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Shen MR, Hammoud MM, Bonham AJ, Aaron B, Ghaferi AA, Varban OA, Carlin AM, Ehlers AP, Finks JF. Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass: impact on reflux and weight loss. Surg Obes Relat Dis 2024:S1550-7289(24)00131-X. [PMID: 38704333 DOI: 10.1016/j.soard.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/31/2024] [Accepted: 04/02/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND Sleeve gastrectomy (SG) is the most commonly performed weight loss operation, and its 2 most common complications are postoperative reflux and weight recurrence. There is limited evidence to guide decision-making in treating these conditions. OBJECTIVES To determine the efficacy of conversion of SG to Roux-en-Y gastric bypass (RYGB) for GERD management and weight loss. SETTING Forty-one hospitals in Michigan. METHODS We conducted a retrospective cohort study examining patients who underwent conversion of SG to RYGB from 2014 to 2022. The primary outcomes were changes in GERD-HRQL scores, anti-reflux medication use, and weight from baseline to 1 year after conversion. Secondary outcomes included 30-day postoperative complications and resource utilization. RESULTS Among 2133 patients undergoing conversion, 279 (13%) patients had baseline and 1-year GERD-HRQL survey data and anti-reflux medication data. GERD-HRQL scores decreased significantly from 24.6 to 6.6 (P < .01). Among these, 207 patients (74%) required anti-reflux medication at baseline, with only 76 patients (27%) requiring anti-reflux medication at 1 year postoperatively (P < .01). Of the 380 patients (18%) with weight loss data, mean weight decreased by 68.4lbs, with a 24.3% decline in total body weight and 51.5% decline in excess body weight. In terms of 30-day complications, 308 (14%) patients experienced any complication and 89 (4%) experienced a serious complication, but there were no leaks, perforations, or deaths. Three-hundred and fifty-five (17%) patients presented to the emergency department and 64 (3%) patients underwent reoperation. CONCLUSIONS This study represents the largest reported experience with conversion from SG to RYGB. We found that conversion to RYGB is associated with significant improvement in GERD symptoms, reduction in anti-reflux medication use, and significant weight loss and is therefore an effective treatment for GERD and weight regain after SG. However, the risks and benefits of conversion surgery should be carefully considered, especially in patients with significant comorbidity burden.
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Affiliation(s)
- Mary R Shen
- Department of Surgery, University of Michigan, Ann Arbor, Michigan; Department of Psychiatry, Mass General Brigham, Boston, Massachusetts
| | - Maya M Hammoud
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Aaron J Bonham
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Bryan Aaron
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Amir A Ghaferi
- Department of Surgery, Froedtert & Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Oliver A Varban
- Department of Surgery, Henry Ford Health System, Detroit, Michigan
| | - Arthur M Carlin
- Department of Surgery, Henry Ford Health System, Detroit, Michigan
| | - Anne P Ehlers
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Jonathan F Finks
- Department of Surgery, University of Michigan, Ann Arbor, Michigan.
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Carbonaro J, McLaughlin T, Seip R, Staff I, Wu Y, Santana C, Bond D, Tishler D, Benbrahim A, Papasavas P. Five-year outcomes of revisional bariatric surgery: gastric band to sleeve gastrectomy or to Roux-en-Y gastric bypass. Surg Endosc 2024:10.1007/s00464-024-10764-4. [PMID: 38532050 DOI: 10.1007/s00464-024-10764-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 02/21/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Revisional bariatric surgery after an index adjustable gastric band (AGB) may be indicated to remedy weight relapse or band-related complications. We examined outcomes five years following revision from AGB to laparoscopic sleeve gastrectomy (AGB-LSG) or to Roux-en-Y gastric bypass (AGB-RYGB). METHODS We conducted a retrospective review to identify patients (men and women, age 18-80) who underwent one revisional bariatric procedure with AGB as the index procedure at two medical centers in our healthcare system between January 2012 and February 2017. We only included patients with a pre-revision BMI > 30 kg/m2 for whom 5-year follow-up data were available. We compared 5-year weight loss and remission of comorbidities in patients undergoing AGB-LSG and AGB-RYGB conversion. RESULTS A total of 114 patients met inclusion criteria (65 AGB-LSG, 49 AGB-RYGB). At 5-year post-revision, percent total weight loss (3.4% vs 19.9%; p < 0.001), percent excess weight loss (7.0% vs 50.8%; p < 0.001) and decrease in BMI (1.5 vs 8.8; p < 0.001) was greater in AGB-RYGB vs. AGB-LSG. No significant difference in remission or development of new comorbidities was observed. CONCLUSION Conversion of AGB to RYGB is associated with superior intermediate-term weight loss compared to conversion of AGB to LSG. Future multicenter studies with larger sample sizes are necessary to further describe the intermediate-term outcomes of revisional bariatric surgery.
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Affiliation(s)
- Joseph Carbonaro
- Hartford Healthcare Surgical Weight Loss Center, Hartford, CT, 06102, USA
| | - Tara McLaughlin
- Department of Surgery, Hartford Hospital, Hartford, CT, 06102, USA
| | - Richard Seip
- Hartford Healthcare Surgical Weight Loss Center, Hartford, CT, 06102, USA
| | - Ilene Staff
- Hartford Healthcare Research Program, Hartford, CT, 06102, USA
| | - Yin Wu
- Hartford Healthcare Research Program, Hartford, CT, 06102, USA
| | - Connie Santana
- Hartford Healthcare Surgical Weight Loss Center, Hartford, CT, 06102, USA
| | - Dale Bond
- Hartford Healthcare Research Program, Hartford, CT, 06102, USA
| | - Darren Tishler
- Hartford Healthcare Surgical Weight Loss Center, Hartford, CT, 06102, USA
| | - Aziz Benbrahim
- Medical Group Department of Bariatrics, Hartford Healthcare, Meriden, CT, 06450, USA
| | - Pavlos Papasavas
- Hartford Healthcare Surgical Weight Loss Center, Hartford, CT, 06102, USA.
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Joseph S, Vandruff VN, Amundson JR, Che S, Zimmermann C, Ishii S, Kuchta K, Denham W, Linn J, Hedberg HM, Ujiki MB. Roux-en-Y gastric bypass versus fundoplication for gastroesophageal reflux disease in patients with obesity results in comparable outcomes. Surgery 2024; 175:587-591. [PMID: 38154997 DOI: 10.1016/j.surg.2023.10.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 09/11/2023] [Accepted: 10/24/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Roux-en-Y gastric bypass and fundoplication are effective treatments for gastroesophageal reflux disease, though the optimal procedure of choice in obesity is unknown. We hypothesize that Roux-en-Y gastric bypass is non-inferior to fundoplication for symptomatic control of gastroesophageal reflux disease in patients with obesity. METHODS We conducted a retrospective review of a prospectively maintained quality database. Patients with a body mass index ≥of 35 who presented for gastroesophageal reflux disease and subsequently underwent Roux-en-Y gastric bypass or fundoplication were included. Perioperative outcomes and pH testing data were reviewed. Patient-reported outcomes included Reflux Symptom Index, Dysphagia, Gastroesophageal Reflux Disease-Health Related Quality of Life, and Short Form-36 scores. Data were analyzed using the Wilcoxon rank sum test. RESULTS Ninety-five patients underwent fundoplication (n = 72, 75.8%) or Roux-en-Y gastric bypass (n = 23, 24.2%) during the study period. All patients saw an improvement in gastroesophageal reflux disease symptoms and overall quality of life. There were no significant differences in postoperative Reflux Symptom Index, Dysphagia, or Short-Form-36 scores. Significant differences in gastroesophageal reflux disease-Health Related Quality of Life scores were seen at preoperative, 1, 2, and 5 years postoperative (P < .05), with better symptom control in the fundoplication group. No significant difference was noted in postoperative DeMeester scores or percent time pH <4. Weight loss was significantly higher in the Roux-en-Y gastric bypass group at all postoperative time points up to 5 years (P < .05). CONCLUSION Roux-en-Y gastric bypass and fundoplication both decrease gastroesophageal reflux disease symptoms. Subjective data shows that patients undergoing Roux-en-Y gastric bypass may complain of worse symptoms compared to patients undergoing fundoplication. Objective data notes no significant difference in postoperative pH testing. Despite previous data, offering fundoplication or Roux-en-Y gastric bypass to patients with a body mass index of ≥35 kg/m2 is appropriate. The choice of surgical approach should be more directed to patient needs and desired goals at the time of the initial clinic visit.
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Affiliation(s)
- Stephanie Joseph
- Department of Surgery, Wayne State University/Detroit Medical Center, Detroit, MI; Department of Surgery, NorthShore University Health System, Evanston, IL.
| | - Vanessa N Vandruff
- Department of Surgery, NorthShore University Health System, Evanston, IL; Department of Surgery, NorthShore University HealthSystem, University of Chicago Medical Center, Chicago, IL
| | - Julia R Amundson
- Department of Surgery, NorthShore University Health System, Evanston, IL; Department of Surgery, NorthShore University HealthSystem, University of Chicago Medical Center, Chicago, IL
| | - Simon Che
- Department of Surgery, NorthShore University Health System, Evanston, IL
| | | | - Shun Ishii
- Department of Surgery, NorthShore University Health System, Evanston, IL
| | - Kristine Kuchta
- Department of Surgery, NorthShore University Health System, Evanston, IL
| | - Woody Denham
- Department of Surgery, NorthShore University Health System, Evanston, IL
| | - John Linn
- Department of Surgery, NorthShore University Health System, Evanston, IL
| | - H Mason Hedberg
- Department of Surgery, NorthShore University Health System, Evanston, IL
| | - Michael B Ujiki
- Department of Surgery, NorthShore University Health System, Evanston, IL
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Monrabal Lezama M, Bras Harriott C, Herbella FAM, Schlottmann F. Gastroesophageal Reflux Disease After Roux-en-Y Gastric Bypass: Pathophysiology and Management. J Laparoendosc Adv Surg Tech A 2024; 34:167-172. [PMID: 38153398 DOI: 10.1089/lap.2023.0289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023] Open
Abstract
Introduction: Patients with obesity are often affected by gastroesophageal reflux disease (GERD). Roux-en-Y gastric bypass (RYGB) is considered the ideal operation for patients with severe obesity and GERD. Although the majority of patients improve their reflux with the operation, some might persist symptomatic and others can even develop de novo GERD. The aim of this study was to determine pathophysiologic factors involved in the development of GERD after RYGB surgery and define potential treatments for this condition. Materials and Methods: Studies including patients with GERD before and after RYGB and/or analyzing possible GERD therapies were analyzed by the authors. Searches were conducted in PubMed, Cochrane Library, and Embase databases. Results: GERD can persist, worsen, or develop after RYGB. There are certain technical elements of the operation identified as potential risk factors for GERD. Medical therapy is effective in the majority of patients. Both endoscopic and surgical procedures can also help resolving GERD after RYGB. Conclusions: Although the majority of patients with GERD after RYGB can be effectively managed with medical therapy, some may require endoscopic or surgical treatment. Critical technical elements of RYGB should be considered to reduce the risk of postoperative GERD.
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Affiliation(s)
| | | | - Fernando A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Francisco Schlottmann
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
- Department of Surgery, University of Illinois, Chicago, Illinois, USA
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Parkitna J, Jaworski P, Binda A, Barski K, Tarnowski W. Effect of SASI procedure (Single Anastomosis Sleeve Ileal) on the symptoms of gastroesophageal reflux disease in bariatric patients - a review of the literature. POLISH JOURNAL OF SURGERY 2023; 96:60-64. [PMID: 38348987 DOI: 10.5604/01.3001.0053.3998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
The problem of gastroesophageal reflux disease among bariatric patients is constantly growing. While bariatric surgery is the most effective method of treating obesity and related diseases, not all surgical procedures lead to improvement or resolution of gastroesophageal reflux disease. The search for the "ideal" surgical procedure for this group of patients is ongoing. The relatively recently introduced SASI procedure seems to have a beneficial effect on GERD symptoms and may be an alternative anti-reflux procedure in obese patients. The presented paper is a review of the latest literature on the impact of SASI procedure on the symptoms of gastroesophageal reflux disease.
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Affiliation(s)
- Joanna Parkitna
- Clinical Department of General, Oncological and Bariatric Surgery CMKP, Warsaw, Poland
| | - Paweł Jaworski
- Clinical Department of General, Oncological and Bariatric Surgery CMKP, Warsaw, Poland
| | - Artur Binda
- Clinical Department of General, Oncological and Bariatric Surgery CMKP, Warsaw, Poland
| | - Krzysztof Barski
- Clinical Department of General, Oncological and Bariatric Surgery CMKP, Warsaw, Poland
| | - Wiesław Tarnowski
- Clinical Department of General, Oncological and Bariatric Surgery CMKP, Warsaw, Poland
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Hage K, Barajas-Gamboa JS, Romero-Velez G, Allemang M, Navarrete S, Corcelles R, Rodriguez J, Ghanem OM, Kroh M, Dang JT. Revisional Procedures after Sleeve Gastrectomy for Weight Recurrence or Inadequate Weight Loss: An Analysis of the MBSAQIP Database. J Clin Med 2023; 12:5975. [PMID: 37762916 PMCID: PMC10531699 DOI: 10.3390/jcm12185975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 09/05/2023] [Accepted: 09/13/2023] [Indexed: 09/29/2023] Open
Abstract
INTRODUCTION The safety of conversional bariatric procedures after sleeve gastrectomy (SG) for weight recurrence (WR) or inadequate weight loss (IWL) is debated due to limited evidence. Conversion options include Roux-en-Y gastric bypass (RYGB), single anastomosis duodeno-ileal bypass (SADI), and biliopancreatic diversion with duodenal switch (BPD-DS). We aimed to compare serious complications and mortality rates between these procedures within 30 days. METHODS Using the 2020 and 2021 MBSAQIP databases, we identified patients who underwent a conversion from SG to RYGB, SADI, or BPD-DS. We performed a multivariable logistic regression to assess predictors of 30-day complications and mortality. RESULTS Among 7388 patients (77.6% RYGB, 8.7% SADI, 13.7% BPD-DS), those undergoing SADI and BPD-DS had higher preoperative body mass index. Conversion reasons included WR (63.0%) and IWL (37.0%). SADI and BPD-DS patients had longer operative times (p < 0.001) and higher leak rates (p = 0.001). Serious complications, reoperations, readmissions, and 30-day mortality were similar across groups. Conversion procedure type was not an independent predictor of complications. CONCLUSION RYGB was the most performed conversional procedure after SG. The study indicated a similar safety profile for revisional RYGB, SADI, and BPD-DS, with comparable 30-day complications and mortality rates. However, SADI and BPD-DS patients had longer operative time and higher leak rates.
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Affiliation(s)
- Karl Hage
- Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Juan S. Barajas-Gamboa
- Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi P.O. Box 112412, United Arab Emirates
| | | | - Matthew Allemang
- Digestive Disease Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | | | - Ricard Corcelles
- Digestive Disease Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - John Rodriguez
- Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi P.O. Box 112412, United Arab Emirates
| | - Omar M. Ghanem
- Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Matthew Kroh
- Digestive Disease Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Jerry T. Dang
- Digestive Disease Institute, Cleveland Clinic, Cleveland, OH 44195, USA
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Mackey EE, Dore FJ, Kelly JF, Crawford AS, Cohen P, Czerniach D, Perugini R, Kelly JJ, Cherng NB. Ligamentum teres cardiopexy for post vertical sleeve gastrectomy gastroesophageal reflux. Surg Endosc 2023; 37:7247-7253. [PMID: 37407712 DOI: 10.1007/s00464-023-10239-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/11/2023] [Indexed: 07/07/2023]
Abstract
PURPOSE Vertical sleeve gastrectomy (VSG) evolved in the early 2000s into the standalone weight loss procedure we see today. While numerous studies highlight VSG's durability for weight loss, and improvements co-morbidities such as type 2 diabetes mellitus and cardiovascular disease, patients with gastroesophageal reflux disease (GERD) have been counseled against VSG due to the concern for worsening reflux symptoms. When considering anti-reflux procedures, VSG patients are unable to undergo traditional fundoplication due to lack of gastric cardia redundancy. Magnetic sphincter augmentation lacks long-term safety data and endoscopic approaches have undetermined longitudinal benefits. Until recently, the only option for patients with a history of VSG with medically refractory GERD has been conversion to roux en Y gastric bypass (RNYGB), however, this poses other risks including marginal ulcers, internal hernias, hypoglycemia, dumping syndrome, and nutritional deficiencies. Given the risks associated with conversion to RNYGB, we have adopted the ligamentum teres cardiopexy as an option for patients with intractable GERD following VSG. METHODS A retrospective chart review was conducted of patients who had prior laparoscopic or robotic VSG and subsequently GERD symptoms refectory to pharmacological management who underwent ligamentum teres cardiopexy between 2017 and 2022. Pre-operative GERD disease burden, intraoperative cardiopexy characteristics, post-operative GERD symptomatology and changes in H2 blocker or PPI requirements were reviewed. RESULTS Of the study's 60 patients the median age was 50 years old, and 86% were female. All patients had a diagnosis of GERD through pre-operative assessments and were taking antisecretory medication. Of the 36 patients who have completed their one year follow up, 81% of patients had either a decrease in dosage or cessation of the antisecretory medication at one year following ligamentum teres cardiopexy. CONCLUSION Ligamentum teres cardiopexy is a viable alternative to RNYGB in patients with a prior vertical sleeve gastrectomy with medical refractory GERD.
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Affiliation(s)
- Emily E Mackey
- Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Fiona J Dore
- Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - John F Kelly
- Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Allison S Crawford
- Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Philip Cohen
- Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Donald Czerniach
- Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Richard Perugini
- Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - John J Kelly
- Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Nicole B Cherng
- Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA.
- Division of Minimally Invasive Surgery, University of Massachusetts Chan Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA.
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Novel Impedance-pH Parameters in Pre-Bariatric Assessment of Patients: A Pilot Study. J Clin Med 2023; 12:jcm12030940. [PMID: 36769588 PMCID: PMC9917402 DOI: 10.3390/jcm12030940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 01/21/2023] [Accepted: 01/22/2023] [Indexed: 01/27/2023] Open
Abstract
Novel impedance-pH parameters, Mean Nocturnal Baseline Impedance (MNBI) and Post-Reflux Swallow-Induced Peristaltic Wave (PSPW) index, have been proposed to improve the gastro-esophageal reflux disease (GERD) diagnostic yield. This study aims to determine the integrity of the esophageal epithelial barrier and chemical clearance using these novel parameters and to correlate them with acid exposure time (AET) and acid clearance time (ACT) in obese patients who are candidates for bariatric surgery (BS). Twenty impedance-pHmetry tracings of patients prior to BS were reviewed. Nine (45%) patients with a conclusive diagnosis of GERD had significantly higher ACT, lower MNBI in the distal esophagus and lower PSPW indexes compared to obese patients without GERD. Moreover, 100% of obese patients with GERD had a pathological ACT compared to obese patients without GERD (p = 0.003). However, the percentage of pathological MNBI and PSPW index did not differ between obese patients with and without GERD. The PSPW index and MNBI of the distal channel significantly correlated with ACT and AET. Further studies are needed to assess the role of time-consuming novel parameters in the routine evaluation of morbidly obese patients candidates for BS. The value of acid clearance time is confirmed as a relevant impedance-pH parameter in these patients.
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Letter to the Editor regarding the article «Gerd symptoms after laparoscopic Roux-en-Y gastric bypass: an emerging scenario» by Antonella Santonicola, Luigi Ruggiero, Rossella Palma, Luigi Angrisani and Paola Iovino. International Journal of Obesity (2022) 46:1076-1078. Int J Obes (Lond) 2022; 46:1936-1937. [PMID: 35933446 DOI: 10.1038/s41366-022-01200-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 07/16/2022] [Accepted: 07/19/2022] [Indexed: 11/09/2022]
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