Esophageal motility disorders in the morbidly obese population

Association Between Different Metabolic Obesity Phenotypes and Erosive Esophagitis: A Retrospective Study

Background and Aim

Obesity is association with elevated risks of erosive esophagitis (EE), and metabolic abnormalities play crucial roles in its development. The aim of the study was to assess the association between metabolic obesity phenotypes and the risk of EE.

Methods

This retrospective study enrolled 11,599 subjects who had undergone upper gastrointestinal endoscopy at the First Affiliated Hospital of Dalian Medical University from January 1, 2008, to December 31, 2023. The enrolled individuals were grouped into four cohorts based on their metabolic health and obesity profiles, namely, metabolically healthy non-obesity (MHNO; n=2134, 18.4%), metabolically healthy obesity (MHO; n=1736, 15.0%), metabolically unhealthy non-obesity (MUNO; n=4290, 37.0%), and metabolically unhealthy obesity (MUO; n=3439, 29.6%). The relationships of the different phenotypes of metabolic obesity with the risks of developing EE in the different sexes and age groups were investigated by multivariate logistic regression analysis.

Results

The MUNO, MHO, and MUO cohorts exhibited elevated risks of developing EE than the MHNO cohort. The confounding factors were adjusted for, and the findings revealed that the MUO cohort exhibited the greatest risk of EE, with odds ratios (ORs) of 5.473 (95% CI: 4.181-7.165) and 7.566 (95% CI: 5.718-10.010) for males and females, respectively. The frequency of occurrence of EE increased following an increase in proportion of metabolic risk factors. Subgroup analyses showed that the individuals under and over 60 years of age in the MHO, MUNO, and MUO cohorts exhibited elevated risks of developing EE. Further analysis suggested that obesity has a stronger influence on the risks of developing EE compared to metabolic disorders.

Conclusion

Metabolic disorders and obesity are both related with an elevated risk of EE, in which obesity has a potentially stronger influence. Clinical interventions should target both obesity and metabolic disorders to reduce EE risk.

Obesity is associated with higher prevalence of gastroesophageal reflux disease and reflux related complications: A global healthcare database study

BACKGROUND

Prior studies have demonstrated that obesity may be associated with the development of gastroesophageal reflux disease (GERD) and GERD-related complications. However, such association has never been assessed in a global-wide real-world patient population.

METHODS

The TriNetX electronic health records network, which involves 92 healthcare organizations in 12 countries, was utilized for this multicenter global health research network study. The cohort with obesity comprised adult patients with body mass index (BMI) of more than 30 kg/m2. We performed 1:1 propensity score matching to decrease confounders effects. The prevalence of GERD and GERD-related complications including erosive esophagitis, Barrett's esophagus (BE), BE with dysplasia, and esophageal adenocarcinoma were assessed.

RESULTS

A total of 2,356,548 patients were included in the obesity and non-obesity groups after propensity score matching. In the group with obesity, patients had a significantly higher prevalence of GERD (30% vs. 24%, OR 1.35, 95% CI 1.34-1.36) compared to the group without obesity. Further analysis showed a higher prevalence of GERD-related complications in the group with obesity with statistical significance: Erosive esophagitis (OR 1.07, 95% CI 1.05-1.08), Barrett's esophagus (1.08, 1.05-1.10), BE with dysplasia (1.11, 1.04-1.18), esophageal cancer (1.32, 1.15-1.51).

CONCLUSION

Globally, obesity was associated with a higher prevalence of GERD and GERD-related complications.

Higher obesity class is associated with more severe esophageal symptoms and reflux burden but not altered motor function or contractile reserve

BACKGROUND

Patients with obesity often report esophageal symptoms, with abnormal reflux and esophageal motility suggested as potential mechanisms. However, prior studies showed varying results, often limited by study design/size and esophageal function/symptom measures utilized. We aimed to examine the relationship between obesity and objective esophageal function testing and patient-reported outcomes, utilizing prospective symptom, manometric and reflux monitoring data with impedance.

METHODS

Adults referred for high-resolution impedance-manometry (HRiM) and multichannel intraluminal impedance-pH monitoring (MII-pH) to evaluate esophageal symptoms were enrolled. Validated symptom and health-related quality of life (HR-QOL) instruments were prospectively collected: GERDQ, reflux symptoms index (RSI), dominant symptom intensity (DSI, multiplied 5-point Likert scales for symptom frequency/severity), global symptom severity (GSS, 100-point visual analog scale), and Short Form-12 (SF-12) for HR-QOL. Esophageal function testing measures were compared across body mass index (BMI) categories and correlated with patient-reported outcomes.

KEY RESULTS

Seven hundred and fifty four patients were included (Normal:281/Overweight:253/Class I obesity:137/Class II/III obesity:83). Reflux burden measures on MII-pH (acid exposure time, total reflux episodes, bolus exposure time), conclusive pathologic reflux (Lyon), and hiatal hernia were increased in higher obesity classes compared to normal BMI. Class II/III obesity was associated with more normal/hypercontractile swallows, less ineffective swallows, and better bolus transit on HRiM. BMI correlated positively with GERDQ/RSI/DSI/GSS, and negatively with physical component score (SF-12). Esophageal symptom severity and HR-QOL correlated strongly with MII-pH findings, but not HRiM measures.

CONCLUSIONS/INFERENCES

Obesity is associated with increased esophageal symptom burden and worse physical HR-QOL, which correlate with higher acid/bolus reflux burden but not altered esophageal motility/transit/contractile reserve.

Mid-term Outcomes of Nissen Fundoplication Versus Roux-en-y Gastric Bypass for Primary Management of Gastroesophageal Reflux Disease in Patients With Obesity

INTRODUCTION

The efficacy and outcomes of laparoscopic Nissen fundoplication (LNF) in patients with obesity is controversial. Specifically, concerns regarding long-term outcomes and recurrence in the setting of obesity has led to interest in laparoscopic Roux-en-Y gastric bypass (RYGB).

METHODS

In this retrospective cohort study, we studied patients with obesity who underwent either LNF or RYGB for gastroesophageal reflux disease. Baseline demographics, clinical variables, operative outcomes, and symptom severity scores were compared.

RESULTS

Baseline demographics, operative outcomes, and quality-of-life scores were similar. Proton pump inhibitor usage, quality-of-life, symptom severity scores, and satisfaction with the operation were similar between groups at mid-term follow-up.

DISCUSSION

RYGB and LNF produced similar improvements in disease-specific quality of life with similar rates of complications, side effects, and need for reoperation. This demonstrates that RYGB and LNF represent possible options for surgical management of gastroesophageal reflux disease in obese patients.

Single-center experience of transitioning from video-assisted laparoscopic to robotic Heller myotomy with Dor fundoplication for esophageal motility disorders

BACKGROUND

Video-assisted laparoscopic Heller myotomy (LHM) has become the standard treatment option for achalasia. While robotic surgery offering some specific advantages such as better three-dimensional (3D) stereoscopic vision, hand-eye consistency, and flexibility and stability with the endowrist is expected to be shorter in learning curve than that of LHM for surgeons who are proficient in LHM. The aim of this study was to describe a single surgeon's experience related to the transition from video-assisted laparoscopic to robotic Heller myotomy with Dor fundoplication.

METHODS

We conducted a retrospective observational study based on the recorded data of the first 66 Heller myotomy performed with laparoscopic Heller myotomy with Dor fundoplication (LHMD, 26 cases) and with the robotic Heller myotomy with Dor fundoplication (RHMD, 40 cases) by the same surgeon in Department of Thoracic Surgery of The First Affiliated Hospital of Nanchang University in China. The operation time and intraoperative blood loss were analyzed using the cumulative sum (CUSUM) method. Corresponding statistical tests were used to compare outcomes of both serials of cases.

RESULTS

The median operation time was shorter in the RHMD group compared to the LHMD group (130 [IQR 123-141] minutes vs. 163 [IQR 153-169]) minutes, p < 0.001). In the RHMD group, one patient (2.5%) experienced mucosal perforation, whereas, in the LHMD group, the incidence of this complication was significantly higher at 19.2% (5 patients) (p = 0.031). Based on cumulative sum analyses, operation time decreased starting with case 20 in the LHMD group and with case 18 in the RHMD group. Intraoperative blood loss tended to decline starting with case 19 in the LHMD group and with case 16 in the RHMD group.

CONCLUSIONS

Both RHMD and LHMD are effective surgical procedures for symptom relief of achalasia patients. RHMD demonstrates superior outcomes in terms of operation time and mucosal perforation during surgery compared to LHMD. Proficiency with RHMD can be achieved after approximately 16-18 cases, while that of LHMD can be obtained after around 19-20 cases.

An analysis of enhanced recovery pathways for bariatric surgery-preoperative fasting, carbohydrate loading, and aspiration risk: a position statement from the International Society for the Perioperative Care of Patients with Obesity

Enhanced recovery pathways (ERPs) and recommendations have become widely accepted for metabolic and bariatric surgery, including recommendations for preoperative carbohydrate loading and duration of fasting status. There is still a lack of consensus regarding such protocols and the underlying issues of gastric emptying time, resting gastric volume and pH, and risk of aspiration in patients with severe obesity and in patients undergoing bariatric surgery. The goal of this position statement by the International Society for the Perioperative Care of Patients with Obesity (ISPCOP) is to provide an analysis of available data on preoperative fasting and loading with oral complex clear carbohydrate drinks as well its potential effects on perioperative risk of aspiration in the context of Enhanced Recovery Pathways for Metabolic and Bariatric Surgery (ERAMBS).

Persistent and De Novo GERD After Sleeve Gastrectomy: Manometric and pH-Impedance Study Findings

PURPOSE

One concerning disadvantage of sleeve gastrectomy (SG) technique as a treatment for obesity is the risk of developing gastroesophageal reflux disease (GERD) or worsening its symptoms after surgery. The purpose of this study is to describe the changes in manometry and 24-h pHmetry with impedance in bariatric patients after SG.

MATERIALS AND METHODS

Retrospective analysis of 225 patients who underwent SG and were subjected to manometry, 24-h phmetry, and 24-h impedance between 2006 and 2016. Patients were subdivided into groups based on the test performed: 66 patients with manometry, 60 with 24-h pHmetry and 53 with 24-h impedance. Descriptive and analytical statistics were used for analysis.

RESULTS

Manometry results showed a decrease in LES pressure from 12.26 ± 6.87 to 8.88 ± 6.28 mmHg in patients after surgery, de novo LES incompetence in 53.33%, worsening of symptoms in 71.4%, increase of inverted gastroesophageal gradient from 6.06% to 48.48% (p<0.05), and a rise in esophageal dysmotility from 18.19% to 37.87%. 24-h pHmetry showed an increase of DeMeester score from 16.71 ± 12.78 to 42.88 ± 32.08 after SG and 79.48% of de novo GERD. Ambulatory 24-h impedance showed an increase of pathological reflux from 47.17% to 88.67% postoperatively.

CONCLUSIONS

Laparoscopic SG is associated with a higher proportion of abnormal DeMeester score and greater incompetence of the LES in post-SG esophageal tests. Hence, SG may predispose the development of gastroesophageal reflux in the postoperative period.

Impacts of sleeve gastrectomy on gastroesophageal reflux disease in severely obese Korean patients

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has established popularity as a bariatric and metabolic surgery. However, the incidence of gastroesophageal reflux disease (GERD) following LSG is controversial. This study aims to describe the prevalence of de novo GERD after LSG.

METHODS

A retrospective chart review was performed for 130 patients who underwent a routine endoscopic surveillance before and after LSG between January 2013 and October 2018. The diagnosis of GERD was determined by presence of symptoms, history of PPI treatment, and endoscopic findings. The esophagogastroduodenoscopy (EGD) was performed annually after LSG and/or when the patients complained of severe reflux symptoms.

RESULTS

The prevalence of GERD before surgery was 18.5%. At 1 year after LSG, GERD was present in 70 (53.8%) of the 130 patients. GERD consisted of 55 patients with newly developed GERD, and 15 with preexisting GERD. 9 (37.5%) out of pre-existing GERD patients were free of symptoms and abnormal finding at EGD following LSG. During the LSG, 66 (50.8%) patients with hiatal hernia underwent re-approximation of the diaphragmatic crura. There was no significant relationship between hiatal hernia repair and postoperative GERD (p = 0.39). Number of patients taking PPI medication before and after LSG were 34 (26.2%) and 49 (37.7%). Out of 56 (43.1%) patients with endoscopic lesions, LA grade A was 31 (23.9%), B = 15 (11.5%), C = 4 (3.1%), and D = 6 (4.6%).

CONCLUSION

In this study, 42.3% (n = 55) of total patients developed newly developed GERD, and 7.7% (n = 10) had LA grade C or D esophagitis.

Achalasia

Achalasia is a rare disorder of the oesophageal smooth muscle characterized by impaired relaxation of the lower oesophageal sphincter (LES) and absent or spastic contractions in the oesophageal body. The key pathophysiological mechanism is loss of inhibitory nerve function that probably results from an autoimmune attack targeting oesophageal myenteric nerves through cell-mediated and, possibly, antibody-mediated mechanisms. Achalasia incidence and prevalence increase with age, but the disorder can affect all ages and both sexes. Cardinal symptoms consist of dysphagia, regurgitation, chest pain and weight loss. Several years can pass between symptom onset and an achalasia diagnosis. Evaluation starts with endoscopy to rule out structural causes, followed by high-resolution manometry and/or barium radiography. Functional lumen imaging probe can provide complementary evidence. Achalasia subtypes have management and prognostic implications. Although symptom questionnaires are not useful for diagnosis, the Eckardt score is a simple symptom scoring scale that helps to quantify symptom response to therapy. Oral pharmacotherapy is not particularly effective. Botulinum toxin injection into the LES can temporize symptoms and function as a bridge to definitive therapy. Pneumatic dilation, per-oral endoscopic myotomy and laparoscopic Heller myotomy can provide durable symptom benefit. End-stage achalasia with a dilated, non-functioning oesophagus may require oesophagectomy or enteral feeding into the stomach. Long-term complications can, rarely, include oesophageal cancer, but surveillance recommendations have not been established.

Impact on sleeve gastrectomy in patients with esophageal motor disorder

BACKGROUND

Gastroesophageal reflux disease (GERD) and esophageal motor disorders (EMD) are frequent conditions among patients with obesity. The effects of sleeve gastrectomy (SG) on esophageal function can worsen GERD, but little is known about its effects on EMD and the consequences of preexisting EMD on GERD after SG.

OBJECTIVES

To study the postoperative outcomes of SG in a population of patients displaying preexisting EMD.

SETTING

University Hospital, France.

METHODS

Patients with EMD confirmed by high-resolution manometry who underwent a laparoscopic SG between 2010 and 2019 were retrospectively included in this monocenter study. GERD symptoms and high-resolution manometry results were recorded before surgery and during follow-up. Conversion to gastric bypass were also recorded.

RESULTS

Thirty-seven patients were included. Mean age was 52.6 ± 12.9 years. Most patients were female (70%). EMD were achalasia (19% of patients), hypercontractile (22%), hypocontractile (30%) and nutcracker esophagus (22%), and ineffective esophageal motility (8%). GERD symptoms were present in 10 patients (27%) preoperatively and 18 (49%) postoperatively. Achalasia was not resolved after SG and was constantly associated with disabling food blockage or GERD symptoms after surgery, and 3 of 4 patients with nutcracker esophagus had postoperative GERD symptoms and underwent gastric bypass.

CONCLUSIONS

This study is the largest to describe the course of GERD and EMD after SG in patients displaying preoperative EMD. Achalasia and nutcracker esophagus are associated with poorer postoperative outcomes, and another procedure such as a gastric bypass should be performed.

Obesity as a risk factor for diseases of the digestive system

Currently, the global prevalence of obesity among the worlds adult population is about 650 million people, which makes it possible to consider this chronic metabolic disease as a non-infectious pandemic of the 21st century. It has been proven that obesity is associated with several gastroenterological diseases, while the mechanisms of these associations are extremely heterogeneous and multifactorial. Hypertrophy and hyperplasia of adipocytes in obesity lead to a change in the profile of adipokine production (a decrease in adiponectin, an increase in leptin), an increase in the production of pro-inflammatory cytokines (interleukin-1, 6, 8, tumor necrosis factor ), C-reactive protein, free fatty acids, as well as active forms of oxygen (superoxide radicals, H2O2). All the above induces the development of chronic slowly progressive inflammation, oxidative stress, and insulin resistance. In addition, peptides secreted by adipocytes (adiponectin, leptin, nesfatin-1 and apelin) can modulate gastrointestinal motility, acting both centrally and peripherally. The qualitative and quantitative changes in the intestinal microbiota observed in obese patients (increased Firmicutes and decreased Bacteroidetes) lead to a decrease in the production of short-chain fatty acids and an increase in the intestinal permeability due to disruption of intercellular tight junctions, which leads to increased translocation of bacteria and endotoxins into the systemic circulation. Numerous studies have demonstrated the association of obesity with diseases of the esophagus (gastroesophageal reflux disease, Barretts esophagus, esophageal adenocarcinoma, esophageal motility disorders), stomach (functional dyspepsia, stomach cancer), gallbladder (cholelithiasis, gallbladder cancer), pancreas (acute pancreatitis, pancreatic cancer), liver (non-alcoholic fatty liver disease, hepatocellular carcinoma), intestine (diverticular disease, irritable bowel syndrome, colorectal cancer).

Current status of gastroesophageal reflux disease after sleeve gastrectomy: Still a long way to go

Obesity is a public health concern that is becoming increasingly more serious around the world. Bariatric surgery has become more prevalent due to the obesity epidemic worldwide. Sleeve gastrectomy (SG) is one of the most popular procedures which is safe and efficient. Despite all its favorable features, however, there is an increasing evidence from the literature that the long-term incidence of gastroesophageal reflux disease (GERD) is likely to represent the Achilles' heel of this procedure. Management of severe reflux after SG usually requires revisional surgery. The relationship between SG and GERD needs to be better ascertained in order to prevent related complications, such as esophageal adenocarcinoma. This review attempts to elucidate the effect of SG on GERD and the postoperative management of reflux disease according to recent literature in the hope of drawing the attention of clinicians to postoperative gastroesophageal reflux and guiding the optimal management strategy associated with this "troublesome complication".

The Outcomes of Laparoscopic Biliopancreatic Diversion with Duodenal Switch on Gastro-esophageal Reflux Disease: the Mayo Clinic Experience

PURPOSE

The outcomes of laparoscopic biliopancreatic diversion with duodenal switch (BPD-DS) on gastro-esophageal reflux disease (GERD) are not well elucidated.

MATERIAL/METHODS

This retrospective review included patients undergoing laparoscopic primary BPD-DS at Mayo Clinic from 2009 to 2019. GERD parameters analyzed included subjective symptom report/anti-reflux medication intake and/or endoscopic findings. GERD-HRQL questionnaire was also utilized post-operatively. Three subgroups were employed to stratify patients depending on GERD outcomes: the "No-effect" subgroup included patients where surgery did not affect either positively (GERD resolution) or negatively (de novo GERD) GERD outcome, "De novo GERD" subgroup, and "GERD-resolved" subgroup. Multinomial logistic modeling was used to examine associations with the 3-level GERD subgroup (p<0.05).

RESULTS

Seventy-six patients were included in the analysis. Thirty-four (44.7%) patients were found to be in the "GERD-resolved" subgroup, 28 (36.8%) patients in the "No-effect" subgroup, and 14 (18.4%) patients in the "De novo GERD" subgroup. Multinomial logistic modeling showed that patients with pre-surgery diabetes mellitus (DM) had lesser odds (OR= 0.248, (95% CI: 0.085-0.724, p=0.0108)) of GERD resolution than patients without pre-surgery DM. An association was also established between %TWL at 6 and 12 months following the procedure and GERD outcome (p=0.017 and 0.008, respectively). Finally, the mean (SD) post-operative GERD-HRQL score was 8.7 (8.1) points, and 69 (91%) patients were currently satisfied with their post-operative condition.

CONCLUSION

Laparoscopic BPD-DS appears to have a satisfactory GERD outcome in most patients undergoing the operation. There appears to be an association between pre-operative DM, %TWL at 6 and 12 months, and GERD prognosis in this population.

Impact of bariatric surgery on gastroesophageal reflux disease and esophageal motility

PURPOSE OF REVIEW

Obesity is rapidly increasing in prevalence, and bariatric surgery has become a popular treatment option that can improve all-cause mortality in obese individuals. Gastroesophageal reflux disease (GERD) and esophageal motility disorders are common in the obese population, and the effects of bariatric surgery on these conditions differ depending on the type of bariatric surgery performed.

RECENT FINDINGS

Laparoscopic adjustable gastric banding has declined in popularity due to its contributions to worsening GERD symptoms and the development of esophageal dysmotility. Although laparoscopic sleeve gastrectomy (LSG) is the most popular type of bariatric surgery, a comprehensive assessment for acid reflux should be performed as LSG has been linked with worsening GERD. Novel methods to address GERD due to LSG include magnetic sphincter augmentation and concomitant fundoplication. Due to the decreased incidence of postoperative GERD and dysmotility compared to other types of bariatric surgeries, Roux-en-Y gastric bypass should be considered for obese patients with GERD and esophageal dysmotility.

SUMMARY

Bariatric surgery can affect esophageal motility and contribute to worsening or development of GERD. A thorough workup of gastrointestinal symptoms before bariatric surgery should be performed with consideration for formal testing with high-resolution manometry and pH testing. Based on these results, the choice of bariatric surgery technique should be tailored accordingly to improve clinical outcomes.

De novo gastroesophageal reflux disease esophageal surgery in bariatrics: a literature review and analysis of the current treatment options

With the exponential increase of worldwide obesity, the number of bariatric surgery (BaS) procedures have equally risen. The surgical management of obesity has been widely established as the standard of care for sustained weight reduction, resolution, and improvement of associated comorbidities. However, BaS itself can have postoperative deleterious effects, including de novo gastroesophageal reflux disease (GERD) and upper gastrointestinal motility disorders. The modified anatomy resulting from BaS, due to either a restrictive or hypoabsorptive component, gives this disorder a multifactorial etiology. The overall management of de novo GERD should focus on three primordial approaches: Non-surgical, endoluminal, and surgical. Even in the absence of de novo GERD following primary or secondary BaS, said disorder should be closely monitored and therapy should be catered in a case-by-case approach. Consequently, treatment strategies have been developed on this principle as to adequately resolve de novo GERD. Despite the presence of multiple and suitable treatment modalities, the operating surgeon should perform them in the best interest of the patient. Short-, medium-, and long-term outcomes should be taken into consideration prior to proceed with any type of preferred management option. This article herein presents an update on the surgical management of de novo GERD following BaS and current practical innovations.

Manometric changes of the esophagus in morbidly obese patients

This prospective study aimed to determine the manometric pattern and the prevalence of esophageal dysmotility in 79 morbidly obese patients selected for laparoscopic sleeve gastrectomy. After clinical evaluation and upper gastrointestinal endoscopy, high-resolution esophageal manometry was performed. The esophageal peristalsis, lower esophageal sphincter (LES) basal pressure, and LES relaxation were evaluated. Demographic data showed a predominance of females (55.70%) and both females and males were in the 5^th decade of life. In addition, approximately 3/4 of the patients (78.48%) were from the urban zone. The mean body mass index of the patients was 46.40±6.0069 kg/m², with a maximum of 61 kg/m². The LES basal pressure was normal in 59.49% of the patients, with a mean value of 31.40±18.43 mmHg. LES basal hypertonia was observed in 26.58%, and LES hypotonia in 13.93% of patients; 46.84% (37 patients) had abnormal manometric findings: 24.05% (19 patients) had EGJ outflow obstruction, 12.66% (10 patients) ineffective esophageal motility, 3.8% (3 patients) distal esophageal spasm, 3.8% (3 patients) Jackhammer esophagus, 2 cases were suggestive for type 2 achalasia but in asymptomatic patients. Ineffective esophageal motility was not associated with diabetes mellitus type 2 or erosive esophagitis according to our data. Hiatal hernia (HH) was manometrically diagnosed in 23 patients (29.11%). Preoperative high-resolution esophageal manometry in obese patients demonstrated a high prevalence of motility disorders, but in asymptomatic patients, thus in the future, we require more studies and larger cohorts to better appreciate the clinical impact.

Mediastinoscopy-assisted Transhiatal Esophagectomy (MATHE) in End-stage Achalasia and Gastric Bypass: Technique and Early Results

INTRODUCTION

Approximately 5% of patients who have undergone prior Heller myotomy and Roux en Y gastric bypass progress to end-stage achalasia (ESA). Surgical options for ESA are often limited to esophagectomy for management of severe dysphagia or life-threatening aspiration episodes. Mediastinoscopy-assisted transhiatal esophagectomy (MATHE) by a small left neck incision combined with an abdominal incision, without using a transthoracic approach, has been reported to reduce pulmonary complications. We herein present the first report of MATHE in 2 consecutive patients with ESA and gastric bypass.

MATERIALS AND METHODS

Between August 2017 and September 2020, 2 patients who had undergone Heller myotomy and Roux en Y gastric bypass underwent MATHE for ESA. Transhiatal esophagectomy with mediastinoscopy-assisted dissection was performed. The remnant stomach was used as the conduit in both cases. The embedded Supplemental Digital Content 1 (http://links.lww.com/SLE/A269) reports our novel technique.

RESULTS

Both cases were completed laparoscopically without conversion to laparotomy or thoracotomy. Median length of hospital stay was 9 days (range, 6 to 11 d). Postoperatively, 1 patient developed a cervical anastomotic leak, which healed with conservative management. No other major complications were observed.

CONCLUSIONS

MATHE can be safely performed in patients with a history of gastric bypass and ESA without requiring thoracoscopic mobilization of the esophagus. Further studies are required to validate reproducibility of our technique as an alternative to using a thoracic incision.

Revisional bariatric surgery to single-anastomosis gastric bypass: a large multi-institutional series

BACKGROUND

Reoperation is often required after bariatric procedures. Single-anastomosis gastric bypass (SAGB) is increasingly utilized as a primary bariatric procedure. Few series document SAGB as a revisional bariatric procedure.

OBJECTIVES

To describe our short-term experience with revisional SAGB, focusing on weight loss and reflux symptom outcomes.

SETTING

Three hospitals in Australia with both private and public (government funded) patients.

METHODS

We reviewed all revisional SAGB cases from 2012 to 2019 at. Complications were considered significant if they were Clavien-Dindo grade 3a or higher. A phone survey was conducted to assess weight loss outcomes, patient satisfaction, reflux symptoms, and other complications.

RESULTS

We identified 254 patients who had a revisional bariatric procedure to SAGB (21 previous sleeve gastrectomies and 233 previous adjustable bands), with a mean follow-up of 22 ± 15.6 months (range, 1-55 mo). The mean percentage of excess weight loss was 77% (183 patients, 72%), and the number of patients with follow-ups at 1 and 4 years was 184 (73%) and 35 patients (14%). Within 30 days, there were 29 patients (11%) who required reinterventions (21 endoscopies, 1 interventional radiology procedure, and 7 reoperations) with no deaths. Beyond 30 days, 27 patients (11%) required rerevision to Roux-en-Y gastric bypass for reflux symptoms and 10 (4%) required a laparotomy or laparoscopy for another reason (e.g., bowel obstruction). At a median follow-up of 36.6 months, 87 patients (34%) completed a phone survey, 45 (52%) of whom were taking proton pump inhibitors and 66 patients (76%) of whom were satisfied with their experience.

CONCLUSION

In our series, revision to SAGB was safe, with low short-term morbidity and favorable weight loss outcomes. However, beyond 1 year, a large proportion of patients experienced severe reflux symptoms and required rerevision.

Prevalence of Upper Gastrointestinal Pathology in Patients with Obesity on Preoperative Endoscopy

Background and Objectives:

The preoperative work up for bariatric surgery is variable and not all centers perform a preoperative upper gastrointestinal endoscopy. A study was undertaken to determine the frequency of clinically significant gross endoscopic and pathological diagnoses in a large sample of patients with obesity undergoing work-up for bariatric surgery.

Methods:

Routine endoscopy was performed on all preoperative bariatric patients. A retrospective chart review of 1000 consecutive patients was performed. Patients were divided into three groups: Group A (no endoscopic findings), Group B (clinically insignificant findings), Group C (clinically significant findings).

Results:

Patients had a mean body mass index (BMI) of 49 kg/m2 and 79% were female. In this sample one finding was found on preoperative EGD in 95.2% of patients, 33.9% had at least two diagnoses, and 29.9% had three or more diagnoses. Group A (no findings) consisted of 4.8% of patient, 52.5% in Group B (clinically insignificant findings), and 42.7% were in Group C (clinically significant findings). Clinically significant findings included hiatal hernia 23.5%, esophagitis 9.5%, H. pylori 7.1%, gastric erosions 5.7%, duodenitis 3.7%, Barrett's esophagus 3.1%, and Schatzki ring 1.2%. There was no significant correlation between preoperative BMI and any endoscopic findings (all p-value 0.05). Patients in Group C were statistically older than Groups A and B.

Conclusion:

Upper gastrointestinal pathology is highly common in patients with obesity. There is a significant rate of clinically significant endoscopy findings and all bariatric surgery patients should undergo preoperative endoscopy.

Treatment of achalasia in the bariatric surgery population: a systematic review and single-institution experience

BACKGROUND

Although the link between achalasia and morbid obesity is unclear, the reported prevalence is 0.5-1% in this population. For bariatric surgery patients, optimal type and timing of achalasia intervention is uncertain.

METHODS

Patient charts from a single academic institution were retrospectively reviewed. Between 2012 and 2019, 245 patients were diagnosed with achalasia, 13 of whom underwent bariatric surgery and were included. Patients were divided into two groups depending on the timing of their achalasia diagnosis and bariatric surgery. Groups were compared in terms of type and timing of intervention as well as treatment response.

RESULTS

Group 1 included 4 patients diagnosed with achalasia before bariatric surgery. Three had laparoscopic Heller myotomy (LHM) and 1 had a per oral endoscopic myotomy (POEM). These patients had laparoscopic gastric bypass (LGB) within 5 years of achalasia diagnosis. Postoperatively, 1 had severe reflux with regurgitation necessitating radiofrequency energy application to the lower esophageal sphincter. All had relief from dysphagia. Group 2 included 9 patients diagnosed with achalasia after bariatric surgery. Achalasia subtypes were evenly distributed. Initial operations were: 5 LGB, 2 laparoscopic sleeve gastrectomy (LSG), 1 duodenal switch (DS), 1 lap band. One LSG patient was converted to LGB concurrently with LHM. On average, achalasia was diagnosed 8.3 years after bariatric surgery. Achalasia interventions included: 1 pneumatic dilation, 1 Botox injection, 1 POEM, 6 LHM. While LHM was the most common procedure, 4 of 6 patients experienced recurrent dysphagia, one of whom required esophagectomy.

CONCLUSIONS

Achalasia is a challenging problem in the bariatric surgery population. Recurrent symptoms are common. Patients treated for achalasia after bariatric surgery tended to have worse symptom resolution than those diagnosed prior to bariatric surgery. Additional prospective studies are needed to elucidate whether interventions for achalasia should be performed concurrently or in a particular sequence for optimal results.

The Malnutrition Universal Screening Tool can predict malnutrition in patients with esophageal achalasia

BACKGROUND

At present, little research has been done to clarify why some achalasia patients do not lose weight or are even obese and to investigate their nutritional status. The aim of this study was to identify predictive factors of malnutrition in these patients and to assess their response to treatment.

METHODS

We conducted a retrospective cohort study on consecutive patients referred to a tertiary-care center for laparoscopic or endoscopic treatment of achalasia. Demographics, anthropometric variables, presenting symptoms, and results of the objective investigation were recorded on a prospectively collected database. The severity of symptoms and the nutritional risk were assessed by the Eckardt score and the Malnutrition Universal Screening Tool (MUST), respectively, before and after treatment.

RESULTS

Between 2013 and 2019, 171 patients met the study inclusion criteria. There were 87 (50.9%) male and the median age was 53.0 (39-66) years. The median Eckardt score was 6 (interquartile range 3). Based on the MUST score, 121 (70.8%) patients were classified at moderate/high risk of malnutrition. Of these, 93 (76.9%) were overweight or obese. Compared to low-risk group, predictive factors of moderate/high risk of malnutrition were higher Eckardt score [odds ratio (OR) 1.63; 95% CI, 1.35-1.99], more severe dysphagia (OR 2.68, 95% CI, 1.66-4.30), and greater absolute weight loss (OR 2.37; 95% CI, 1.77-3.17). The latter was the only independent predictive factor of malnutrition (OR 2.54; 95% CI, 1.69-3.82). After treatment, the measured MUST score was 0 in 96% of patients.

CONCLUSIONS

Over 70% of achalasia patients were at moderate/high risk of malnutrition. These individuals may benefit from a perioperative multidisciplinary approach including dietary intervention to stabilize weight and improve their nutritional status.

Potential involvement of adiponectin in obesity-associated erosive esophagitis

A strong causal relationship between obesity and erosive esophagitis has been proposed. Obesity may affect the pathogenesis of erosive esophagitis through adipokines as well as acid reflux. We evaluated the involvement of adiponectin in obesity-associated erosive esophagitis. In total, 1,902 patients who underwent endoscopy during medical check-ups were selected for study. Variables including the body mass index (BMI) and adiponectin level were compared between subjects with erosive esophagitis and normal controls. The subjects were classified by quartiles (Qs) of adiponectin level. Q4 was the reference group. The median adiponectin level differed by gender (men, 5.3 µg/ml vs women, 9.3 µg/ml; p<0.001). As the severity of erosive esophagitis increased in men, the BMI increased (p<0.001) while the adiponectin level decreased (p = 0.026). The multivariate odds ratio for erosive esophagitis was 1.79 for Q1, 1.73 for Q2, 2.34 for obesity, and 27.40 for hiatal hernia in men. When classified by obesity, the multivariate odds ratio for erosive esophagitis was 1.94 for Q1, 2.10 for Q2, and 18.47 for hiatal hernia only in obese men. In women, there were no trends in BMI, adiponectin levels, or severity of erosive esophagitis. We demonstrated that low adiponectin levels are involved in obesity-associated erosive esophagitis in men but not women.

Higher Esophageal Symptom Burden in Obese Subjects Results From Increased Esophageal Acid Exposure and Not From Dysmotility

BACKGROUND & AIMS

Esophageal motor disorders (EMD) and pathologic reflux are often identified in obese individuals, but it is not clear how obesity contributes to these symptoms. We examined the relationships among symptom burden, EMD, acid exposure time (AET), symptom association probability, and body mass index (BMI).

METHODS

We performed a retrospective study of 1089 consecutive patients who underwent high-resolution manometry, of which 426 patients also underwent reflux monitoring off acid suppression, over a 2-year period at a tertiary referral center. Symptom burden was assessed by questionnaires to determine dominant symptom intensity (DSI; product of symptom severity, and frequency, on 5-point Likert scales) and global symptom severity (GSS; global esophageal symptoms on 10-cm visual analog scales) at the time of esophageal testing; BMIs were recorded. We compared proportions of patients with EMD and abnormal reflux burden among BMI categories and correlated them with symptom burden.

RESULTS

Four-hundred thirty-three patients (39.8%) met the criteria for EMD. Esophageal outflow obstruction was observed in higher proportions of patients with low BMIs (underweight, 25.9%; normal, 14.1%; overweight, 13.9%; and obese, 9.8%; P = .037), but EMDs were less frequent in obese patients (P = .047), despite higher symptom burden compared with non-obese patients (DSI, 10.5 ± 0.3 vs 9.7 ± 0.2; P = .03 and GSS, 6.5 ± 1 vs 5.9 ± 1; P = .01). Among the 426 patients who underwent reflux monitoring, the proportions with total AET (P = .02), and upright AET (P < .001) increased among BMI categories, supine AET trended strongly (P = .06), in combination with increasing DSI and GSS (P ≤ .001 for each comparison). BMI correlated with symptom burden, higher AET, and positive symptom association probability (P < .01 for each analysis).

CONCLUSIONS

Increased symptom burden in obese individuals correlates with esophageal acid burden but not with motor disorders.

Achalasia and obesity: patient outcomes and impressions following laparoscopic Heller myotomy and Dor fundoplication

PURPOSE

The optimal management of achalasia in obese patients is unclear. For those who have undergone Heller myotomy and fundoplication, the long-term outcomes and their impressions following surgery are largely unknown.

METHODS

A retrospective review of patients who underwent laparoscopic Heller myotomy and Dor fundoplication (LHMDF) for achalasia was performed. From this cohort, Class 2 and 3 obese (BMI > 35 kg/m²) patients were identified for short- and long-term outcome analysis.

RESULTS

Between 2003 and 2015, 252 patients underwent LHMDF for achalasia, and 17 (7%) patients had BMI > 35 kg/m². Pre-operative Eckardt scores varied from 2 to 9, and at short-term (2-4 week) follow-up, scores were 0 or 1. Ten (58%) patients had available long-term (2-144 months) follow-up data. Eckardt scores at this time ranged from 0 to 6. Symptom recurrence was worse for patients with BMI > 40 kg/m² compared to patients with BMI < 40 kg/m². BMI was largely unchanged at long-term follow-up regardless of pre-intervention BMI. Most patients were satisfied with surgery but would have considered a combined LHMDF and weight-loss procedure had it been offered.

CONCLUSION

LHMDF for achalasia in obese patients is safe and effective in the short term. At long-term follow-up, many patients had symptom recurrence and experienced minimal weight loss. Discussing weight-loss surgery at the time LHMDF may be appropriate to ensure long-term achalasia symptom relief.

Laparoscopic Heller Myotomy and Roux-en-Y Gastric Bypass as Treatment for Patients with Achalasia and Morbid Obesity: Outcomes in a Short Series of Patients

Background: The association between morbid obesity and esophageal achalasia is very infrequent. However, over the last decade, these cases started to increase because of the disturbing rise of morbid obesity worldwide. Heller myotomy (HM) and laparoscopic fundoplication represent the best treatment option for esophageal achalasia. However, in morbidly obese patients with achalasia, the best treatment option is not established. We present laparoscopic HM and Roux-en-Y gastric bypass (RYGB) as an alternative treatment for morbidly obese patients with achalasia. Materials and Methods: We analyzed the course of patients with achalasia and morbid obesity in our institution undergoing a laparoscopic HM and RYGB, with at least 1 year of follow-up. Symptoms questionnaire, body mass index (BMI), and minuted esophagogram before and after treatment were performed in all patients. Results: Seven patients underwent laparoscopic HM and RYGB. All patients had dysphagia. The mean BMI before the onset of symptoms was 42 kg/m² (range 40 to 50). In 5 patients, preoperative contrast esophagram showed mild or marked dilated esophagus, and in 2, one esophageal curve and severe dilation. Manometry confirmed the diagnosis. At a mean follow-up of 38 months (range 14-69), all patients reported a marked improvement in dysphagia, with median overall satisfaction rating of 10 (range 9-10), and no symptom of gastroesophageal reflux disease (GERD). The mean percentage excess weight loss (%EWL) was 77.1% (range 70.1-98.1) and the mean BMI was 25.7 kg/m² (range 23-31). Conclusion: HM and RYGB are an excellent treatment for morbidly obese patients with achalasia. All patients reported a marked improvement of their dysphagia and no symptoms of GERD. The %EWL and BMI descent was very good and maintained through time, showing also an excellent control for morbid obesity.

Peroral Endoscopic Myotomy Is Feasible and Safe in a Gastric Bypass Population

BACKGROUND

Obesity is public health problem of epidemic proportions. Esophageal dysmotility including achalasia is more commonly seen in an obese population. Standard therapy for achalasia can be complicated by hepatomegaly and a post-surgical anatomy in a pre- and post-bariatric population. Peroral endoscopic myotomy (POEM) has not been adequately studied in this population.

METHODS

A retrospective review of a prospectively collected database was completed. Patients who had undergone a Roux-en-y gastric bypass (RYGB) prior to or following a POEM were enrolled. Patient demographics, operative information and post-operative course data was collected.

RESULTS

Six patients underwent POEM prior to or after RYGB. There were no peri-operative complications with an average length of stay of 1.2 days. Five patients experienced a clinical success with excellent symptom resolution. The one failure was in the setting of type III achalasia, but did have objective evidence of lower esophageal sphincter (LES) relaxation post-operatively.

CONCLUSION

POEM in the setting of bariatric surgery is safe and feasible. The potential increase in GERD following POEM is obviated by RYGB anatomy. In an obese individual, a staged POEM prior to or following a RYGB is an appropriate treatment algorithm for obese and achalasia.

Outcomes of routine upper gastrointestinal series screening and surveillance after laparoscopic adjustable gastric banding

BACKGROUND

Esophageal dilatation and dysmotility are known complications of the laparoscopic adjustable gastric band (LAGB), but their incidence varies widely in the literature. There are no formal recommendations guiding surveillance for these potentially underdiagnosed pathologies. This study demonstrates the utility and outcomes of a yearly upper gastrointestinal series screening protocol to detect and manage esophageal dysfunction after LAGB.

METHODS

We reviewed charts for all patients presenting for an outpatient surgical encounter related to LAGB between January 1, 2015 and December 31, 2017. Exclusion criteria included failure to undergo UGIS 6 months or more after band placement, or having undergone band placement in combination with another bariatric procedure. Descriptive statistics were used to characterize demographics, imaging findings and surgical outcomes. All imaging classifications were based on final radiologist report. Means were compared using a Student's t test.

RESULTS

A total of 322 records were reviewed with 39 patients excluded; 31 without UGIS and 8 with concomitant gastric bypass. 85% were female with an average age of 50 years. 66.8% identified as white or Caucasian with 24.7% black/African-American. Greater than 75% of the cohort had at least 5-year follow-up interval. UGIS was performed for symptoms in 66.1% and for routine screening in 33.9%. Of asymptomatic patients, 47.9% demonstrated esophageal dilatation or dysmotility on UGIS, similar to 51.3% of symptomatic patients. 96.8% of all patients went on to band removal. Sixty-four patients had repeat UGIS an average of 8 months following band removal, of which 40.6% were persistently abnormal.

CONCLUSIONS

The incidence of esophageal pathology was significantly higher than most reported series, as was the number of patients with persistently abnormal UGIS despite band removal. The data supports our policy of yearly UGIS for all post-LAGB patients, with strong recommendation for band removal if esophageal dilatation or dysmotility is found.

Phenotype of obesity and gastroesophageal reflux disease in the context of comorbidity in patients with cardiovascular diseases

The relevance of studying such problems as gastroesophageal reflux disease (GERD) and obesity is caused by their high prevalence in the developed countries of the world. Epidemiological data indicate that obesity is a significant risk factor for developing GERD due to increased intra-abdominal pressure and gastroesophageal gradient, slowing of gastric evacuation and formation of hiatal hernia. Abdominal obesity increases the likelihood of complications of GERD: erosive esophagitis, Barrett's esophagus and adenocarcinoma. This fact is connected with humoral influences: increased production of pro-inflammatory cytokines and leptin, and decreased secretion of adiponectin. Treatment of comorbid patients requires higher dosages and longer courses of antisecretory medicines, and an additional prescription of ursodeoxycholic acid.

Myogenic oxidative imbalance interferes with antral motility in obese subjects

BACKGROUND

Obesity is characterized by a systemic low-grade chronic inflammatory oxidative condition that affects vascular and cardiac smooth muscle relaxation. In human antrum, relaxation is mediated by vasoactive intestinal peptide (VIP) through cAMP and cGMP signaling pathways. A genome-wide association study has demonstrated an association between VIP and obesity.

AIM

To evaluate smooth muscle activity in human obese antrum, both in in vitro preparations as well as in vivo.

METHODS

Antral muscle strips and cells were isolated from surgical gastric samples from obese and normal weight subjects. Muscle contraction and relaxation, myogenic oxidative stress and inflammatory status were analyzed in vitro. Distal antral motility was evaluated in vivo by magnetic resonance imaging.

RESULTS

Obese antral muscle cells showed an oxidative-inflammatory imbalance with overexpression of NLRP3 inflammasome, increased IL-1β secretion and caspase1-activation, and reduced antioxidant capacity associated with a myogenic motor impairment of VIP-induced relaxation. The intracellular alterations were characterized by a decreased activation of the cAMP-signaling pathway and a decreased expression of eNOS. These in vitro alterations coincided with the hindering of antral motor activity observed in vivo. Apocynin treatment, counteracting oxidative stress, reverted alterations observed in obese antral muscle.

CONCLUSION

Antral myogenic activity of obese subjects can be impaired by alterations of signaling pathways induced by oxidative stress.

Gastroesophageal Reflux Disease in Obese Patients

Gastroesophageal reflux disease (GERD) and obesity coexist in many patients in the Western population. The association is not coincidental, since GERD pathophysiology is, in part, linked to obesity. Visceral adipose tissue secretes hormones, which increase the risk of GERD. Obesity increases esophageal motor disorders and higher number of transient lower esophageal sphincter relaxations. Central obesity increases abdominal-thoracic pressure gradient and disrupts the gastroesophageal junction by inducing hiatal hernia formation. Obese patients benefit from weight loss by diet to decrease GERD symptoms; however, Roux-en-Y gastric bypass surgery is associated with a higher weight loss and a decrease in GERD symptoms, and is considered the best way to treat both diseases at the same time.

De novo gastroesophageal reflux disease after sleeve gastrectomy: role of preoperative silent reflux

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has become the most frequently performed bariatric procedure to date. However, LSG is known to worsen pre-operative and result in de novo gastroesophageal reflux disease (GERD). Pre-operative evaluation reveals a high percentage of silent GERD of so far unknown influence on post-operative GERD.

METHODS

Prospective data of patients undergoing primary LSG between 01/2012 and 12/2015 were evaluated. Pre-operative GERD-specific evaluation consisted of validated questionnaires, upper endoscopy, 24 h-pH-manometry, and esophagograms. Patients were followed-up with questionnaires every 6 months, upper endoscopies after 1 year and 24 h-pH-metry after 2 years. Silent GERD was defined as esophagitis grade > B and/or abnormal esophageal acid exposure in absence of symptoms. LSG was performed over a 32F bougie, hiatal hernias > 1 cm were addressed with posterior hiatoplasty. Excluded were patients with hiatal hernias > 4 cm, patients with incorrect anatomy (stenosis, fundus too large) and conversion to RYGB for early leaks.

RESULTS

222 patients were included. Mean follow-up was 32 ± 16 months, mean preoperative body mass index 49.6 ± 7.2 kg/m². 116 patients (52%) presented with post-operative GERD-symptoms, of which 85 (73%) had de novo symptoms. Of those, 48 (of 85, 56%) had no preoperative GERD and 37 (of 85, 44%) silent GERD. 57 patients (26%) had neither pre- nor post-operative GERD, 7 (3%) had silent pre-operative and no postop GERD, and in 19 patients (9%) GERD was cured with LSG. 31 patients (14%) stayed symptomatic. Of 56 patients (25%) with pre-operative silent GERD, 37 (of 54, 66%) became symptomatic.

CONCLUSION

LSG leads to a considerable rate of post-operative GERD. De novo-GERD consist of around half of pre-operative silent GERD and completely de novo-GERD. Most patients with pre-operative silent GERD became symptomatic.

Expanding Role of Third Space Endoscopy in the Management of Esophageal Diseases

OPINION STATEMENT: "Third space" endoscopy, also commonly referred as submucosal endoscopy, is founded on the principle that the deeper layers of the gastrointestinal (GI) tract can be accessed by tunneling in the submucosal space without compromising the integrity of the overlying mucosa. Peroral endoscopic myotomy (POEM), endoscopic submucosal dissection (ESD), and submucosal tunneling endoscopic resection (STER) are innovative techniques within the field of third space endoscopy in the management of esophageal disorders. POEM has become an accepted minimally invasive therapy for achalasia and related motility disorders with excellent short-term results, with early studies yielding similar efficacy to surgical myotomy and increased durability when compared to pneumatic balloon dilation (PBD). Data are needed to establish long-term outcomes with POEM, with particular interest on the incidence of gastroesophageal reflux, which appears to be higher than initially anticipated. ESD, a mature endoscopic resection technique in Asia, has recently gained traction in the West as a viable option for the management of early Barrett's esophagus (BE) neoplasia. Compared to standard endoscopic mucosal resection (EMR), ESD allows the en bloc resection of lesions irrespective of size, which may facilitate histological interpretation and reduce recurrence rates. Large prospective randomized controlled trials are needed to validate the efficacy and safety of this technique and to further define its role in the endoscopic armamentarium in early BE neoplasia. STER is an attractive technique that theoretically permits the resection of subepithelial esophageal tumors (SETs) arising from the deeper GI layers. Initial studies from highly experienced endoscopic centers support its technical feasibility and safety, although these results should be interpreted with caution due to variability arising from small numbers and heterogeneity among studies. Overall, third space endoscopy is an expanding field within endoscopic therapeutics for the treatment of esophageal diseases. While initial results have been very promising, large prospective studies, long-term data, and structured training programs with the establishment of competency parameters are needed before third space endoscopy can be advocated outside of highly specialized centers.

Achalasia after bariatric Roux-en-Y gastric bypass surgery reversal

Achalasia is a rare esophageal motility disorder that is characterized by a loss of peristalsis in the distal esophagus and failure of lower esophageal sphincter relaxation. The risk of developing esophageal motility disorders, including achalasia, following bariatric surgery is controversial and differs based on the type of surgery. Most of the reported cases occurred with laparoscopic adjustable gastric banding. To our knowledge, there are only three reported cases of achalasia after Roux-en-Y gastric bypass and no reported cases after revision of the surgery. We present a case of a 70-year-old female who had a previous history of Roux-en-Y gastric bypass with revision. She presented with persistent nausea and regurgitation for one month. Esophagogastroduodenoscopy showed a dilated esophagus without strictures or stenosis. A barium study was performed after the endoscopy and was suggestive of achalasia. Those findings were confirmed by a manometry. The patient was referred for laparoscopic Heller’s myotomy.

Gastrointestinal Complications of Obesity

Obesity usually is associated with morbidity related to diabetes mellitus and cardiovascular diseases. However, there are many gastrointestinal and hepatic diseases for which obesity is the direct cause (eg, nonalcoholic fatty liver disease) or is a significant risk factor, such as reflux esophagitis and gallstones. When obesity is a risk factor, it may interact with other mechanisms and result in earlier presentation or complicated diseases. There are increased odds ratios or relative risks of several gastrointestinal complications of obesity: gastroesophageal reflux disease, erosive esophagitis, Barrett's esophagus, esophageal adenocarcinoma, erosive gastritis, gastric cancer, diarrhea, colonic diverticular disease, polyps, cancer, liver disease including nonalcoholic fatty liver disease, cirrhosis, hepatocellular carcinoma, gallstones, acute pancreatitis, and pancreatic cancer. Gastroenterologists are uniquely poised to participate in the multidisciplinary management of obesity as physicians caring for people with obesity-related diseases, in addition to their expertise in nutrition and endoscopic interventions.

Short- and Long-Term, 11-22 Years, Results after Laparoscopic Nissen Fundoplication in Obese versus Nonobese Patients

BACKGROUND

Some studies suggest that obesity is associated with a poor outcome after Laparoscopic Nissen Fundoplication (LNF), whereas others have not replicated these findings. The effect of body mass index (BMI) on the short- and long-term results of LNF is investigated.

METHODS

Inclusion criteria were only patients who undergone a LNF with at least 11-year follow-up data available, patients with preoperative weight and height data available for calculation of BMI (Kg/m²), and patients with a BMI up to a maximum of 34.9.

RESULTS

201 patients met the inclusion criteria: 43 (21.4%) had a normal BMI, 89 (44.2%) were overweight, and 69 (34.4%) were obese. The operation was significantly longer in obese patients; the use of drains and graft was less in the normal BMI group (p < 0.0001). The hospital stay, conversion (6,4%), and intraoperative and early postoperative complications were not influenced by BMI.

CONCLUSIONS

BMI does not influence short-term outcomes following LNF, but long-term control of reflux in obese patients is worse than in normal weight subjects.

Gastric Stenosis After Laparoscopic Sleeve Gastrectomy: Diagnosis and Management

PURPOSE

The use of laparoscopic sleeve gastrectomy (LSG) is increasing worldwide. Although post-LSG gastric stenosis (GS) is less frequent, it has not been well defined and lacks standardized management procedures. The objective of the present study was to describe a series of patients with GS symptoms after LSG and to develop a standardized management procedure for this complication.

METHODS

We performed a retrospective analysis of a prospective database of patients presenting with GS after LSG procedures performed between January 2008 and March 2014. The primary efficacy criterion was the frequency of post-LSG GS. GS was classified as functional (i.e. a gastric twist) or organic. The secondary efficacy criteria included the time interval between LSG and diagnosis of GS, the type of stenosis, the type of management, and the follow-up data.

RESULTS

During the study period, 1210 patients underwent primary or secondary LSG. Seventeen patients had post-operative symptoms of GS (1.4%); one patient had achalasia that had not been diagnosed preoperatively and thus was excluded from our analysis. The median time interval between LSG and diagnosis of GS was 47.2 days (1-114). Eleven patients had organic GS and six had functional GS. Seven patients required nutritional support. Endoscopic treatment was successful in 15 patients (88.2%) after balloon dilatation (n = 13) or insertion of a covered stent (n = 2). Two of the 15 patients required conversion to Roux-en-Y gastric bypass (11.8%).

CONCLUSION

GS after LSG is a rare complication but requires standardized management. Most cases can be treated successfully with endoscopic balloon dilatation.

Surgery for Gastroesophageal Reflux Disease in the Morbidly Obese Patient

The prevalence of gastroesophageal reflux disease (GERD) has mirrored the increase in obesity, and GERD is now recognized as an obesity-related comorbidity. There is growing evidence that obesity, specifically central obesity, is associated with the complications of chronic reflux, including erosive esophagitis, Barrett's esophagus, and esophageal adenocarcinoma. While fundoplication is effective in creating a competent gastroesophageal junction and controlling reflux in most patients, it is less effective in morbidly obese patients. In these patients a bariatric operation has the ability to correct both the obesity and the abnormal reflux. The Roux-en-Y gastric bypass is the preferred procedure.

Usefulness of Upper Gastrointestinal Symptoms as a Driver to Prescribe Gastroscopy in Obese Patients Candidate to Bariatric Surgery. A Prospective Study

BACKGROUND

Before bariatric surgery, the necessity of routine upper gastrointestinal endoscopy is controversial, and guidelines recommend endoscopy in symptomatic cases. However, impaired visceral sensation occurring in obese patients may be misleading. The purpose of the study is to evaluate prospectively the prevalence of gastrointestinal symptoms, endoscopic findings, and the relation between symptoms and endoscopic findings in obese patients before surgery.

MATERIALS AND METHODS

One hundred forty-two consecutive patients candidate to primary bariatric surgery filled out the validated Rome III symptomatic questionnaire and performed endoscopy.

RESULTS

With a median age of 41 years and BMI of 44 Kg/m(2), 83% were females. Symptoms were referred by 43% of patients: gastroesophageal reflux disease (GERD) (27.9%) and dyspepsia (24.6%), subdivided in postprandial distress (PDS) (66.7%) and epigastric pain (33.3%) syndromes. Of GERD patients, 19.7% presented concomitantly PDS. Belching was present in 8.2% and nausea and/or vomiting in 1.6% of patients. At endoscopy, one or more lesions were present in 47.1% of the patients: erosive esophagitis (5.6%), hiatal hernia (23.2%), gastroduodenal erosions (6.3%), and peptic ulcers (3.5%). At histology, 24% of patients have Helicobacter pylori infection, and its prevalence in gastroduodenal erosions and ulcers was 22.2 and 60%, respectively. Surprisingly, in patients with peptic lesions H. pylori-negative, no chronic use of NSAIDs was reported. Analyzing the coexistence of symptoms and lesions, these resulted equally distributed beyond the presence of symptoms, being present in 44.2 and 49.4% of symptomatic and asymptomatic patients, respectively.

CONCLUSIONS

The presence of symptoms cannot be considered as a valuable guide to indicate endoscopy since the majority of endoscopic lesions were asymptomatic and not H. pylori-related.

Prevalence of Barrett's Esophagus in Bariatric Patients Undergoing Sleeve Gastrectomy

BACKGROUND

The appearance and incidence of gastroesophageal reflux after sleeve gastrectomy is not yet resolved, and there is an important controversy in the literature. No publications regarding the appearance of Barrett's esophagus after sleeve gastrectomy are present in the current literature.

PURPOSE

The purpose of this paper was to report the incidence of Barrett's esophagus in patients submitted to sleeve.

MATERIAL AND METHODS

Two hundred thirty-one patients are included in this study who were submitted to sleeve gastrectomy for morbid obesity. None had Barrett's esophagus. Postoperative upper endoscopy control was routinely performed 1 month after surgery and 1 year after the operation, all completed the follow-up in the first year, 188 in the second year, 123 in the third year, 108 in the fifth year, and 66 patients over 5 years after surgery.

RESULTS

Among 231 patients operated on and followed clinically, reflux symptoms were detected in 57 (23.2%). Erosive esophagitis was found in 38 patients (15.5%), and histological examination confirmed Barrett's esophagus in 3/231 cases (1.2%) with presence of intestinal metaplasia.

CONCLUSION

Bariatric surgeons should be aware of the association of gastroesophageal reflux (GER) disease and obesity. Appropriate bariatric surgery should be indicated in order to prevent the occurrence of esophagitis and Barrett's esophagus.

The impact of bariatric surgery on esophageal function

Obesity is a worldwide epidemic. There is increasing evidence that obesity is associated with benign gastroesophageal disease, including gastroesophageal reflux disease (GERD) and esophageal dysmotility. Bariatric surgery-including sleeve gastrectomy, gastric bypass, and adjustable gastric band placement-can effectively result in weight loss and control of obesity-related conditions, including GERD. However, there is increasing evidence that bariatric surgery itself can have a deleterious effect on esophageal function. In this review, we address the effect of obesity and bariatric surgery on esophageal dysfunction.

Achalasia and chronic opiate use: innocent bystanders or associated conditions?

High-resolution manometry identifies three subtypes of achalasia. However, type 3 differs from classic achalasia. Although opiates affect esophageal motility, opiate use and achalasia have not been studied. Patients with a new diagnosis of achalasia at Mayo Clinic Rochester between June 1, 2012 and January 3, 2014 were identified. Clinical records were reviewed to assess symptoms, opiate use, and therapy. Fifty-six patients with achalasia were identified, 14 (25%) were on opiates. Opiate prescription was unrelated to achalasia in all cases, with chronic back and joint pain constituting the majority. Of patients on opiates, five (36%) had type 3 achalasia compared with four (10%) not on opiates (P = 0.02). No patients on opiates had type 1 achalasia. Clinical presentation did not differ with opiates, although those on opiates were more likely to report chest pain (39 vs. 14%, P = 0.05) and less likely to have esophageal dilation (62 vs. 82%, P = 0.13), none with greater than 5-cm diameter. Contractile vigor was greater with opiate use, with distal contractile integral of 7149 versus 2615.5 mmHg/cm/second (P = 0.08). Treatment response was inferior on opiates, with persistent symptoms in 22% compared with 3% without opiates (P = 0.06). Opiate use is common in type 3 achalasia, with the majority of patients on opiates. No patients on opiates were diagnosed with type 1 achalasia. Manometric findings of type 3 achalasia mimic those induced by opiates, suggesting a physiologic mechanism for opiate induced type 3 achalasia. Treatment outcome is inferior with opiates, with opiate cessation perhaps preferable. Further studies assessing opiate use and achalasia are needed.