatal hernia (HH) with pouch migration after previous laparoscopic Roux-en-Y gastric bypass (RYGB) is an uncommon complication, with limited extant evidence for the utility of surgical repair.

OBJECTIVE

To evaluate the presentation and resolution of symptoms in patients with HH repair after previous RYGB.

SETTING

Multicenter University Hospital.

METHODS

A retrospective review was conducted from 2010 to 2022. Patients with prior RYGB who were undergoing subsequent isolated HH repair were included. Patients undergoing incidental HH repair during concomitant revisional bariatric surgery were excluded. Baseline characteristics and surgical outcomes were evaluated and presented as medians (25th-75th percentile).

RESULTS

Forty-four patients met the inclusion criteria. The time from RYGB to HH repair was 59 months (39-88). Body mass index at HH repair was 31 kg/m2 (27-39). The most common presenting symptoms of hernia were dysphagia (52%), gastric reflux (39%), and abdominal pain (36%). All HH repairs were completed with a minimally invasive approach (98% laparoscopic, 2% robotic). Nonabsorbable suture was used in 98% of patients, with bioabsorbable mesh in 30%. At a median 28-day (12-117) follow-up, 70% of patients reported full symptom resolution and 23% partial resolution. At follow-up, 2 patients had radiologic HH recurrence, with 1 requiring reoperation.

CONCLUSIONS

This is the largest series of isolated HH repair for symptomatic pouch migration after previous RYGB. Common presenting symptoms are dysphagia and reflux, and surgical repair yields a high rate of symptom resolution in the short term. Longer follow-up is needed to evaluate the durability of this intervention.

Gastroesophageal reflux after Roux-en-Y gastric bypass: Is it just related to technical details?

Although it is uncommon, gastroesophageal reflux disease can present after Roux-en-Y gastric bypass, and it is usually related to technical errors. Hiatal hernia, a narrow calibrated gastrojejunostomy and a long gastric pouch are all factors associated with the development of pathologic gastroesophageal reflux. Techniques are available to treat this condition, such as fundoplications with the gastric remnant, gastropexy to the arcuate ligament, teres ligament repair, or sphincter augmentation with the LINX device. Despite the growing number of reports of gastroesophageal reflux after Roux-en-Y gastric bypass, it should be still considered the best surgical option for patients with obesity and a large hiatal hernia or complications secondary to gastroesophageal reflux disease.

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

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

Surveillance Endoscopy After Foregut Surgery: Is It Necessary?

Patients undergoing foregut surgeries can have de novo findings or worsening of underlying upper gastrointestinal pathologies including Barrett’s esophagus and gastric intestinal metaplasia. These changes carry a potentially increased risk for malignancy development in the future raising the question of the utility of post-operative surveillance endoscopy after esophagectomy, bariatric and metabolic surgeries (Sleeve gastrectomy and Roux-en-Y Gastric Bypass), achalasia treatment, and anti-reflux surgery. In this narrative review, we conduct a literature exploration of available data on post-operative endoscopic surveillance findings following the procedures summarizing the prevalence of upper gastrointestinal pathologies and recommendations on the utility of postoperative endoscopy from established medical societies.

Best practice approach for redo-surgeries after sleeve gastrectomy, an expert's modified Delphi consensus

BACKGROUND

Sleeve gastrectomy (SG) is the most common metabolic and bariatric surgical (MBS) procedure worldwide. Despite the desired effect of SG on weight loss and remission of obesity-associated medical problems, there are some concerns regarding the need to do revisional/conversional surgeries after SG. This study aims to make an algorithmic clinical approach based on an expert-modified Delphi consensus regarding redo-surgeries after SG, to give bariatric and metabolic surgeons a guideline that might help for the best clinical decision.

METHODS

Forty-six recognized bariatric and metabolic surgeons from 25 different countries participated in this Delphi consensus study in two rounds to develop a consensus on redo-surgeries after SG. An agreement/disagreement ≥ 70.0% on statements was considered to indicate a consensus.

RESULTS

Consensus was reached for 62 of 72 statements and experts did not achieve consensus on 10 statements after two rounds of online voting. Most of the experts believed that multi-disciplinary team evaluation should be done in all redo-procedures after SG and there should be at least 12 months of medical and supportive management before performing redo-surgeries after SG for insufficient weight loss, weight regain, and gastroesophageal reflux disease (GERD). Also, experts agreed that in case of symptomatic GERD in the presence of adequate weight loss, medical treatment for at least 1 to 2 years is an acceptable option and agreed that Roux-en Y gastric bypass is an appropriate option in this situation. There was disagreement consensus on efficacy of omentopexy in rotation and efficacy of fundoplication in the presence of a dilated fundus and GERD.

CONCLUSION

Redo-surgeries after SG is still an important issue among bariatric and metabolic surgeons. The proper time and procedure selection for redo-surgery need careful considerations. Although multi-disciplinary team evaluation plays a key role to evaluate best options in these situations, an algorithmic clinical approach based on the expert's consensus as a guideline can help for the best clinical decision-making.

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.

A case-control comparative study between Toupet-Sleeve and conventional sleeve gastrectomy in patients with preoperative gastroesophageal reflux

INTRODUCTION

The aim of that study was to compare outcomes after Toupet-Sleeve (T-Sleeve) and sleeve gastrectomy (SG) as primary bariatric procedures in obese patients presenting with preoperative gastro-esophageal reflux disease (GERD).

MATERIAL AND METHODS

The outcomes of 19 consecutive patients operated between 2017 and 2019 by T-Sleeve were compared to the outcomes of 38 patients operated in 2014 by SG. The two groups were matched by age, sex, ASA classification, BMI, food habits and severity of esophagitis. Postoperative weight loss and evolution of GERD symptoms were the study end-points.

RESULTS

The preoperative BMI was 43 ± 5 in the T-Sleeve and 42 ± 5 in the SG group (NS). All the procedures were completed by laparoscopy. The operative time was higher in the T-Sleeve group: 89 ± 18 vs. 68 ± 12 min. (p < 0.001). A lower weight loss was observed in the T-Sleeve group. Respectively 1 and 2 years after surgery, the mean BMI were: 32 ± 6 and 34 ± 6 in the T-Sleeve vs. 28 ± 5 (p < 0.006) and 30 ± 6 (p < 0.05) in the SG group and the mean %EWL were: 61 ± 23 and 54 ± 26% in the T-Sleeve vs. 86 ± 25 (p < 0.002) and 75 ± 28% (p < 0.03) in the SG group. Better control of GERD was noted in the T-Sleeve group: the number of patients with complete resolution of GERD symptoms was 17 (89%) vs. 13 (34%) in the SG group (p < 0.001).

CONCLUSION

T-Sleeve was an effective procedure for GERD treatment but, the weight loss was significantly much lower than after conventional SG. Studies with longer follow-up are mandatory to validate the T-Sleeve procedure.

Clinical Endoscopic and Histologic Findings of a Long-Term Follow-Up (10.7 Years) After Roux-en-Y Laparoscopic Gastric Bypass: a Prospective Study

INTRODUCTION

Bariatric surgery, with laparoscopic Roux-en-Y gastric bypass (LYGB), is one of the most effective treatments for long-term weight loss. However, there are few publications concerning endoscopic evaluations at late control. The purpose was to evaluate the macroscopic and histological findings at the distal esophagus, gastric pouch, jejunal limb and the evolution of Barrett's esophagus (BE) in the long term.

METHODS

Cohort of 110 patients with obesity underwent LYGB in a university hospital. Several clinical, endoscopic and histological evaluations were performed after surgery. Exclusion criteria were previous bariatric procedure, hiatal hernia > 4 cm, BE with histological dysplasia and body mass index (BMI) > 50 kg/m².

RESULTS

Average age was 38.7 ± 9 years with 70% females. BMI averaged 39.6 ± 6 kg/m². Follow-up was 10.7 ± 2 years, and 18 patients (16.4%) were lost. The total weight loss was 23.4 ± 7 kg. Erosive esophagitis, present in 33% of patients, decreased to 5%. After surgery, intestinal metaplasia regressed to cardial mucosa in 5 of 8 patients. One patient developed a short-segment BE. The level of control to gastroesophageal reflux disease (GERD) symptom control was 87% to responders (Visick I-II) and 13% to non-responders (Visick III-IV). An increase in dilated cardia type III was observed (p < 0.001). The length of the gastric pouch increased significantly after surgery (p < 0.001). Anastomotic ulcers healed at 6 months with proton pump inhibitor (PPI) use, without recurrence.

CONCLUSION

LYGB is a very effective surgical procedure to control symptoms of GERD and/or endoscopic erosive esophagitis. Besides, regression of Barrett's mucosa to carditis occurred in 62%.

Combined Partial Toupet Fundoplication With Laparoscopic Sleeve Gastrectomy for Patients With Morbid Obesity and Symptomatic GERD: Preliminary Results of the T-sleeve Technique

AIM

The aim of this study to reveal preliminary results of our Toupet-sleeve technique in morbid obese patients with symptomatic gastroesophageal reflux disease (GERD) and compare their outcomes with laparoscopic sleeve gastrectomy (LSG) patients' outcomes.

METHODS

The study included 103 patients who underwent primary LSG between March 2018 and October 2020 and 18 patients who underwent partial T-sleeve. Patients were stratified into 2 groups according to the surgical technique. All of the patients had preoperative symptomatic GERD. Patients were reevaluated with regard to GERD symptoms and weight loss in the postoperative period. Two groups' data were compared.

RESULTS

The mean age of the patients was 39.2±10.2 years (63% female), and the mean body mass index was 43.2±6.4 kg/m2. The median operative time was 93 minutes (75 to 110 min) in group A (primary LSG) and 110 minutes (90 to 120 min) in group B (partial T-sleeve). The mean body mass index decreased to 28±4.5 kg/m2 in group A and 25.8±3.5 kg/m2 in group B at 12 months after the surgery. At the 12th month, the patients were reevaluated for GERD symptoms. Reflux symptoms were found to be resolved in 62% of the patients (n=64) in group A, while 32% of the patients (n=39) had persistent GERD symptoms. In group B, all of the patients had discontinued proton pump inhibitors postoperatively, and GERD symptoms were completely resolved in 94% of these patients (n=17).

CONCLUSIONS

The present study showed that T-sleeve provides a very good weight loss and reflux control in patients with symptomatic GERD with morbid obesity in the short-term period. This technique can be proposed in some cases as a primary treatment modality. High numbers of patients and longer follow-up are needed.

ANTI-REFLUX PROCEDURES AFTER ROUX-EN-Y GASTRIC BYPASS

BACKGROUND

Roux-en-Y gastric bypass (RYGB) has been the choice of bariatric procedure for patients with symptomatic reflux - and is known to be effective in reducing the need for anti-reflux medication postoperatively. However, a small number of RYGB patients can still develop severe reflux symptoms that require a surgical intervention.

AIM

To examine and describe the patient population that requires an anti-reflux procedure after RYGB evaluating demographics, characteristics, symptoms and diagnosis.

METHODS

A retrospective chart review was performed on 32 patients who underwent a hiatal hernia repair and/or Nissen fundoplication after RYGB Jul 1st, 2014 and Dec 31st, 2019. Patients were identified using the MBSAQIP database and their electronic medical records were reviewed.

RESULTS

Most patients were female (n=29, 90.6%). The mean age was 52.8 years and the mean body mass index (BMI) was 34.1 kg/m2 at the time of anti-reflux procedure. Patients underwent the anti-reflux procedure at a mean of 7.9 years after the RYGB procedure. The mean percentage of excess BMI loss during the time between RYGB and anti-reflux procedure was 63.4%.

CONCLUSIONS

Female patients with a significant weight loss may develop a severe reflux symptoms years after RYGB. Complaints of reflux after RYGB should not be overlooked. Careful follow-up and appropriate treatment (including surgical intervention) is needed for this population.

GASTROESOPHAGEAL SYMPTOMS AFTER LAPAROSCOPIC GASTRIC BYPASS: MISTAKES IN PERFORMING THE PROCEDURE?

Laparoscopic Roux-en-Y gastric bypass (LGB) is the recommended procedure for morbidly obese patients with gastroesophageal reflux disease (GERD). However, there have been reported gastroesophageal reflux symptoms or esophagitis after LGB. Few functional esophageal studies have been reported to date.

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.

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.

The Impact of Bariatric Procedures on Esophageal Motility

Bariatric operations may cause or cure gastroesophageal reflux disease (GERD). The comprehension of esophageal motility following different types of bariatric procedures may help understand the relationship between GERD and bariatric surgery. This review focused on the impact of bariatric procedures on esophageal motility. We found that lower esophageal sphincter resting pressure is increased after adjustable gastric banding; is unaltered or decreased after Roux-en-Y gastric bypass; and is decreased after sleeve gastrectomy. Lower esophageal sphincter relaxation may be abnormal after all these procedures. Esophageal body contractility is worsened after sleeve gastrectomy.

Barrett's Esophagus and Intestinal Metaplasia

Intestinal metaplasia refers to the replacement of the differentiated and mature normal mucosal epithelium outside the intestinal tract by the intestinal epithelium. This paper briefly describes the etiology and clinical significance of intestinal metaplasia in Barrett’s esophagus. This article summarizes the impact of intestinal metaplasia on the diagnosis, monitoring, and treatment of Barrett’s esophagus according to different guidelines. We also briefly explore the basis for the endoscopic diagnosis of intestinal metaplasia in Barrett’s esophagus. The identification techniques of goblet cells in Barrett’s esophagus are also elucidated by some scholars. Additionally, we further elaborate on the current treatment methods related to Barrett’s esophagus.

GERD after Bariatric Surgery. Can We Expect Endoscopic Findings?

Background and Objectives: Bariatric surgery remains the gold standard treatment for morbidly obese patients. Roux-en-y gastric bypass and laparoscopic sleeve gastrectomy are the most frequently performed surgeries worldwide. Obesity has also been related to gastroesophageal reflux disease (GERD). The management of a preoperative diagnosis of GERD, with/without hiatal hernia before bariatric surgery, is mandatory. Endoscopy can show abnormal findings that might influence the final type of surgery. The aim of this article is to discuss and review the evidence related to the endoscopic findings after bariatric surgery. Materials and Methods: A systematic review of the literature has been conducted, including all recent articles related to endoscopic findings after bariatric surgery. Our review of the literature has included 140 articles, of which, after final review, only eight were included. The polled articles included discussion of the endoscopy findings after roux-en-y gastric bypass and laparoscopic sleeve gastrectomy. Results: We found that the specific care of bariatric patients might include an endoscopic diagnosis when GERD symptoms are present. Conclusions: Recent evidence has shown that endoscopic follow-up after laparoscopic sleeve gastrectomy could be advisable, due to the pathological findings in endoscopic procedures in asymptomatic patients.

Does Roux-en-Y Gastric Bypass Really Cure Gastroesophageal Reflux Disease? Analysis of Objective Data

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is considered the treatment of choice for obesity with gastroesophageal reflux disease (GERD). There are few reports showing objective data based on esophageal function tests (EFTs). The aim of our study was to evaluate the influence of LRYGB on GERD. Methods: Candidates for laparoscopic sleeve gastrectomy (LSG) underwent preoperative esophageal manometry (EM) and 24-hour pH monitoring. Based on the negative influence of LSG on GERD, patients with abnormal pH were offered LRYGB. Those patients repeated EFTs, esophagogastroduodenoscopy, and symptom questionnaire 1 year after surgery. Results: Two hundred fifty LSG candidates underwent preoperative EFTs; 38% were redirected to LRYGB due to abnormal pH and 13 (18%) completed EFTs postoperatively. In ten women, age: 40 ± 7 years, body mass index: 41 ± 1 kg/m². EM: lower esophageal sphincter (LES) length increased from 2.6 to 2.9 cm (P = not statistically significant [NS]), and LES pressure decreased from 15 to 14.2 mmHg (P = NS). Preoperatively, LES was normotensive in 12 (92%) patients and postoperatively in 11 (85%) (P = NS). DeMeester score decreased from 35.7 to 11 (P < .001). Postoperatively, 9 (69%) patients resolved their GERD, 3 (23%) improved, and 1 (8%) remained the same (P < .001). Symptoms decreased significantly after surgery. Two patients (15%) had Grade A esophagitis. One of them was able to resolve it, while the other 1 remained the same. Conclusions: Our preliminary data showed that after LRYGB, LES pressure remained the same and DeMeester score decreased, while 69% of patients resolved their GERD. Therefore, LRYGB seems to be an excellent option for obesity and GERD.

Sleeve Gastrectomy Failure-Revision to Laparoscopic One-Anastomosis Gastric Bypass or Roux-n-Y Gastric Bypass: a Multicenter Study

INTRODUCTION

Laparoscopic sleeve gastrectomy (LSG) is the most popular bariatric procedure performed worldwide. However, many patients undergo secondary surgery due to either weight-related and complication-related reasons or both. Conversional options vary with one-anastomosis gastric bypass (OAGB) and Roux-n-Y gastric bypass (RYGB) being the most common. The aim of the study was to assess the safety and efficacy of converting failed LSG to either OAGB or RYGB, and compare weight-related results and post-conversion complications.

METHODS

Retrospective review of hospital records of patients who underwent conversion from LSG to either RYGB or OAGB due to insufficient weight loss or weight regain in 7 bariatric centers between 2013 and 2019. Data retrieved included demographics, anthropometrics, comorbidities, indication for conversion, conversion type, complications, and weight loss.

RESULTS

During the study period, 396 patients were included in the study. Eighty-four (21%) patients were lost to follow-up. RYGB and OAGB were performed in 119 and 144 patients, respectively. Mean age and body mass index (BMI) at revision were 44.2 years (range 19-72) and 40.6 ± 5.9 kg/m² (range 35-71), respectively. Of these, 191 (73%) were female. Percent total body weight loss (%TWL) was 16% ± 1% for the RYGB group vs. 23% ± 12% for the OAGB group (p = 0.0007) at a median follow-up of 29 months (range 7-78 months) following conversion. Gastroesophageal reflux disease (GERD) was significantly higher 1 year following conversion to OAGB vs. RYGB occurring in 25 (17.4%) and 9 (7.6%) patients, respectively (p = 0.018).

CONCLUSIONS

Conversion of LSG to OAGB, compared to RYGB, results in increased weight loss but a higher rate of GERD and potential nutritional deficiencies.

Bariatric Surgery-How Much Malabsorption Do We Need?-A Review of Various Limb Lengths in Different Gastric Bypass Procedures

The number of obese individuals worldwide continues to increase every year, thus, the number of bariatric/metabolic operations performed is on a constant rise as well. Beside exclusively restrictive procedures, most of the bariatric operations have a more or less malabsorptive component. Several different bypass procedures exist alongside each other today and each type of bypass is performed using a distinct technique. Furthermore, the length of the bypassed intestine may differ as well. One might add that the operations are performed differently in different parts of the world and have been changing and evolving over time. This review evaluates the most frequently performed bariatric bypass procedures (and their variations) worldwide: Roux-en-Y Gastric Bypass, One-Anastomosis Gastric Bypass, Single-Anastomosis Duodeno-Ileal Bypass + Sleeve Gastrectomy, Biliopancreatic Diversion + Duodenal Switch and operations due to weight regain. The evaluation of the procedures and different limb lengths focusses on weight loss, remission of comorbidities and the risk of malnutrition and deficiencies. This narrative review does not aim at synthesizing quantitative data. Rather, it provides a summary of carefully selected, high-quality studies to serve as examples and to draw tentative conclusions on the effects of the bypass procedures mentioned above. In conclusion, it is important to carefully choose the procedure and small bowel length excluded from the food passage suited best to each individual patient. A balance has to be achieved between sufficient weight loss and remission of comorbidities, as well as a low risk of deficiencies and malnutrition. In any case, at least 300 cm of small bowel should always remain in the food stream to prevent the development of deficiencies and malnutrition.

Roux-en-Y gastric bypass as revisional surgery

The Roux-en-Y gastric bypass (RYGB) is a worldwide-performed procedure as primary surgery, and as conversional procedure after complications and/or failure of other bariatric procedures. RYGB can be performed as revisional surgery after adjustable gastric banding, vertical banded gastroplasty, sleeve gastrectomy and one anastomosis gastric bypass. Each of these revisional procedures may be technically challenging, and accurate preoperative work-up and operative planning is required. If correctly performed, RYGB as revisional procedure is associated with satisfying outcomes and is indicated in the treatment of insufficient weight loss and postoperative complications of a primary bariatric procedure - such as chronic leak or gastroesophageal reflux after sleeve gastrectomy. The present article analyzes the most important indications, technical points and tips and tricks to safely perform RYGB as a secondary procedure.

Applying an Anti-reflux Suture in the One Anastomosis Gastric Bypass to Prevent Biliary Reflux: a Long-Term Observational Study

INTRODUCTION

The one anastomosis gastric bypass (OAGB) is an effective treatment to induce sustained weight loss in morbidly obese patients. Concerns remain regarding the development of reflux. The aim of this study was to investigate the effect of an "anti-reflux suture" as anti-reflux modification to prevent reflux.

METHOD

This is a single-center retrospective cohort study of patients who underwent a primary OAGB at the Center Obesity North-Netherlands (CON) between January 2015 and December 2016. Reflux was defined as symptoms of acid/bilious regurgitation or pyrosis. This was consequently asked and reported at each follow-up visit. Outcomes of patients with an anti-reflux suture were compared to those without.

RESULTS

In 414 (59%) of the 703 included patients, an anti-reflux suture was applied. Follow-up at 3 years was 74%. The incidence of reflux did not differ between patients with or without an anti-reflux suture (57 versus 56%, respectively; P = 0.9). The presence of an anti-reflux suture was significantly associated with a lower incidence of conversion to Roux-en-Y gastric bypass (RYGB) for reflux (OR 0.56, 95%CI 0.34-0.91). Patients preoperatively diagnosed with gastroesophageal reflux disease (GERD) were 5.2 times more likely to need a conversion to RYGB for reflux (95%CI 2.7-10.1).

CONCLUSION

The presence of preoperative GERD should be weighted heavily in the decision to perform an OAGB as this is a major risk factor for conversion surgery due to reflux. The anti-reflux suture might be a valuable addition to the procedure of the OAGB because it results in fewer conversion surgeries for reflux.

Repair of post-bariatric surgery, recurrent, and de novo hiatal hernias improves bloating, abdominal pain, regurgitation, and food intolerance

BACKGROUND

Post-bariatric surgery hiatal hernias are associated with a cluster of symptoms, including bloating (nausea/vomiting or fullness), abdominal pain, regurgitation, and food intolerance or dysphagia (BARF).

OBJECTIVES

To report the short-term outcomes of repairing post-bariatric surgery hiatal hernias in patients with BARF.

SETTING

Large, multispecialty group practice with university affiliation.

METHODS

We reviewed the records of all consecutive patients who underwent repair of post-bariatric surgery hiatal hernias (2012-2020). Data are shown as means ± standard deviations.

RESULTS

We repaired hiatal hernias in 52 patients (age, 57 ± 10 yr), 4 ± 3 years post sleeve gastrectomy (SG; n = 27), 11 ± 6 years following Roux-en-Y gastric bypass (RYGB; n = 24), and 11 years post duodenal switch with SG (DS-SG; n = 1). Diagnoses were made by upper gastrointestinal contrast study (80%), computed tomography (70%), and/or endoscopy (56%). Hernias in patients with SG were repaired by a posterior cruroplasty after reducing the neo-stomach into the abdomen (n = 11 SG patients; n = 1 DS-SG patient) or converting the SG to RYGB (n = 16). All 24 RYGB patients underwent hernia repair similarly. At 12 ± 10 months of follow-up, dysphagia or regurgitation improved in >80% of patients; nausea, vomiting, or abdominal pain improved in 70% of patients; and heartburn persisted in 56% of patients. Subsequent recurrent hernias that required operative repair developed in 3 patients.

CONCLUSIONS

Hiatal hernias containing the neo-stomach present earlier after SG than RYGB. The diagnosis can be made with a combination of imaging studies and endoscopy. Repair of post-bariatric surgery hiatal hernias markedly improves symptoms of BARF in most patients.

Type IV Hiatal Hernia Containing the Gastric Pouch and Proximal Roux Limb: A Rare Cause of Bowel Obstruction Following Roux-en-Y Bypass Surgery

Roux-en-Y gastric bypass (RYGB) is considered the gold standard for weight loss surgery and is an effective, safe treatment for morbid obesity and associated metabolic derangements. Complications such as small bowel obstruction are rare with a reported incidence of 5%. Obstruction caused by hiatal herniation of the gastric pouch and alimentary limb occurs even less frequently. Prompt recognition and treatment are imperative as delayed intervention may result in significant morbidity. At the time of this manuscript there have only been four reported cases in the literature highlighting a paucity of clinical guidance for the recognition and management of this complication. Here we present a case of acute small bowel obstruction secondary to hiatal herniation of the gastric pouch and proximal Roux limb. Furthermore, we review the literature and discuss the key aspects for the management of this complication.

Bariatric surgery in patients with gastroesophageal reflux disease and/or hiatus hernia

INTRODUCTION

Gastroesophageal reflux disease (GERD) and hiatus hernia (HH) are frequently encountered comorbidities in patients seeking bariatric and metabolic surgery (BMS) for obesity. sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and one anastomosis gastric bypass (OAGB) are the three commonest bariatric procedures performed worldwide. The purpose of this review was to analyze and compare the data on outcomes of these three procedures in patients with GERD and/or HH.

EVIDENCE ACQUISITION

We examined published English language scientific literature available on PubMed for data comparing SG, RYGB, and OAGB with specific focus on GERD outcomes and outcomes in those with GERD and/or HH.

EVIDENCE SYNTHESIS

Several authors have addressed the outcome of GERD after bariatric surgery. There have been randomized control trials and comparative studies in the literature comparing the results of these procedure. But very few studies have exclusively looked into the outcome of different procedures in patients with pre-existing GERD and/or HH. In this narrative review, we evaluate pros and cons of three commonest bariatric procedures worldwide in this subgroup of patients seeking BMS. We also suggest an algorithm on the basis of our experience and the available data in scientific literature.

CONCLUSIONS

Though RYGB is the best anti reflux procedure it is associated with significant higher morbidity/mortality as compared to SG and OAGB. These two procedures can be used in the majority of patients with GERD and/or HH seeking BMS with an acceptance that some patients will need conversion to RYGB in the long term.

Modern Esophageal Function Testing and Gastroesophageal Reflux Disease in Morbidly Obese Patients

BACKGROUND

The implementation of high-resolution manometry (HRM) and the Lyon Consensus statement facilitate evaluation of gastroesophageal reflux disease and motility disorders in morbidly obese patients. Therefore, we aimed to investigate prevalence and phenotype of (borderline) GERD and esophageal motility disorders in this population.

METHODS

Consecutive morbidly obese (BMI ≥ 35 kg/m²) patients were offered evaluation by means of HRM, ambulatory 24-h pH impedance monitoring, endoscopy, and a clinical examination at our tertiary academic center. Data were collected prospectively.

RESULTS

Out of 448 eligible individuals, 147 patients (females = 75, 51%) with a median age of 41.6 (33.4; 52.3) years and a BMI of 44 (40.9; 49.4) kg/m² were included during the study period. The Chicago Classification revealed motility disorders in 50 (34%) patients, dominated by outflow obstruction (18.4%, n = 27) and a novel disorder (7.5%, n = 11), nicknamed jackhammer esophagus (JE). According to the Lyon Consensus, 52 (35.4%) patients had evidence of true GERD, whereas borderline GERD was noted in another 60 (40.8%). Hypersensitive esophagus was observed in 6.8% (n = 10). Sensitivity and specificity of symptoms for GERD were 53.8% and 68.4%, respectively.

CONCLUSIONS

The current gold standard of assessment revealed that the prevalence of esophageal motility disorders and (borderline) GERD is high in the morbidly obese population. Further longitudinal data are needed to delineate the natural course of novel motility disorders like JE in obesity and to identify risk factors for adverse outcomes following bariatric surgery.

Management of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) continues to be one of the most prevalent gastrointestinal tract disorders. Management of GERD is individualized for each patient depending on severity of symptoms, complications of GERD and patient/physician preference. The different management options include life style modification, pharmacological therapy, minimally invasive procedures and surgery. The final decision regarding management should be made based on an individualized patient centered approach on a case-by-case basis in consultation with a multidisciplinary team including primary care physician, gastroenterologist and surgeon. We provide a comprehensive review for the management of GERD.