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Aiolfi A, Bona D, Lipham JC, Bonavina L. Is Endoscopic Surveillance Needed After Laparoscopic Sleeve Gastrectomy? Curr Obes Rep 2024; 13:183-185. [PMID: 38172480 DOI: 10.1007/s13679-023-00545-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/27/2023] [Indexed: 01/05/2024]
Affiliation(s)
- Alberto Aiolfi
- Department of Biomedical Sciences for Health, Division of General Surgery, Ospedale Galeazzi-Sant'Ambrogio, University of Milan, Milan, Italy
| | - Davide Bona
- Department of Biomedical Sciences for Health, Division of General Surgery, Ospedale Galeazzi-Sant'Ambrogio, University of Milan, Milan, Italy
| | - John C Lipham
- Division of Upper GI and General Surgery, Keck Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Luigi Bonavina
- Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, Via Morandi 30, 20097, San Donato Milanese, Milan, Italy.
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Tolone S, Conzo G, Flagiello L, Gambardella C, Lucido FS, Brusciano L, Parisi S, De Bortoli N, Savarino EV, Del Genio G, Docimo L. De Novo Gastroesophageal Reflux Disease Symptoms Are Infrequent after Sleeve Gastrectomy at 2-Year Follow-Up Using a Comprehensive Preoperative Esophageal Assessment. J Clin Med 2024; 13:545. [PMID: 38256679 PMCID: PMC10816106 DOI: 10.3390/jcm13020545] [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: 08/04/2023] [Revised: 09/12/2023] [Accepted: 12/12/2023] [Indexed: 01/24/2024] Open
Abstract
Pathological obesity is a growing public health concern, and its association with gastroesophageal reflux disease (GERD) poses challenges in selecting the appropriate bariatric procedure. Sleeve gastrectomy (SG) has become a popular choice due to its simplicity and effectiveness in weight loss. However, concerns regarding postoperative GERD have been raised. This study aimed to evaluate the association between preoperative assessment of esophageal function and the risk of developing postoperative GERD in patients undergoing SG. A comprehensive evaluation was conducted, including symptom assessment, upper endoscopy, high-resolution esophageal manometry (HRM), and 24 h esophageal pH impedance monitoring (MII-pH). A total of 500 obese patients were included, and their data were compared with 25 healthy volunteers. This study revealed that patients without GERD symptoms, normal endoscopy, HRM, and MII-pH were suitable candidates for SG, with low risk of developing postoperative GERD. The addition of fundoplication techniques to SG may be considered in patients with mild reflux or those at risk of developing it. This study emphasizes the importance of preoperative evaluation in selecting the appropriate bariatric procedure to minimize the risk of postoperative GERD and expand the indications for SG in obese patients.
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Affiliation(s)
- Salvatore Tolone
- Division of General, Mininvasive, Oncologic and Bariatric Surgery, Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, Via Pansini 5, 80131 Naples, Italy (L.F.); (L.B.); (S.P.); (G.D.G.); (L.D.)
| | - Giovanni Conzo
- Division of General, Mininvasive, Oncologic and Bariatric Surgery, Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, Via Pansini 5, 80131 Naples, Italy (L.F.); (L.B.); (S.P.); (G.D.G.); (L.D.)
| | - Luigi Flagiello
- Division of General, Mininvasive, Oncologic and Bariatric Surgery, Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, Via Pansini 5, 80131 Naples, Italy (L.F.); (L.B.); (S.P.); (G.D.G.); (L.D.)
| | - Claudio Gambardella
- Division of General, Mininvasive, Oncologic and Bariatric Surgery, Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, Via Pansini 5, 80131 Naples, Italy (L.F.); (L.B.); (S.P.); (G.D.G.); (L.D.)
| | - Francesco Saverio Lucido
- Division of General, Mininvasive, Oncologic and Bariatric Surgery, Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, Via Pansini 5, 80131 Naples, Italy (L.F.); (L.B.); (S.P.); (G.D.G.); (L.D.)
| | - Luigi Brusciano
- Division of General, Mininvasive, Oncologic and Bariatric Surgery, Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, Via Pansini 5, 80131 Naples, Italy (L.F.); (L.B.); (S.P.); (G.D.G.); (L.D.)
| | - Simona Parisi
- Division of General, Mininvasive, Oncologic and Bariatric Surgery, Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, Via Pansini 5, 80131 Naples, Italy (L.F.); (L.B.); (S.P.); (G.D.G.); (L.D.)
| | - Nicola De Bortoli
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56127 Pisa, Italy;
| | - Edoardo Vincenzo Savarino
- Division of Gastroenterology, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, 35128 Padua, Italy;
| | - Gianmattia Del Genio
- Division of General, Mininvasive, Oncologic and Bariatric Surgery, Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, Via Pansini 5, 80131 Naples, Italy (L.F.); (L.B.); (S.P.); (G.D.G.); (L.D.)
| | - Ludovico Docimo
- Division of General, Mininvasive, Oncologic and Bariatric Surgery, Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, Via Pansini 5, 80131 Naples, Italy (L.F.); (L.B.); (S.P.); (G.D.G.); (L.D.)
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Abdelbaki TN. Bikini-line Hiatal Hernia Repair (BLHHR) During Sleeve Gastrectomy. Obes Surg 2023; 33:3879-3888. [PMID: 37857940 PMCID: PMC10687131 DOI: 10.1007/s11695-023-06881-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 09/29/2023] [Accepted: 10/04/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND To preserve the aesthetic benefits achieved with Bikini line sleeve gastrectomy (BLSG), we have devised a novel approach for simultaneous hiatal hernia repair (HHR), known as bikini-line hiatal hernia repair (BLHHR). This manuscript presents our initial experience with BLHHR and assesses its feasibility and outcomes. METHODS A prospective preliminary study was conducted on patients who underwent BLHHR between September 2020 and October 2022. Patient demographics, preoperative assessments, operative details, postoperative outcomes, and aesthetic evaluations were recorded. Feasibility and safety were assessed. RESULTS Among 891 BLSG patients, 89 (9.9%) underwent BLHHR. The mean distances between the xiphoid process and the umbilicus, symphysis pubis, and anterior superior iliac spine (ASIS) were 28.8 ± 2.2, 33.9 ± 3.1, and 31.2 ± 1.8 cm, respectively. Optimal visualization and accessibility of the gastroesophageal junction (GEJ) were achieved without compromising HHR repair or sleeve gastrectomy. The mean operative time was 76.5 ± 11 min, longer than the 58 ± 10 min required for BLSG alone. Patient scar satisfaction ranged from 87.5 to 97.9%, and the mean pain score was 2.9 ± 0.8. No major complications were reported. At 6 months, %EWL (percentage of excess weight loss) was 53.3 ± 13.7%, GERD (gastroesophageal reflux disease) remission was achieved in 62.8% of patients and comorbidities were improved. CONCLUSION BLHHR was potentially feasible and safe. Outcomes related to patient scar satisfaction, weight loss, improvement of associated comorbidities, and GERD symptoms were not compromised. The aesthetic benefits achieved by BLSG were maintained.
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Affiliation(s)
- Tamer N Abdelbaki
- General Surgery Department, Alexandria University Faculty of Medicine, Midan Khartoum, Alexandria, Egypt.
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Kumar A, Madhav JV, Singla V, Monga S, Aggarwal S. Concomitant Hiatal Hernia Repair With Sleeve Gastrectomy: Impact on Gastroesophageal Reflux? Surg Laparosc Endosc Percutan Tech 2023; 33:435-439. [PMID: 37671614 DOI: 10.1097/sle.0000000000001216] [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: 05/17/2023] [Accepted: 07/18/2023] [Indexed: 09/07/2023]
Abstract
BACKGROUND Hiatal hernia (HH), whenever encountered during sleeve gastrectomy (SG), needs to be addressed because of its strong association with gastroesophageal reflux disease (GERD). However, the mid-term to long-term effects of hiatal hernia repair (HHR) on GERD remain unclear. METHODS This was a cross-sectional observational analysis of patients who underwent SG + HHR and had completed at least 1 year of follow-up. The preoperative data were retrieved from a prospectively maintained database. Of the 590 patients who underwent SG, 63 patients (10.7%) with concomitant HHR were assessed for the use of proton pump inhibitors (PPIs) and symptoms of GERD using the GERD-Q questionnaire. RESULTS Of the 63 patients, 11 were lost to follow-up, and one underwent Roux-en-Y gastric bypass for HH recurrence and severe reflux. The remaining 51 patients were assessed at a mean follow-up of 3.7±2.0 years. Of these, 51% (26/51) patients had preoperative reflux symptoms. On follow-up, 69.2% (18/26) had complete resolution with significant improvement in their GERD-Q scores (9.8±3.1 to 6.5±2.1; P =0.001), while 76.2% (16/21) of patients were off the PPIs. The incidence of de novo GERD was found in 20% (5/25) of the patients. CONCLUSIONS In patients of morbid obesity with HH, concomitant HHR with SG leads to improvement of the reflux symptoms in more than two-thirds of the patients, besides alleviating the use of PPIs.
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Affiliation(s)
- Arun Kumar
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
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Adarkwah CC, Hirsch O, Menzel M, Labenz J. Endoscopic measurement of hiatal hernias: is it reliable and does it have a clinical impact? Results from a large prospective database. Postgrad Med 2023; 135:615-622. [PMID: 37571982 DOI: 10.1080/00325481.2023.2239135] [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: 05/14/2023] [Accepted: 07/18/2023] [Indexed: 08/13/2023]
Abstract
OBJECTIVES The aim of our study was to compare the results of endoscopy and manometry with regard to the presence and longitudinal size of hiatal hernias using a cohort of patients with PPI-refractory reflux symptoms. In addition, we aimed to investigate the clinical relevance of hiatal hernias and their size in relation to the occurrence of GERD. METHODS Five hundred patients with suspected GERD due to typical reflux symptoms (heartburn and regurgitation) and inadequate response to PPI therapy underwent standardized screening at a reflux center. After 2 weeks of PPI withdrawal, all patients underwent endoscopy, 24-h pH impedance measurement, and high-resolution manometry (HRM). Both endoscopy and HRM results were available for 487 patients. RESULTS There was a high correlation between the endoscopic and manometric measured longitudinal size of hernias (rho = .768 (p < .001)). Absolute differences differ on a small effect basis (Cohen's d = 0.23). The presence of hernias increases significantly with the severity of GERD, regardless of whether the hernia was diagnosed by endoscopy or manometry. CONCLUSION In summary, endoscopically and manometrically measured hiatal hernia size are highly significantly correlated. Patients with refractory reflux symptoms and a hernia size of 4 cm are very likely to have GERD. In the future, this finding could greatly simplify the diagnosis of GERD.
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Affiliation(s)
- Charles Christian Adarkwah
- Care and Public Health Research Institute, Department of Health Services Research, Maastricht University, Maastricht, The Netherlands
- Institute of General Practice, Philipps-University, Marburg, Germany
| | | | | | - Joachim Labenz
- Department of Medicine and Reflux Center Siegerland, Diakonie Hospital Jung Stilling, Siegen, Germany
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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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Alvarez R, Ward BL, Xiao T, Zadeh J, Sarode A, Khaitan L, Abbas M. Independent association of preoperative Hill grade with gastroesophageal reflux disease 2 years after sleeve gastrectomy. Surg Obes Relat Dis 2022; 19:563-575. [PMID: 36635190 DOI: 10.1016/j.soard.2022.12.013] [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: 09/04/2022] [Revised: 11/01/2022] [Accepted: 12/01/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND The sleeve gastrectomy (SG) is associated with postoperative gastroesophageal reflux disease (GERD). Higher endoscopic Hill grade has been linked to GERD in patients without metabolic surgery. How preoperative Hill grade relates to GERD after SG is unknown. OBJECTIVE To explore the relationship between preoperative Hill grade and GERD outcomes 2 years after SG. SETTING Academic hospital, United States. METHODS All patients (n = 882) undergoing SG performed by 5 surgeons at a single academic institution from January 2015 to December 2019 were included. Complete data sets were available for 360 patients, which were incorporated in analyses. GERD was defined as the presence of a diagnosis in the medical record accompanied by pharmacotherapy. Patients with GERD postoperatively (n = 193) were compared with those without (n = 167). Univariable and multivariable analyses were conducted to explore independent associations between preoperative factors and GERD outcomes. RESULTS The presence of any GERD increased at the postoperative follow-up of 25.2 (3.9) months compared with preoperative values (53.6% versus 41.1%; P = .0001). Secondary GERD outcomes at follow-up included de novo (41.0%), persistent (33.1%), resolved (28.4%), worsened (26.4%), and improved (12.2%) disease. Postoperative endoscopy and reoperation for GERD occurred in 26.4% and 6.7% of the sample. Patients with GERD postoperatively showed higher prevalence of Hill grade III-IV (32.6% versus 19.8%; P = .0062) and any hiatal hernia (HH) (36.3% versus 25.1%; P = .0222) compared with patients without postoperative GERD. Frequencies of gastritis, esophagitis A or B, duodenitis, and peptic ulcer disease were similar between groups. Higher prevalence of preoperative GERD (54.9% versus 25.1%; P < .0001), obstructive sleep apnea (66.8% versus 54.5%; P = .0171), and anxiety (25.4% versus 15.6%; P = .0226) was observed in patients with postoperative GERD compared with those without it. Baseline demographics, weight, other obesity-associated diseases, whether an HH was repaired at index SG, and follow-up length were statistically similar between groups. After adjusting for collinearity, preoperative GERD (odds ratio [OR] = 3.6; 95% confidence interval [CI], 2.2-5.7; P < .0001) and Hill grade III-IV (OR [95% CI]: 1.9 [1.1-3.1]; P = .0174) were independently associated with the presence of any GERD postoperatively. The preoperative presence of an HH >2 cm and whether an HH was repaired at index SG showed no independent association with GERD at follow-up. CONCLUSIONS More than 50% of patients experienced GERD 2 years after SG. Preoperative GERD confers the highest risk for GERD postoperatively. Hill grade III-IV is independently associated with GERD after SG. Whether a hiatal hernia repair was performed did not influence GERD outcomes. Preoperative esophagogastroduodenoscopy should be obtained before SG and Hill grade routinely captured and used to counsel patients about the risk of postoperative GERD after this procedure. Hill grade may help guide the choice of metabolic operation.
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Affiliation(s)
- Rafael Alvarez
- University Hospitals, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio.
| | - Brandon L Ward
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Tianqi Xiao
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jonathan Zadeh
- University Hospitals, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Anuja Sarode
- University Hospitals, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Leena Khaitan
- University Hospitals, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Mujjahid Abbas
- University Hospitals, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
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Karila-Cohen P, Pelletier AL, Saker L, Laouénan C, Bachelet D, Khalil A, Arapis K. Staple Line Intrathoracic Migration After Sleeve Gastrectomy: Correlation between Symptoms, CT Three-Dimensional Stomach Analysis, and 24-h pH Monitoring. Obes Surg 2022; 32:1-9. [PMID: 35501634 DOI: 10.1007/s11695-022-06074-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 04/15/2022] [Accepted: 04/20/2022] [Indexed: 12/11/2022]
Abstract
PURPOSE Migration of the staple line is the definition of sliding hiatus hernia in sleeve gastrectomy patients. The main aim was to determine the frequency and measurement of intrathoracic staple line migration and its correlation with GERD symptoms and pH monitoring. MATERIALS AND METHODS This was a prospective clinical trial including all patients who underwent sleeve gastrectomy more than 1 year previously. All the patients underwent computed tomography (CT) imaging, and migration of the proximal end of the suture above the level of the hiatus was measured in mm. All the patients with symptoms suggestive of GERD were assessed using the GERD impact scale (GIS), and wireless 24-h esophageal pH and symptom association monitoring (SAP) were carried out. Analysis of risk factors for postoperative staple line migration was performed. RESULTS Between March 2018 and December 2018, 194 patients were evaluated (mean age 45.1 ± 11.2 years; 161 females); 88/194 (45.4%) presented an average intrathoracic migration of 16.2 ± 6.9 mm. Thirty-eight of 194 (19.5%) patients presented symptoms suggestive of gastroesophageal reflux. There was a significant relationship between staple line intrathoracic migration and postsleeve GERD symptomatology (p = 0.0004, OR = 4.25 [1.92-9.39]). However, there was no significant correlation between positive 24-h pH monitoring and intrathoracic migration of the staple line (p = 0.1). CONCLUSION A migration greater than 17 mm was strongly correlated with postsleeve GERD symptoms but not with positive 24-h pH monitoring.
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Affiliation(s)
- Pascale Karila-Cohen
- Department of Radiology, Bichat-Claude Bernard University Hospital, Paris, France
| | - Anne-Laure Pelletier
- Department of Hepato-Gastro-Enterology, Bichat-Claude Bernard University Hospital, Paris, France
| | - Loukbi Saker
- Department of Radiology, Bichat-Claude Bernard University Hospital, Paris, France
| | - Cédric Laouénan
- UMR 1137, Université de Paris, INSERM, Paris, France.,INSERM, Centre d'Investigation clinique - Epidémiologie Clinique 1425, Hôpital Bichat, Paris, France.,Department of Epidemiology Biostatistics and Clinical Research, Hôpital Bichat, AP-HP, Paris, France
| | - Delphine Bachelet
- INSERM, Centre d'Investigation clinique - Epidémiologie Clinique 1425, Hôpital Bichat, Paris, France.,Department of Epidemiology Biostatistics and Clinical Research, Hôpital Bichat, AP-HP, Paris, France
| | - Antoine Khalil
- Department of Radiology, Bichat-Claude Bernard University Hospital, Paris, France
| | - Konstantinos Arapis
- Department of Digestive, Bariatric and Endocrinal Surgery, Avicenne University Hospital, 125 route de Stalingrand, 93000 CEDEX, Bobigny, Paris, France.
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Santonicola A, Ruggiero L, Palma R, Angrisani L, Iovino P. Gerd symptoms after laparoscopic Roux-en-Y gastric bypass: an emerging scenario. Int J Obes (Lond) 2022; 46:1076-1078. [PMID: 35066564 DOI: 10.1038/s41366-022-01072-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 01/05/2022] [Accepted: 01/12/2022] [Indexed: 02/07/2023]
Abstract
Laparoscopic Roux-en-Y gastric bypass (RYGB) is the second most performed bariatric procedure and it is considered the procedure of choice to treat patients with severe obesity and gastroesophageal reflux disease (GERD). However, some authors described the new onset or the recurrence of GERD symptoms after RYGB, and data at follow-up were scanty. In our center, we evaluated trend in weight, GERD symptoms and obesity-related comorbidities in 45 patients undergone RYGB at least 60 months before (mean follow-up 99.9 ± 22.9 months). At RYGB 51.1% patients referred preoperative GERD symptoms; among them, 47.8% showed an intraoperative hiatal hernia (HH). At medium-term follow-up mean BMI was significantly lower compared to baseline (p < 0.001). Among patients with preoperative GERD, 69.6% had GERD resolution and 30.4% reported postoperative GERD symptoms. Furthermore, 18.2% without preoperative GERD referred postoperative GERD new onset. We confirmed that RYGB as primary intervention provides satisfactory weight loss and a high percentage of GERD symptoms resolution. However, about 24.4% of patients complained of GERD symptoms at medium-term follow-up. The pathophysiology of GERD after RYGB, de novo or persistence, is not completely understood and several hypotheses could be drawn; however, further studies focusing the pathophysiology of these symptoms are needed.
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Affiliation(s)
- Antonella Santonicola
- University of Salerno, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", Baronissi, SA, Italy
| | - Luigi Ruggiero
- University of Salerno, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", Baronissi, SA, Italy
| | - Rossella Palma
- Department of Surgical Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Luigi Angrisani
- Department of Public Health, "Federico II" University of Naples, Naples, Italy
| | - Paola Iovino
- University of Salerno, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", Baronissi, SA, Italy.
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De la Cruz-Ku G, Rázuri C, Chambergo-Michilot D, Dongo P, Salinas G. Effect of Gastric Sleeve Surgery on Esophagitis in Obese Patients: A Pre-post Surgery Study. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2022. [DOI: 10.29333/ejgm/11883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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11
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Preoperative high-resolution esophageal manometry and postoperative symptoms in patients undergoing bariatric surgery: a retrospective cohort study. Surg Obes Relat Dis 2021; 18:85-94. [PMID: 34756565 DOI: 10.1016/j.soard.2021.10.003] [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: 04/20/2021] [Revised: 09/30/2021] [Accepted: 10/02/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND The increasing incidence of obesity has led to a rise in bariatric surgeries. Obesity can be associated with various gastrointestinal symptoms as well as abnormal findings on high-resolution esophageal manometry (HRM). Bariatric procedures have variable effects on esophageal function and may contribute to postoperative symptoms. Preoperative HRM is not performed routinely on patients undergoing bariatric surgery but may identify patients likely to experience postoperative esophageal symptoms via delineation of structural or functional abnormalities. OBJECTIVES To evaluate whether prebariatric surgery HRM could predict persistent or de novo postoperative esophageal symptoms. SETTING Academic tertiary care hospital, United States. METHODS Retrospective data were collected for 20 patients undergoing HRM and 100 controls 18 years and older from May 2012 to May 2015. Propensity score matching was performed to adjust for baseline differences between the 2 groups. Preoperative and postoperative esophageal symptoms (reflux, dysphagia, nausea/vomiting, bloating, fullness, early satiety, pain, and intolerance) were compared between HRM and control patients, and associations among HRM findings, Chicago Classification, and symptoms were analyzed. All included patients had follow-up beyond 3 months postoperatively. Data were analyzed with 2-tailed Fisher's exact test, Wilcoxon rank-sum test, and odds ratio. RESULTS Compared to controls, patients undergoing preoperative HRM had a higher rate of postoperative chronic intolerance (25% versus 8%, P = .041). This difference was not observed in propensity score matching analysis. Identification of elevated integrated relaxation pressure and esophagogastric junction outflow obstruction predicted chronic intolerance (odds ratio = 21.0; 95% confidence interval: 1.40-314; P = .027 for each). CONCLUSIONS Preoperative HRM abnormalities were associated with postoperative symptoms in patients undergoing bariatric surgery. HRM can identify patients who are more likely to experience postoperative esophageal symptoms and may aid in discussion of suitability for surgery and selection of bariatric intervention.
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Chan DL, Chern TY, Iliopoulos J, Hennessy A, Wong SKH, Ng EKW, Talbot ML. Accuracy of High-Resolution Manometry in Hiatal Hernia Diagnosis in Primary and Revision Bariatric Surgery. Obes Surg 2021; 31:2906-2912. [PMID: 33852151 DOI: 10.1007/s11695-021-05335-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 03/02/2021] [Accepted: 03/04/2021] [Indexed: 12/26/2022]
Abstract
PURPOSE There is a complex association between obesity, hiatal hernia (HH), and reflux. There is a deficiency of literature on the accuracy of preoperative high-resolution manometry (HRM) in detecting HH before both primary and revision bariatric surgery. MATERIALS AND METHODS A retrospective analysis of a prospective database of all HRM performed before bariatric surgery from 2014 to 2019. An electronic medical records review was conducted. Sensitivity, specificity, and global diagnostic test accuracy were calculated. RESULTS Sixty-seven patients with HRM (mean age of 44.0 ± 11.3 years, body mass index 40.8 ± 6.9 kg/m2) were eligible. Intraoperative diagnosis of HH was made in 37 patients (55.2% prevalence). The HRM sensitivity was 48.7% (95% confidence interval (CI) 31.9-65.6%), specificity 90.0% (95% CI 73.5-97.9%), and accuracy was 67.2% (95% CI 54.6-78.2%). Comparing primary (28) and revision (39) surgery, the sensitivity (37.5% vs 57.1%), specificity (75.0% vs 100%), and diagnostic accuracy (54.3% vs 76.3%) were comparable, with overlapping 95% CI. Endoscopy performed in 30 patients had a sensitivity of 25.5% (95% CI 6.8-49.9%), specificity of 100% (95% CI 75.3-100%), and accuracy of 57.8% (95% CI 38.5-75.5%) and was comparable to HRM. CONCLUSION High-resolution manometry for the detection of HH before bariatric surgery has a high specificity and maintains a high accuracy in both primary and revision bariatric surgery.
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Affiliation(s)
- Daniel L Chan
- Department of Surgery, St George Hospital, Gray St, Sydney, NSW, 2217, Australia. .,School of Medicine, Western Sydney University, Sydney, NSW, 2751, Australia. .,Faculty of Medicine, The University of New South Wales, Sydney, NSW, 2052, Australia. .,Division of Upper Gastrointestinal & Metabolic Surgery, Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, SAR, China.
| | - Tien Y Chern
- Department of Surgery, St George Hospital, Gray St, Sydney, NSW, 2217, Australia.,Faculty of Medicine, The University of New South Wales, Sydney, NSW, 2052, Australia
| | - Jim Iliopoulos
- Department of Surgery, St George Hospital, Gray St, Sydney, NSW, 2217, Australia.,School of Medicine, Western Sydney University, Sydney, NSW, 2751, Australia.,Faculty of Medicine, The University of New South Wales, Sydney, NSW, 2052, Australia
| | - Annemarie Hennessy
- School of Medicine, Western Sydney University, Sydney, NSW, 2751, Australia
| | - Simon K H Wong
- Division of Upper Gastrointestinal & Metabolic Surgery, Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, SAR, China
| | - Enders K W Ng
- Division of Upper Gastrointestinal & Metabolic Surgery, Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, SAR, China
| | - Michael L Talbot
- Department of Surgery, St George Hospital, Gray St, Sydney, NSW, 2217, Australia.,School of Medicine, Western Sydney University, Sydney, NSW, 2751, Australia.,Faculty of Medicine, The University of New South Wales, Sydney, NSW, 2052, Australia
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13
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Iovino P, Theron B, Prew S, Menon S, Trudgill N. The mechanisms associated with reflux episodes in ambulant subjects with gastro-esophageal reflux disease. Neurogastroenterol Motil 2021; 33:e14023. [PMID: 33112052 DOI: 10.1111/nmo.14023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 09/29/2020] [Accepted: 10/01/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND The mechanisms associated with gastro-esophageal reflux (GER) episodes were studied using combined High-resolution Impedance Manometry (HRIM) and pH monitoring in ambulant subjects with different patterns of GERD. METHODS Sixteen subjects with mild-moderate esophagitis (Los Angeles (LA) grade A&B) (group A) and 11 subjects with severe esophagitis (LA grade C&D) or Barrett's esophagus (BE) were studied before and after a meal, resting, while walking, and during standardized exercise, using a HRIM and a pH probe. KEY RESULTS Post-prandial acid GER episodes were more common in group B (median 10 range (3-18) vs A (6.5 (0-18), p = 0.048). Postprandial acid clearance time was much longer in group B (median 0.71( 0.07-2.66 min) vs A (0.17 (0.04-2.44 min), p = 0.02). Transient lower esophageal sphincter relaxation (TLESR) was the most frequent mechanism associated with GER episodes in both groups. Post-prandial TLESRs with GER were more common in group B (median 17 (9-24) vs A 13.5 (7-34), p = 0.014), particularly during exercise (B 8 (6-9) vs A 6 (5-6.8), p = 0.007). Post-prandially TLESR with acid reflux increased during exercise in both groups (A rest median 2.4 (0-6.4) per hour vs exercise 4.7 (0-17.3), p = 0.005 and B 4 (0.8-9.6) vs 5.3 (2.7-13.3) per hour, p = 0.045). CONCLUSIONS AND INFERENCES TLESR was the most common mechanism associated with reflux episodes in all subjects. Acid reflux episodes were more common in subjects with severe esophagitis or BE and esophageal acid clearance was much slower. Post-prandial exercise increased TLESR with acid reflux and GERD patients should be encouraged to avoid exercise immediately after a meal.
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Affiliation(s)
- Paola Iovino
- Department of Gastroenterology, Sandwell & West Birmingham Hospitals NHS Trust, Lyndon, West Bromwich, UK
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi, Italy
| | - Byron Theron
- Department of Gastroenterology, Sandwell & West Birmingham Hospitals NHS Trust, Lyndon, West Bromwich, UK
| | - Sandra Prew
- Department of Gastroenterology, Sandwell & West Birmingham Hospitals NHS Trust, Lyndon, West Bromwich, UK
| | - Shyam Menon
- Department of Gastroenterology, Sandwell & West Birmingham Hospitals NHS Trust, Lyndon, West Bromwich, UK
| | - Nigel Trudgill
- Department of Gastroenterology, Sandwell & West Birmingham Hospitals NHS Trust, Lyndon, West Bromwich, UK
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14
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Assakran BS, Alrakbi K, Alharbi MA, Almatroudi MA, Alshowaiman A, Alromaih AH, Alaqil N, Alharbi B, Alsoghayer A. Prevalence of Asymptomatic Hiatal Hernia in Obese Patients During Preoperative Upper Gastrointestinal Endoscopy Assessments and Correlation With Body Mass Index. Cureus 2021; 13:e13396. [PMID: 33758697 PMCID: PMC7978160 DOI: 10.7759/cureus.13396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction In obese patients, hiatal hernia (HH) can be asymptomatic or may present with one or few symptoms, such as heartburn, nausea, or vomiting. Routine upper gastrointestinal (GI) endoscopy is the most frequent method used to determine the presence of any abnormalities, including HH. This study aimed to assess the prevalence of asymptomatic HH in obese patients during routine upper GI endoscopy assessments and to examine the correlation with body mass index (BMI). Materials and methods This was an observational, retrospective cohort study conducted at King Fahad Specialist Hospital, Buraydah, Qassim, Saudi Arabia. The data were extracted from the medical records and electronic charts of all obese patients who underwent preoperative upper GI endoscopy assessment between January 2017 and December 2019. Data were tabulated in Microsoft Excel and analyzed using the Statistical Package for the Social Sciences (SPSS) Version 21 (IBM Corp., Armonk, NY, USA). Results Among the 690 obese patients, HH was found in 103 (14.9%) patients. The chi-square test revealed that abdominal pain (X2=3.885; p=0.049), shortness of breath (X2=8.057; p=0.005), vomiting (X2=4.302; p=0.038), nausea (X2=4.090; p=0.043), and other HH symptoms (X2=3.897, p=0.048) were the most frequently reported HH related symptoms, but BMI was not (X2=2.126; p=0.345). In the multivariate regression model, the use of PPI (proton-pump inhibitor) medication (adjusted OR [AOR]=0.237; 95% CI=0.074-0.760; p=0.023) was found to be higher in those with HH. Vomiting (AOR=1.722; 95% CI=1.025-2.890; p=0.040) and nausea (AOR=1.698; 95% CI=1.012-2.849; p=0.045) were the most frequently reported symptoms related to HH. Conclusion Asymptomatic HH among obese patients is not widely prevalent in our region. The use of PPI medications was found to decrease the symptoms associated with HH, such as vomiting and nausea. However, there was no evidence linking BMI to the development of HH.
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Affiliation(s)
| | - Khaled Alrakbi
- General Surgery, King Fahad Specialist Hospital, Burydah, SAU
| | | | | | | | | | - Naif Alaqil
- General Surgery, Qassim University, Burydah, SAU
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15
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Palma R, Angrisani L, Santonicola A, Fierro F, Iovino P. Late-term hiatal hernia after gastric bypass: an emerging problem. "What came first, the chicken or the egg?". Surg Obes Relat Dis 2020; 16:1623-1624. [PMID: 32800522 DOI: 10.1016/j.soard.2020.06.055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 06/23/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Rossella Palma
- Department of Surgical Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Luigi Angrisani
- Department of Public Health, "Federico II" University of Naples, Naples, Italy
| | - Antonella Santonicola
- Gastrointestinal Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, Salerno, Italy
| | - Francesca Fierro
- Gastrointestinal Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, Salerno, Italy
| | - Paola Iovino
- Gastrointestinal Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, Salerno, Italy
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16
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Clapp B. Response to letter to editor: Late-term hiatal hernia after gastric bypass: an emerging problem. Surg Obes Relat Dis 2020; 16:1624. [PMID: 32873510 DOI: 10.1016/j.soard.2020.07.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 07/27/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Benjamin Clapp
- Paul L Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas
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17
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Boru CE, Coluzzi MG, de Angelis F, Silecchia G. Long-Term Results After Laparoscopic Sleeve Gastrectomy with Concomitant Posterior Cruroplasty: 5-Year Follow-up. J Gastrointest Surg 2020; 24:1962-1968. [PMID: 31410817 DOI: 10.1007/s11605-019-04355-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 07/30/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Hiatal hernia (HH) repair during laparoscopic sleeve gastrectomy (LSG) has been advocated to reduce the incidence of postoperative gastroesophageal reflux disease (GERD) and/or intrathoracic migration (ITM). The necessity of intraoperative repair in asymptomatic patients is still controversial. Previous, mid-term results of a prospective, comparative study evaluating posterior cruroplasty concomitant with LSG (group A 48 patients with simple vs. group B 48 reinforced with bioabsorbable mesh) confirmed the safety and effectiveness of simultaneous procedures. Present aim was to report the 60 months follow-up update, evaluating GERD and esophageal lesions' incidence and HH's recurrence. RESULTS Follow-up was completed in 87.5% of the patients. Recurrent GERD was registered in 6/38 (15.7%, group A) and in 9/46 (19.5%, group B) (p = 1.0000). Grade A esophagitis and GERD was shown in 2 patients (5.2%), respectively 2 (4.3%) of each group (p = 1.0000), and recurrent HH was confirmed subsequently by contrast study and CT scan. Neither Barrett's lesions nor de novo GERD was found in any patient. Failure of the cruroplasty with ITM was recorded in 7 patients from group A (18.4%) and 2 patients from group B (4.3%) p < 0.05; hence, a repeat posterior, reinforced cruroplasty was performed in all cases. A total of 12 patients (14.2%, 8 respective 4) were converted within 5 years for persistent/recurrent GERD, with only 1 case of de novo (group B). CONCLUSIONS Accurate patient selection and proper sleeve technique, combined with posterior cruroplasty (simple or reinforced) ensure effectiveness, with a rate of failure (HH recurrence) at 5 years of 10.7%.
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Affiliation(s)
- Cristian Eugeniu Boru
- Division of General Surgery & Bariatric Center of Excellence-IFSO EC, Department of Medico-Surgical Sciences and Biotechnologies, University La Sapienza of Rome, Via F. Faggiana, 1668, Latina, Italy.
| | - Maria Grazia Coluzzi
- Division of General Surgery & Bariatric Center of Excellence-IFSO EC, Department of Medico-Surgical Sciences and Biotechnologies, University La Sapienza of Rome, Via F. Faggiana, 1668, Latina, Italy
| | - Francesco de Angelis
- Division of General Surgery & Bariatric Center of Excellence-IFSO EC, Department of Medico-Surgical Sciences and Biotechnologies, University La Sapienza of Rome, Via F. Faggiana, 1668, Latina, Italy
| | - Gianfranco Silecchia
- Division of General Surgery & Bariatric Center of Excellence-IFSO EC, Department of Medico-Surgical Sciences and Biotechnologies, University La Sapienza of Rome, Via F. Faggiana, 1668, Latina, Italy
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18
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Angrisani L, Santonicola A, Borrelli V, Iovino P. Sleeve gastrectomy with concomitant hiatal hernia repair in obese patients: long-term results on gastroesophageal reflux disease. Surg Obes Relat Dis 2020; 16:1171-1177. [PMID: 32593594 DOI: 10.1016/j.soard.2020.04.049] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/14/2020] [Accepted: 04/30/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hiatal hernia repair (HHR) during Sleeve Gastrectomy (SG) is recommended when the defect is intraoperatively found; however, the long term effect on gastro-esophageal reflux disease (GERD) remains controversial. OBJECTIVES This study aimed to report long-term follow-up data, at least after 7 years, of SG with concomitant HHR and the outcome on GERD symptoms. SETTING Tertiary-care referral hospital. METHODS This study retrospectively analyzed 91 obese patients submitted to SG + HHR with a minimum of 7-years follow-up. The preoperative evaluation included GERD symptoms assessment by a standardized questionnaire, proton pump inhibitor usage evaluation, an upper gastrointestinal endoscopy, and a barium-swallow esophagogram to detect the presence of HH. At long-term follow-up visit, GERD assessment was performed to evaluate remission, persistence, or new onset of typical GERD symptoms; proton pump inhibitor usage was also investigated. Patients underwent barium-swallow esophagogram and/or upper gastrointestinal endoscopy. RESULTS At long-term evaluation, 2 of 91 patients (2.2%) were lost and 1 patient underwent Roux-en-Y gastric bypass. Of patients with preoperative GERD, 60% had GERD resolution; however, 27 of 88 (30.6%) patients reported postoperative GERD symptoms. Among these patients 15 (55.5%) showed the HH recurrence detected by barium-swallow esophagogram. All patients with HH recurrence had esophagitis and 1 case had a Barrett's esophagus. In the remaining 12 patients (44.4%) with postoperative GERD without HH recurrence, the barium-swallow esophagogram showed signs of reflux in reverse Trendelenburg. CONCLUSIONS At long-term follow-up HH recurrence was consistently related to the presence of GERD symptoms and to a high rate of esophagitis and Barrett's esophagus. In all patients with GERD symptoms after SG + HHR, a HH recurrence should be suspected and an upper gastrointestinal endoscopy strongly recommended to rule out esophagitis, and especially Barrett's esophagus.
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Affiliation(s)
- Luigi Angrisani
- Department of Public Health, "Federico II" University, Naples, Italy
| | - Antonella Santonicola
- Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana," University of Salerno, Salerno, Italy.
| | - Vincenzo Borrelli
- General Surgery Unit, Istituto di Cura Città di Pavia-Gruppo San Donato, Pavia, Italy
| | - Paola Iovino
- Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana," University of Salerno, Salerno, Italy
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19
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Chan DL, Wong SKH, Lok HT, Iliopoulos J, Talbot ML, Hennessy A, Ng EKW. Accuracy of hiatal hernia diagnosis in bariatric patients: Preoperative endoscopy versus intraoperative reference. JGH OPEN 2020; 4:1074-1078. [PMID: 33319039 PMCID: PMC7731797 DOI: 10.1002/jgh3.12388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 12/18/2022]
Abstract
Background and Aim Obesity is becoming increasingly prevalent in Asia. Bariatric surgery in the region is growing in popularity to reflect increasing demand. Hiatal hernia (HH) is common among the obese population. There is a lack of evidence comparing preoperative endoscopy against intraoperative findings as a standard of reference for HH diagnosis. Methods This was a retrospective analysis of a bariatric procedure database from a single tertiary teaching hospital and high‐volume endoscopy center. Electronic medical records were reviewed. Endoscopy results were compared to intraoperative findings, and subgroup analysis of >2 cm hernias was performed. Sensitivity, specificity, predictive values, likelihood ratios, and global diagnostic test accuracy were calculated. Results A total of 434 patients were eligible for this study, of which HH was detected in 37 patients (prevalence rate 8.55%). Mean age was 41.51 ± 11.07 years, and body mass index was 39.37 ± 5.67 kg/m2. Endoscopy sensitivity was 75.68% (95% confidence interval, 58.80–88.23%) and specificity 91.44% (88.24–94.00%). Positive likelihood ratio was 8.53 (6.11–12.79) and negative likelihood ratio 0.27 (0.15–0.47). Positive predictive value was 45.16% (36.27–54.38%) and negative predictive value 97.58% (95.80–98.62%). Accuracy of endoscopy for preoperative HH diagnosis was 90.09% (86.89–92.74%). Conclusion Endoscopy can have a high diagnostic accuracy of preoperative HH diagnosis in obese Asian patients using intraoperative diagnosis as the reference standard.
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Affiliation(s)
- Daniel L Chan
- Division of Upper Gastrointestinal and Metabolic Surgery, Department of Surgery, Faculty of Medicine The Chinese University of Hong Kong Hong Kong SAR China.,School of Medicine Western Sydney University Sydney New South Wales Australia.,Faculty of Medicine The University of New South Wales Sydney New South Wales Australia
| | - Simon K-H Wong
- Division of Upper Gastrointestinal and Metabolic Surgery, Department of Surgery, Faculty of Medicine The Chinese University of Hong Kong Hong Kong SAR China
| | - Hon Ting Lok
- Division of Upper Gastrointestinal and Metabolic Surgery, Department of Surgery, Faculty of Medicine The Chinese University of Hong Kong Hong Kong SAR China
| | - Jim Iliopoulos
- School of Medicine Western Sydney University Sydney New South Wales Australia
| | - Michael L Talbot
- School of Medicine Western Sydney University Sydney New South Wales Australia.,Faculty of Medicine The University of New South Wales Sydney New South Wales Australia
| | - Annemarie Hennessy
- School of Medicine Western Sydney University Sydney New South Wales Australia
| | - Enders K-W Ng
- Division of Upper Gastrointestinal and Metabolic Surgery, Department of Surgery, Faculty of Medicine The Chinese University of Hong Kong Hong Kong SAR China
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