Gastroesophageal Reflux Disease and Sleeve Gastrectomy

Reflux After Sleeve Gastrectomy: Safety and Effectiveness of Laparoscopic Ligamentum Teres Cardiopexy, a Single-Center Experience

BACKGROUND

Obesity is a well-known risk factor for gastroesophageal reflux disease (GERD). Even though symptoms may be mitigated or resolved with the weight loss caused by sleeve gastrectomy (SG), it may be associated with higher incidences of postoperative GERD. Ligamentum teres cardiopexy (LTC) is an alternative to Roux-en-Y gastric bypass, the gold standard treatment for GERD.

METHODS

This study was a retrospective single-center chart review, all patients in this cohort underwent LTC to treat refractory GERD at our institution. The option for LTC was presented after patients' refusal to undergo RYGB conversion. We collected baseline characteristics, standard demographics, pre-operative tests and imaging, and SG information, as well as intraoperative and perioperative data regarding LTC, and postoperative complications.

RESULTS

Our cohort included 29 patients; most were Caucasian (44.8%) females (86.2%). The mean weight and BMI before LTC were 216.5 ± 39.3 lb and 36.1 ± 5.4 kg/m2, respectively. Mean total body-weight loss (TBWL) at 12 and 24 months were 28.7% ± 9.5% and 28.4% ± 12.4%, respectively. The mean interval between the index bariatric surgery and LTC was 59.9 ± 34.9 months, mean operative time was 67 ± 18.2 min, and median length of stay (LOS) was 1 day (IQR = 1-2 days). Twelve patients (57.1%) were able to discontinue antisecretory medications, while 9 (42.9%) still required them to remain asymptomatic. Mortality and reoperation rates were 0% and the incidence of complication was 19.4% (n = 6).

CONCLUSIONS

LTC is a safe and effective surgical alternative to treat refractory GERD symptoms after SG.

Current Status of Anti-Reflux Surgery as a Treatment for GERD

Anti-reflux surgery (ARS) is an efficient treatment option for gastroesophageal reflux disease (GERD). Despite growing evidence of the efficacy and safety of ARS, medications including proton pump inhibitors (PPIs) remain the most commonly administered treatments for GERD. Meanwhile, ARS can be an effective treatment option for patients who need medications continuously or for those who are refractory to PPI treatment, if proper candidates are selected. However, in practice, ARS is often regarded as a last resort for patients who are unresponsive to PPIs. Accumulating ARS-related studies indicate that surgery is equivalent to or better than medical treatment for controlling typical and atypical GERD symptoms. Furthermore, because of overall reduced medication expenses, ARS may be more cost-effective than PPI. Patients are selected for ARS based on endoscopic findings, esophageal acid exposure time, and PPI responsiveness. Although there is limited evidence, ARS may be expanded to include patients with normal acid exposure, such as those with reflux hypersensitivity. Additionally, other factors such as age, body mass index, and comorbidities are known to affect ARS outcomes; and such factors should be considered. Nissen fundoplication or partial fundoplication including Dor fundoplication and Toupet fundoplication can be chosen, depending on whether the patient prioritizes symptom improvement or minimizing postoperative symptoms such as dysphagia. Furthermore, efforts to reduce and manage postoperative complications and create awareness of the long-term efficacy and safety of the ARS are recommended, as well as adequate training programs for new surgeons.

Third time's a charm: band to sleeve to bypass

BACKGROUND

Adjustable gastric bands (AGB) are frequently converted to sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) due to weight recurrence or band complications. Such conversions carry a higher-risk than primary procedures. Some patients undergo two conversions-from AGB to SG, and subsequently from SG to RYGB. This presents a unique situation with limited literature on indications and complication rates associated with these double conversions.

METHODS

We examined the 2020-2021 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Participant Use File to evaluate conversions from AGB to SG and then to RYGB. Patient and operative characteristics, along with outcomes, were evaluated. Descriptive statistics were applied.

RESULTS

We identified 276 patients who underwent a conversion from AGB to SG and then to RYGB. The primary reason for the second conversion (SG to RYGB) was gastroesophageal reflux disease (GERD) at 55.1%, followed by inadequate weight loss or weight regain (IWL/WR) at 36.9%. The remaining reasons included dysphagia, nausea, vomiting, or others. Patients converted for IWL/WR demonstrated a higher baseline body mass index and prevalence of sleep apnea compared to other cohorts (both p < 0.001). Meanwhile, patients in the "other reasons" group had the highest rate of open surgical approaches (9.1%) and concurrent lysis of adhesions (p = 0.001 and p = 0.022), with correspondingly higher rates of anastomotic leak, reoperations, serious complications, and mortality.

CONCLUSIONS

Patients undergoing double conversions (AGB to SG to RYGB) do so primarily for GERD or IWL/WR. Further research is required to better define the optimal primary operation for each patient, aiming to reduce the necessity for multiple conversions.

Long-Term Results of Laparoscopic Sleeve Gastrectomy: a Review of Studies Reporting 10+ Years Outcomes

Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric procedure worldwide. Systematic search of Pubmed, Cochrane, and Embase was performed in order to find all the articles reporting 10+ years of LSG results. Eleven studies including 1020 patients met the inclusion criteria. Overall weighted mean %TWL was 24.4% (17-36.9%), and remission rates from TD2M to HTN were 45.6% (0-94.7%) and 41.4% (0-78.4%), respectively. De novo GERD had an overall prevalence of 32.3% (21.4-58.4%), and five cases (0.5%) of Barrett's disease were reported. Revisional surgery was required for 19.2% (1-49.5%) of patients, Roux-en-Y gastric bypass being the most common secondary procedure.

Barrett`s Esophagus in Bariatric Surgery: Regression or Progression?

INTRODUCTION

Morbid obesity is well known as a risk factor for gastroesophageal reflux disease (GERD) and its related disorders such as Barrett's esophagus (BE). This study aimed to evaluate the development of BE in patients who underwent bariatric surgery.

MATERIALS AND METHODS

Using a single-center prospectively established database of obese patients who underwent bariatric surgery from 01/2012 to 12/2019, we retrospectively compared the preoperative endoscopic findings of BE to those after 1-2 years and 3-5 years following bariatric surgery. The change of BE was detected endoscopically according to Prague classification and histologically according to the British guidelines of detecting columnar epithelium on the distal esophagus.

RESULTS

Among 914 obese patients who underwent bariatric surgery and received a preoperative esophagogastroduodenoscopy (EGD), we found 119 patients (13%) with BE. A follow-up EGD was performed in 74 of the BE patients (62.2%). A total of 37 (50%) patients underwent a follow-up EGD after 1-2 years and 45 (60.8%) patients underwent it after 3-5 years. Among many clinical parameters, the surgical procedure was the only significant factor for the change of BE after bariatric surgery (p < 0.05). A regression of BE was found in 19 patients (n = 54, 35%) after laparoscopic Roux-en-Y- gastric bypass (LRYGB). Furthermore, a progression of BE was detected in six patients (n = 20, 30%) after laparoscopic sleeve gastrectomy (LSG).

CONCLUSION

RYGB should be considered in obese patients with BE. Detecting BE prior to bariatric surgery may have an impact on decision-making regarding the suitable surgical bariatric procedure.

Comparison of upper gastrointestinal series and symptom questionnaires with intraoperative diagnosis of hiatal hernia during sleeve gastrectomy

BACKGROUND

Hiatal hernias are common in bariatric surgery patients, but the utility of preoperative hiatal hernia diagnosis prior to sleeve gastrectomy (SG) is debated.

OBJECTIVE

This study compared preoperative and intraoperative hiatal hernia detection rates in patients undergoing laparoscopic SG.

SETTING

University hospital, United States.

METHODS

As part of a randomized trial evaluating the role of routine crural inspection during SG, an initial cohort was prospectively studied to assess the correlation between preoperative upper gastrointestinal (UGI) series, reflux and dysphagia symptoms, and intraoperative hiatal hernia diagnosis. Preoperatively, patients completed the Gastroesophageal Reflux Disease Questionnaire (GerdQ), the Brief Esophageal Dysphagia Questionnaire (BEDQ), and a UGI series. Intraoperatively, patients with an anteriorly visible defect underwent hiatal hernia repair followed by SG. All others were randomized to standalone SG or posterior crural inspection with repair of any hiatal hernia identified prior to SG.

RESULTS

Between November 2019 and June 2020, 100 patients (72 female patients) were enrolled. Preoperative UGI series identified hiatal hernia in 28% (26 of 93) of patients. Intraoperatively, hiatal hernia was diagnosed during initial inspection in 35 patients. Diagnosis was associated with older age, lower body mass index, and Black race but did not correlate with GerdQ or BEDQ. Using the standard conservative approach, compared with intraoperative diagnosis, sensitivity and specificity of the UGI series were 35.3% and 80.7%, respectively. Hiatal hernia was identified in an additional 34% (10 of 29) of patients randomized to posterior crural inspection.

CONCLUSION

Hiatal hernias are highly prevalent in SG patients. However, GerdQ, BEDQ, and a UGI series unreliably identify hiatal hernia in the preoperative setting and should not influence intraoperative evaluation of the hiatus during SG.

Comparison of Sleeve Volume Between Banded and Non-banded Sleeve Gastrectomy: Midterm Effect on Weight and Food Tolerance-a Retrospective Study

BACKGROUND

Sleeve dilatation after laparoscopic sleeve gastrectomy (LSG) causes weight regain (WR). Banded sleeve gastrectomy (BSG) was proposed to prevent dilatation and reduce WR.

METHODS

A retrospective cohort study on patients who underwent BSG and LSG and completed 4 years of follow-up from 2016 to 2021 was included. Body mass index (BMI), percentage of excess weight loss (%EWL), percentage of total weight loss (%TWL), and FT scores were calculated at 1, 2, 3, and 4 years. The sleeve volume was estimated at 6 months, 1 year, and 4 years. Multi-variate analysis was conducted to assess correlations between covariates. WR was calculated as weight gain > 10%, > 10 kg above the nadir, or BMI increase of ≥ 5 kg/m 2 above the nadir.

RESULTS

This study included LSG 1279 patients and BSG 132 patients. Mean %EWL at 1 year was 83.87 ± 17.25% in LSG vs. 85.71 ± 7.92% in BSG and was 83.47 ± 18.87% in LSG and 85.54 ± 7.48% in BSG at 4 years. Both had significant weight loss over time (p. < 0.001) with no significant main effect of surgery (p.0.438). Mean sleeve volume at 6 months was 102.32 ± 9.88 ± 10.28 ml in LSG vs. 101.89 ± 10.019 ml in BSG and at 4 years was 580.25 ± 112.25 ml in LSG vs. 157.94 ± 12.54 ml in BSG (p. < 0.001). WR occurred in 136 (10.6%) and 4 (3.1%) (p.0.002) in LSG and BSG patients, 90 (7%) vs. zero (0%) (p.0.002) and 31 (2.4%) vs. zero (0%) (p.0.07) using the > 10%, > 10 kg increase above the nadir and the ≥ 5 kg/m 2 BMI increases above the nadir formulas, respectively.

CONCLUSION

BSG had significantly lower sleeve volume, significantly lower WR, and significantly lower FT scores than LSG after 4 years from surgery; however, volume changes were not correlated with weight loss.

Long-term Reported Outcomes Following Primary Laparoscopic Sleeve Gastrectomy

BACKGROUND

Long-term laparoscopic sleeve gastrectomy (LSG) outcomes in patients with obesity are scarce. We aimed to examine the outcomes and subjective experience of patients who underwent primary LSG with long-term follow-up.

METHODS

The study is a retrospective observational analysis of patients who underwent primary LSG in a single center with 5-15 years of follow-up. Patients' hospital chart data supplemented by a detailed follow-up online questionnaire and telephone interview were evaluated.

RESULTS

The study sample included 578 patients (67.0% female) with 8.8 ± 2.5 years of mean follow-up, with a response rate to the survey of 82.8%. Mean baseline age and body mass index (BMI) were 41.9 ± 10.6 years and 42.5 ± 5.5 kg/m², respectively. BMI at nadir was 27.5 ± 4.9 kg/m², corresponding to a mean excess weight loss (EWL) of 86.9 ± 22.8%. Proportion of patients with weight regain, defined as nadir ≥ 50.0% EWL, but at follow-up < 50.0% EWL, was 34.6% (n = 200) and the mean weight regain from nadir was 13.3 ± 11.1 kg. BMI and EWL at follow-up were 32.6 ± 6.4 kg/m² and 58.9 ± 30.1%, respectively. The main reasons for weight regain given by patients included "not following guidelines," "lack of exercise," "subjective impression of being able to ingest larger quantities of food in a meal," and "not meeting with the dietitian." Resolution of obesity-related conditions at follow-up was reported for hypertension (51.7%), dyslipidemia (58.1%) and type 2 diabetes (72.2%). The majority of patients (62.3%) reported satisfaction with LSG.

CONCLUSIONS

In the long term, primary LSG was associated with satisfactory weight and health outcomes. However, weight regain was notable.

Relationship between gastroesophageal reflux disease and laparoscopic sleeve gastrectomy: a narrative review

This paper aims to revisit the relationship between gastroesophageal reflux disease and laparoscopic sleeve gastrectomy in obese patients by reviewing the recent available literature, in the form of a narrative review. The interpretation of the current evidence is challenged by the fact that published data are contradictory and comparison between studies is difficult. Most studies investigate the presence of gastroesophageal reflux disease by assessing only the symptoms reported by patients. A few studies have objectively investigated gastroesophageal reflux disease by functional tests and endoscopic evaluation. Also, the surgical technique of laparoscopic sleeve gastrectomy plays an important role in the incidence of postoperative gastroesophageal reflux disease. In conclusion, surgeons must be aware of the existence of gastroesophageal reflux disease and, at the same time, patients should be informed regarding the possible effect of laparoscopic sleeve gastrectomy on gastroesophageal reflux disease.

Ten-Year Results of Laparoscopic Sleeve Gastrectomy: Retrospective Matched Comparison with Laparoscopic Adjustable Gastric Banding-Is There a Significant Difference in Long Term?

BACKGROUND

The laparoscopic sleeve gastrectomy (LSG) is the most common bariatric procedure performed worldwide while the laparoscopic adjustable gastric banding (LAGB) has been almost abandoned. Aim of this study was to retrospectively assess 10-year outcomes of LSG through a matched comparison with LAGB.

MATERIALS AND METHODS

Retrospective search of prospectively maintained database of our university was carried out to find all patients that underwent LSG before December 2010. Each subject with LSG was matched one-to-one with a patient that had undergone LAGB in the same period with correspondent preoperative age, BMI, and sex.

RESULTS

A total of 76 patients underwent LSG before 2010 and were all included in this study; a matched group of 76 out of 178 LAGB patients with 10-year follow-up was retrieved from our database. Comparison between the two groups showed better outcomes after LSG at 1 and 5 years but weight loss was comparable with the LAGB group at 10 years (%TWL 22.2 ± 13 vs 21.2 ± 16.1; p = 0.89). No significant difference was found in conversion/removal rate (15.8% vs 18.4%; p = 0.67).

CONCLUSION

LSG is an effective stand-alone bariatric procedure with better outcomes than LAGB in medium term, but results are comparable at 10 years. Subjects undergoing LSG should be informed that conversion to RYGB or OAGB may be necessary to achieve further weight loss or to treat reflux.

Management of the Crura During Laparoscopic Sleeve Gastrectomy

METHODS

This is a retrospective cohort study that evaluated patients undergoing LSG performed by a single surgeon in a 7-year period. Data were collected via chart review. The primary endpoint was hiatal hernia presence at 5 years post-operatively. Secondary endpoints included post-procedural complications (nausea, vomiting, dysphagia, or reflux) at 30 days post-operatively.

RESULTS

A total of 361 patients were included in the analysis: 154 without crural closure, 164 primary crural closure, and 43 primary crural closure with mesh reinforcement. Rates of hiatal hernia occurrence at 5 years were 9.7% (no closure), 14.0% (primary closure), and 16.3% (closure with mesh reinforcement), respectively, and did not differ significantly among the 3 cohorts (P = .37). Overall rates of 30-day complications were 11.5%, 21.5%, and 28.6%, respectively (P = .015).

CONCLUSION

Rates of hiatal hernia after sleeve gastrectomy do not differ, regardless of management of the crura. In addition, and perhaps more significantly, avoidance of crural closure was associated with fewer 30-day complications. In fact, the highest rate of 30-day complications was seen in the group that received closure with mesh reinforcement. These data suggest that crural closure during LSG should be avoided. Further prospective study of these findings is warranted.

GERD and Barrett's esophagus as indications for revisional surgery after sleeve gastrectomy: experience of a bariatric center of excellence IFSO-EC and narrative review

INTRODUCTION

Laparoscopic sleeve gastrectomy is the most commonly performed bariatric procedure worldwide; due to its extensive impact and analysis, multiple procedure-related early and late complications have been described. Gastroesophageal reflux and Barrett's esophagus are highly debated issues related to sleeve gastrectomy in long-term follow-up. This review aims to explore the association between sleeve gastrectomy and gastroesophageal reflux in terms of their occurrence, and to analyze the protective or affecting factors.

AREAS COVERED

Gastroesophageal reflux and Barrett's esophagus after laparoscopic sleeve gastrectomy.

EXPERT OPINION

Gastroesophageal reflux is the Achilles' heel of sleeve gastrectomy and is affected by multiple procedure-related functional or mechanical factors (intrathoracic migration, stenosis, lower esophageal sphincter incompetence). Its postoperative incidence is about 30% with significant variability among groups, especially in terms of preoperative workup (lack of routine upper gastro-intestinal endoscopy and symptom assessment). Strict patient selection and mandatory pre-operative endoscopy are the primary steps taken to prevent and reduce the incidence of post-operative severe gastroesophageal reflux. However, patients should also be informed of the possibility of the 'de novo gastroesophageal reflux disease' (incidence - 22-50%) and the need for surgical revision in selected cases (0.5-7%).

Reflux After Sleeve Gastrectomy: An Update

Background: Modifications of gastric anatomy, function, and of the esophagogastric junction secondary to sleeve gastrectomy (SG) can worsen the symptoms of gastroesophageal reflux disease (GERD). Its late diagnosis and poor treatment can lead to serious complications. In recent years, attempts have been made to optimize preoperative studies and improve surgical techniques to prevent this problem. The aim of this study was to update on the presence of GERD and their symptoms post-SG. Methods: A literature review of articles based on randomized clinical trials on the presence of GERD after SG was carried out, in a period of 10 years. Results: A result of 336 articles was obtained, of which 327 were discarded and 9 were included. The variables of GERD post-SG were analyzed according to their symptoms ("improved," "worsened," and "unchanged"), "remission," or appearance "de novo." Conclusion: GERD is a frequently associated pathology in obese patients. Several authors reported that symptoms worsen after SG, and has been diagnosed de novo. The application of exhaustive preoperative studies and a correct surgical technique could reduce its incidence.

Cruroplasty added to laparoscopic sleeve gastrectomy; does it decrease postoperative incidence of de-novo acid reflux?: A randomised controlled trial

BACKGROUND

Laparoscopic sleeve gastrectomy(LSG) is the most popular bariatric surgery worldwide. Postoperative de-novo acid reflux is one of the major common complications of the procedure. Different additive anti-reflux surgical techniques have been tried to decrease the complication although no favorable outcome is obtained. This study was conducted to evaluate effects of concurrent cruroplasty during LSG on postoperative de-novo acid reflux incidence rate.

METHODS

In current participant-blinded randomised controlled trial total of 80 subjects who were candidate for LSG were enrolled from the September 2018 to the December 2019. Following matching patients by gender and age, simple randomization method was held to allocate participants to LSG alone and LSG + cruroplasty groups with equal 40 members in each. Demographic data, length of hospital stay, and operation time was registered. Presence of acid reflux was looked by using gastroesophageal reflux disease-health related quality of life(GERD-HRQL) questionnaire prior and 6 months after surgery in follow-up visit.

RESULTS

Finally 12/28 and 14/26 male/females with 38.5 ± 10.7 and 39.7 ± 8.2 years of age were recruited in LSG alone and LSG + cruroplasty, respectively.(p > 0.05) The length of operative time was significantly shorter in LSG alone(p < 0.01) although no obvious difference was existed in length of hospital stay between groups.(p = 0.7) Postoperative de-novo acid reflux also was not considerably lesser after cruroplasty compared with controls.(p = 0.1) The GERD-HRQL scores were not remarkable between subjects of study groups.(p > 0.05).

CONCLUSION

Equipping LSG with concurrent cruroplasty to diminish postoperative de-novo gastroesophageal acid reflux is not effective and not recommended in absence of other indications.

Imaging after laparoscopic sleeve gastrectomy - literature review with practical recommendations

In the XXI century obesity has become one of the most demanding epidemiological threats worldwide. At the same time, bariatric surgery has established itself as an effective treatment for morbidly obese patients, with laparoscopic sleeve gastrectomy (LSG) emerging as the most popular bariatric procedure. This paper reviews the role of imaging studies of patients after LSG. Computed tomography is widely considered as the method of choice in detection of complications in early postoperative period. The dynamic character of upper gastrointestinal examination allows for the assessment of passage through the gastric remnant. The paper also discusses evaluation of the shape and volume of the gastric remnant assessed by imaging studies.

Accuracy of High-Resolution Manometry in Hiatal Hernia Diagnosis in Primary and Revision Bariatric Surgery

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.

Impact of Laparoscopic Sleeve Gastrectomy on Gastroesophageal Reflux Disease and Risk Factors Associated with Its Occurrence Based Upon Quality of Life

BACKGROUND

To assess the impact of laparoscopic sleeve gastrectomy (LSG) on gastroesophageal reflux disease (GERD) symptoms and to determine factors associated with the occurrence of post-LSG GERD symptoms.

MATERIAL AND METHODS

This is a retrospective study that included all obese patients who underwent LSG in Aseer Central Hospital, during the period from August 2017 to August 2019. GERD-Health-Related Quality of Life questionnaire was used to assess the patients' pre- and postoperative GERD symptoms and their satisfaction toward their general health.

RESULTS

The study included 326 patients (195 males and 131 females) with a mean age of 39.43 ± 11.17 years. Postoperatively, GERD symptoms newly developed in 105 patients (32.2%), while 25 patients out of 127 with preoperative GERD symptoms (19.69%) showed resolution of symptoms. There were significant associations (p < 0.001) between the old age, smoking and existence of comorbidities, and the occurrence of postoperative heartburn and regurgitation symptoms. Postoperatively, excess weight loss (EWL) was significantly associated with postoperative regurgitation (p = 0.045) and patients showed significant improvement in their satisfaction toward their health condition even those who developed GERD symptoms.

CONCLUSIONS

After LSG, GERD symptoms developed in about one-third of the patients while symptoms improved in only one-fifth of patients. Older patients, smokers, patients with comorbidities, and patients with more EWL had significantly worse GERD symptoms postoperatively. Weight loss rather than GERD symptoms significantly influenced patients' satisfaction toward their general health. Further prospective studies are needed to determine the relationship between weight loss and other factors associated with post-LSG reflux and overall quality of life.

Roux-en-Y gastric bypass versus one anastomosis-mini gastric bypass as a rescue procedure following failed restrictive bariatric surgery. A systematic review of literature with metanalysis

BACKGROUND

Although different procedures have been proposed as revisional surgery for patients who had previously undergone a failed primary restrictive procedure, the ideal revisional procedure is still a matter of debate.

METHODS

A systematic search was performed in all electronic databases to find studies comparing one anastomosis-mini gastric bypass (OAGB-MGB) or Roux-en-Y gastric bypass (RYGB) as revisional bariatric surgery for weight regain or intolerance/complications of a primary restrictive procedure. The data regarding sample size, patients' gender, age, primary surgery type, number of perioperative complications, operative time, pre- and post-revisional body mass index (BMI), and excess weight loss % (EWL%) at 1-year follow-up were extracted. Five studies were included in the analysis.

RESULTS

The primary bariatric procedures were represented by vertical banded gastroplasty (VBG), laparoscopic adjustable gastric band (LAGB) and laparoscopic sleeve gastrectomy (LSG). About perioperative complications, both RYGB and OAGB-MGB showed a similar rate of leaks but OAGB-MGB had a lower rate of bleedings; considering the progression from pre- to post-revisional BMI, OAGB-MGB reveals a better outcome as well as a shorter operative time.

CONCLUSIONS

Our meta-analysis has shown OAGB-MGB, used as revisional intervention after failed restrictive surgery, achieves outcomes comparable to RYGB in terms of perioperative complications providing a simpler and more effective technique.

Metabolic surgery: A clinical update

Metabolic and bariatric surgery has grown beyond 'experimental' weight-loss surgery. As techniques have advanced over the last few decades, so has the growing body of research and evidence, proving that both weight-loss and metabolic health improvement are induced. Metabolic surgery has become the more appropriate term for weight-loss surgery because of the altered gastrointestinal anatomy and subsequent beneficial metabolic effects. Although the tool of metabolic surgery has been well refined, a large portion of the global population does not have adequate access to it. This clinical update aims to (a) inform healthcare providers from all disciplines about the myriad of benefits of metabolic surgery and (b) equip them with the necessary knowledge to bridge the gap between patients in need of metabolic treatment and the therapies in metabolic surgery available to them.

WHEN SHOULD BE CONVERTED LAPAROSCOPIC SLEEVE GASTRECTOMY TO LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS DUE TO GASTROESOPHAGEAL REFLUX?

Background:

Gastroesophageal reflux (GER) is one of the most common indications for conversion of sleeve gastrectomy (LSG) to laparoscopic Roux-en-Y gastric bypass (LRYGBP). Objective evaluations are necessary in order to choose the best definitive treatment for these patients.

Aim:

To present and describe the findings of the objective studies for gastroesophageal reflux disease performed before LSG conversion to LRYGBP in order to support the indication for surgery.

Method:

Thirty-nine non-responder patients to proton pump inhibitors treatment after LSG were included in this prospective study. They did not present GER symptoms, esophagitis or hiatal hernia before LSG. Endoscopy, radiology, manometry, 24 h pH monitoring were performed.

Results:

The mean time of appearance of reflux symptoms was 26.8+24.08 months (8-71). Erosive esophagitis was found in 33/39 symptomatic patients (84.6%) and Barrett´s esophagus in five. (12.8%). Manometry and acid reflux test were performed in 38/39 patients. Defective lower esophageal sphincter function was observed independent the grade of esophagitis or Barrett´s esophagus. Pathologic acid reflux with elevated DeMeester´s scores and % of time pH<4 was detected in all these patients. more significant in those with severe esophagitis and Barrett´s esophagus. Radiologic sleeve abnormalities were observed in 35 patients, mainly cardia dilatation (n=18) and hiatal hernia (n=11). Middle gastric stricture was observed in only six patients.

Conclusion:

Patients with reflux symptoms and esophagitis or Barrett´s esophagus after SG present defective lower esophageal sphincter function and increased acid reflux. These conditions support the indication of conversion to LRYGBP.

Sometimes the Best Solution Is Transit Bipartition: Video Case Report

The simplest definition of Santoro's operation is a sleeve gastrectomy with transit bipartition. Santoro et al. reported long-term data regarding sleeve gastrectomy with transit bipartition, which is a similar operation to duodenal switch but without complete exclusion of the duodenum to minimize nutritional complications and to allow endoscopic management of obstructive jaundice. Afterward, several studies proved the efficacy and safety of transit bipartition; the real benefit of this operation is the reduction of side effects and protein malnutrition compared with the bilio-pancreatic diversion with duodenal switch or Roux-en-Y gastric bypass. One of the well-known complications of sleeve gastrectomy is reflux which usually responds well to medical treatment, but in few cases, the reflux is refractory to conservative management and warrants surgical intervention as a conversion of the sleeve gastrectomy to other bariatric procedures. There are many theories concerning the increased incidence of gastro-esophageal reflux disease after sleeve gastrectomy which included reduction of lower esophageal sphincter pressure due to the division of ligaments and blunting of the angle of His, reduction in gastric compliance, increased sleeve pressure with an intact pylorus due to the use of Bougie < 40 Fr, decreased sleeve volume and distensibility, and dilated upper part of the final shape with a relative narrowing of the mid-stomach without complete obstruction. Our video report aims to present a unique surgical case and to show the surgical technique in this patient despite the complex surgical history.

Evaluation of reflux following sleeve gastrectomy and one anastomosis gastric bypass: 1-year results from a randomized open-label controlled trial

Background

Recent reports have demonstrated that de novo reflux and worsening of pre-existing symptoms occur after SG; concerns are still expressed about the risk of symptomatic biliary reflux gastritis and oesophagitis. The aim of our study was to investigate and compare the rate of postoperative acid and non-acid reflux following Mini-/One anastomosis gastric bypass (MGB/OAGB) and laparoscopic sleeve gastrectomy (LSG).

Study design

A prospective randomized open-label, controlled trial registered on clinicaltrial.gov (NCT number: NCT02987673) has been carried out to evaluate esophagogastric junction exposure to reflux in the first year after MGB/OAGB and LSG using high impedance manometry, endoscopy, and a validated questionnaire.

Results

A total of 58 individuals were eventually enrolled in this trial and represented the per-protocol population (n = 28 MGB/OAGB, n = 30 LSG). No difference was found between the two groups in terms of demographic characteristics, PAGI-SYM score, acid exposure time percent of the esophagus (AET%), esophagitis, and other HRiM and MII-pH data at baseline. Comparing MII-pH outcomes of the two groups, AET% resulted significantly higher after LSG at 12 months. Endoscopic findings showed a significant increase of esophagitis ≥ B in the LSG group after 1 year; postoperative esophagitis ≥ B resulted also significantly worsened after LSG when compared to MGB/OAGB.

Conclusion

Since AET% and rate of esophagitis are significantly higher after LSG when compared to MGB/OAGB, this procedure should be preferred in case of preoperative subclinical reflux or low grade (A) esophagitis.

Evaluation of Patient Reported Gastroesophageal Reflux Severity at Baseline and at One-Year after Bariatric Surgery

OBJECTIVE

To assess patient-reported gastroesophageal reflux disease (GERD) severity before and after sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB).

SUMMARY BACKGROUND DATA

Development of new-onset or worsening GERD symptoms following bariatric surgery varies by procedure, but there is a lack of patient-reported data to help guide decision-making.

METHODS

Retrospective cohort study of patients undergoing bariatric surgery in a statewide quality collaborative between 2013-2017. We used a validated GERD survey with symptom scores ranging from 0 (no symptoms) to 5 (severe daily symptoms) and included patients who completed surveys both at baseline and one-year after surgery (n = 10,451). We compared the rates of improved and worsened GERD symptoms after SG and RYGB.

RESULTS

Within our study cohort, 8,680 (83%) underwent SG and 1,771 (17%) underwent RYGB. Mean baseline score for all patients was 0.94. Patients undergoing SG experienced similar improvement in GERD symptoms when compared to RYGB (30.4% vs 30.8%, p = 0.7015). However, SG patients also reported higher rates of worsening symptoms (17.8% vs 7.5%, p < 0.0001) even though they were more likely to undergo concurrent hiatal hernia repair (35.1% vs 20.0%, p < 0.0001). More than half of patients (53.5%) did not report a change in their score.

CONCLUSIONS

Although SG patients reported higher rates of worsening GERD symptoms when compared to RYGB, the majority of patients (>80%) in this study experienced improvement or no change in GERD regardless of procedure. Using clinically relevant patient-reported outcomes can help guide decisions about procedure choice in bariatric surgery for patients with GERD.

Hiatal Hernia Evaluation Before Bariatric Surgery: Should It Be Routinely Done?

PURPOSE

The necessity of routine preoperative esophagogastroduodenoscopy (EGD) and upper gastrointestinal series (UGIS) in the evaluation of hiatal hernia (HH) among bariatric surgery candidates is controversial since most are detected during surgery, regardless of the preoperative work-up. The aim is to determine the accuracy of preoperative EGD and UGIS for HH diagnosis among bariatric surgery candidates.

MATERIAL AND METHODS

The records of bariatric surgery patients between 2011 and 2015 were reviewed. Patients underwent routine UGIS and/or EGD before the surgery. The positive and negative predictive values (PPV, NPV) for each study were calculated based on operative findings.

RESULTS

A total of 463 patients were included in the study. Mean age was 44.34 ± 12.99 years. Mean preoperative body mass index (BMI) was 42.7 ± 5.15 kg/m². A total of 450 patients (97.2%) had a UGIS, 263 patients underwent EGD (56.8%), and 258 (55.7%) patients had both tests. HH was diagnosed in 26 (5.8%), 60 (13%), and 72 (27.8%) patients, respectively. HH was found intra-operatively in 53 patients (11.4%). It was associated with heartburn (P = 0.005) and previous bariatric surgery (P = 0.008). EGD had a greater sensitivity than UGIS (47.4% vs. 30.2%) and a lower specificity (81.4% vs. 97.5%). PPV and NPV for UGIS and EGD were 61.5% and 91.3% vs. 30% and 90.2%, respectively. The sensitivity of both tests when combined together reached 60.5%.

CONCLUSIONS

Both EGD and UGIS, whether solely performed or combined, have low sensitivity for diagnosis of HH and can probably be omitted from the preoperative evaluation, except for high-risk patients.

Magnetic sphincter augmentation at the time of bariatric surgery: an analysis of the MBSAQIP

BACKGROUND

Magnetic sphincter augmentation (MSA) has gained popularity as a treatment for gastroesophageal reflux disease (GERD). The role of MSA in treating GERD in metabolic and bariatric surgery (MBS) patients at the time of primary MBS is unknown.

OBJECTIVE

To determine the short-term outcomes of MSA placed at the time of MBS.

SETTING

National database, United States.

METHODS

We queried the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database for MSA performed at time of the sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) for the years 2017-2018. A propensity adjusted analysis was performed to assess 30-day outcomes of patients who had MSA placed versus those who did not.

RESULTS

There were 319,580 patients who underwent MBS in the study period. Twenty-four patients had MSA at time of surgery. These patients did not have a higher reported rate of preoperative GERD (P = .93). Six patients (25%) with MSA had a RYGB; the other 18 patients (75%) patients had SG (P < .001). Operative times were similar between the groups and there was no difference in length of stay. After propensity matched analysis (with 24 patients in each arm), patients who underwent an MSA had shorter discharge times (1.4 days [.8] versus 2.0 [.9], P = .012).

CONCLUSION

MSA is safe in the short term in MBS. There is no difference in major morbidity or mortality and operative times are similar in MSA patients. The long-term efficacy of this practice is unknown.

Esophagitis evolution after sleeve gastrectomy or gastric bypass in consecutive cases

BACKGROUND

Erosive esophagitis (EE) is related to esophageal mucosal damage caused by GERD and is implicated in the development of Barret´s esophagus and adenocarcinoma, which incidence is rising in association with obesity. It is known that the correlation between symptoms and endoscopic findings is relatively poor, with a predictive value of only 40%. The objective of this study is to report the incidence of EE 1 year after sleeve gastrectomy (SG) and gastric bypass (GBP) in consecutive patients in order to obtain an objective parameter of the impact of the two most popular bariatric procedures on esophageal mucosa.

METHODS

A retrospective review of a prospective database including every primary GBP and SG consecutive cases performed between January 2014 and December 2016. Esophagitis evolution was compared between patients with adequate weight loss versus those with inadequate weight loss. The comparison of baseline and 1-year EE, BMI, %EWL, and %TWL was made by using the Chi square test for categorical variables and Student "t" test for continuous samples.

RESULTS

Two hundred and twenty-seven patients were included. GBP was performed to 35.2% (n = 80) and SG to 64.8% (n = 147). Pre- and postoperatively EE evolution in GBP decreased from 54 to 26.2% (p = 0.002) and in SG increased from 8.2 to 30% (p = 0.04) Barret´s esophagus in GBP decreased from 7.5 to 5% (p = 0.001). No statistical difference was observed when we compared the evolution of EE in patients with adequate or inadequate weight loss in both groups.

CONCLUSIONS

The incidence of EE 1 year after SG is greater than GBP. Moreover, not only GBP seems to improve this condition, but also SG tends to worsen EE. These results are to be associated with GERD disease.

From the Knife to the Endoscope-a History of Bariatric Surgery

PURPOSE OF REVIEW

Current bariatric surgical practice has developed from early procedures, some of which are no longer routinely performed. This review highlights how surgical practice in this area has developed over time.

RECENT FINDINGS

This review outlines early procedures including jejuno-colic and jejuno-ileal bypass, initial experience with gastric bypass, vertical banded gastroplasty and biliopancreatic diversion with or without duodenal switch. The role laparoscopy has played in the widespread utilization of surgery for treatment of obesity will be described, as will the development of procedures which form the mainstay of current bariatric surgical practice including gastric bypass, sleeve gastrectomy and adjustable gastric banding. Endoscopic therapies for the treatment of obesity will be described. By outlining how bariatric surgical practice has developed over time, this review will help practicing surgeons understand how individual procedures have evolved and also provide insight into potential future developments in this field.

VERTICAL GASTRECTOMY VS. EXTENDED VERTICAL GASTRECTOMY: WHAT IS THE IMPACT ON GASTROESOPHAGEAL REFLUX DISEASE IN OBESE RATS?

BACKGROUND

Extended vertical gastrectomy is a variation of the vertical gastrectomy technique requiring studies to elucidate safety in relation to gastroesophageal reflux.

AIM

To analyze comparatively vertical gastrectomy (VG) and extended vertical gastrectomy (EVG) in rats with obesity induced by cafeteria diet in relation to the presence of reflux esophagitis, weight loss and macroscopic changes related to the procedures.

METHODS

Thirty Wistar rats were randomized into three groups, and after the obesity induction period by means of a 28-day cafeteria diet, underwent a simulated surgery (CG), VG and VGA. The animals were followed up for 28 days in the post-operative period, and after euthanasia, the reflux esophagitis evaluation was histopathologically performed. Weight and macroscopy were the other variables; weight was measured weekly and the macroscopic evaluation was performed during euthanasia.

RESULTS

All animals presented some degree of inflammation and the presence of at least one inflammation criterion; however, there was no statistically significant difference in the analysis among the groups. In relation to weight loss, the animals in CG showed a gradual increase during the whole experiment, evolving to super-obesity at the end of the study, while the ones with VG and EVG had weight regain after the first post-operative period; however, a less marked regain compared to CG, both for VG and EVG.

CONCLUSION

There is no difference in relation to reflux esophagitis VG and EVG, as well as macroscopic alterations, and both techniques have the ability to control the evolution of weight during postoperative period in relation to CG.

Can Omentopexy Reduce the Incidence of Gastroesophageal Reflux Disease After Laparoscopic Sleeve Gastrectomy

BACKGROUND

De novo gastroesophageal reflux disease (GERD) is one of the complications that may occur after laparoscopic sleeve gastrectomy (LSG). This study was conducted to examine whether omentopexy can be effective in reducing the incidence of GERD after LSG.

METHODS

A total of 201 patients (145 females) were compared in this retrospective cohort study, including Group A (n = 100) and Group B (n = 101), consisting of patients undergoing LSG with omentopexy and LSG without omentopexy, respectively. One year after surgery, the patients were evaluated by GERD-Q; those obtaining a score of eight or above also underwent upper endoscopy to confirm their de novo GERD.

RESULTS

Thirty-seven patients had a GERD-Q score ≥ 8 and therefore underwent upper endoscopy. Seventeen patients had fully normal endoscopy results, and no significant differences was observed between the two groups in terms of the incidence of de novo GERD (P = 0.966). There were also no significant differences between the groups in terms of age (P = 0.517), sex (P = 0.193), diabetes (P = 0.979), and GERD-Q score (P = 0.880). The pre-operative mean weight (P = 0.003) and total weight loss (TWL) showed significant intergroup differences (P = 0.001). The mean body mass index (BMI) showed significant differences between the groups before the operation (P = 0.001) and 1 year after the surgery (P = 0.009). Excess BMI loss (EBMIL) was also significantly higher in Group A 1 year after the surgery (P = 0.004). Even after omitting confounder effect of BMI between two groups with and without omentopexy, GerdQ was not significantly different.

CONCLUSION

Omentopexy does not have a significant effect on reducing the incidence of de novo GERD after LSG, even in individuals with higher BMI and weight.

Accuracy of hiatal hernia diagnosis in bariatric patients: Preoperative endoscopy versus intraoperative reference

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.

Association of bariatric surgery with all-cause mortality and incidence of obesity-related disease at a population level: A systematic review and meta-analysis

BACKGROUND

Previous clinical trials and institutional studies have demonstrated that surgery for the treatment of obesity (termed bariatric or metabolic surgery) reduces all-cause mortality and the development of obesity-related diseases such as type 2 diabetes mellitus (T2DM), hypertension, and dyslipidaemia. The current study analysed large-scale population studies to assess the association of bariatric surgery with long-term mortality and incidence of new-onset obesity-related disease at a national level.

METHODS AND FINDINGS

A systematic literature search of Medline (via PubMed), Embase, and Web of Science was performed. Articles were included if they were national or regional administrative database cohort studies reporting comparative risk of long-term mortality or incident obesity-related diseases for patients who have undergone any form of bariatric surgery compared with an appropriate control group with a minimum follow-up period of 18 months. Meta-analysis of hazard ratios (HRs) was performed for mortality risk, and pooled odds ratios (PORs) were calculated for discrete variables relating to incident disease. Eighteen studies were identified as suitable for inclusion. There were 1,539,904 patients included in the analysis, with 269,818 receiving bariatric surgery and 1,270,086 control patients. Bariatric surgery was associated with a reduced rate of all-cause mortality (POR 0.62, 95% CI 0.55 to 0.69, p < 0.001) and cardiovascular mortality (POR 0.50, 95% CI 0.35 to 0.71, p < 0.001). Bariatric surgery was strongly associated with reduced incidence of T2DM (POR 0.39, 95% CI 0.18 to 0.83, p = 0.010), hypertension (POR 0.36, 95% CI 0.32 to 0.40, p < 0.001), dyslipidaemia (POR 0.33, 95% CI 0.14 to 0.80, p = 0.010), and ischemic heart disease (POR 0.46, 95% CI 0.29 to 0.73, p = 0.001). Limitations of the study include that it was not possible to account for unmeasured variables, which may not have been equally distributed between patient groups given the non-randomised design of the studies included. There was also heterogeneity between studies in the nature of the control group utilised, and potential adverse outcomes related to bariatric surgery were not specifically examined due to a lack of available data.

CONCLUSIONS

This pooled analysis suggests that bariatric surgery is associated with reduced long-term all-cause mortality and incidence of obesity-related disease in patients with obesity for the whole operated population. The results suggest that broader access to bariatric surgery for people with obesity may reduce the long-term sequelae of this disease and provide population-level benefits.

Prevalence of Endoscopic Findings Before Bariatric Surgery and Their Influence on the Selection of the Surgical Technique

PURPOSE

Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) are the two most popular procedures performed. The decision of which technique is most appropriate depends on the surgeon's preferences and experience. However, several factors strongly influence the decision of the procedure performed, including gastrointestinal disorders or asymptomatic upper gastrointestinal endoscopy (UGE) findings. This study aimed to describe the pathological endoscopic findings in morbidly obese patients undergoing preoperative routine UGE.

MATERIALS AND METHODS

A retrospective review of a prospectively collected database of all UGEs performed before bariatric surgery was performed. UGE was routinely performed to all the patients as part of the preoperative evaluation protocol.

RESULTS

A total of 790 patients were included. Surgical technique included 610 (77.2%) RYGB and 180 (22.8%) SG. Twenty-one asymptomatic patients presented esophagitis at UGE. In only seven patients (0.89%), the endoscopic findings of esophagitis had changed the initial surgical decision. The presence of ulcers or adenomatous or incompletely resected polyps was an indication for SG, to assure future endoscopic access in case it is needed. In 25 patients (3.17%), the initial operation would have been changed based on UGE findings.

CONCLUSION

Preoperative UGE allows the diagnosis of asymptomatic esophagitis related to gastroesophageal reflux disease and the identification of asymptomatic polyps and ulcers, with the potential ability for malignant transformation. In up to 3.17% of the cases, the endoscopic findings changed the operative strategy. As the complication rate associated with the procedure is low, we recommend the routine performance of preoperative UGE before bariatric surgery.

Gastroesophageal Reflux and Laparoscopic Sleeve Gastrectomy: Results of the First International Consensus Conference

BACKGROUND

Gastroesophageal reflux disease (GERD) is probably the main drawback of laparoscopic sleeve gastrectomy (LSG). Herein, we critically discuss the issue and report the results of the first international consensus conference held in Montpellier, France, during June 2019.

METHODS

Fifty international bariatric experts from 25 countries convened for 2 days for interactive discussions, and to formulate the most relevant questions by electronically submitting 55 preliminary questions to panelists. Following the meeting, a final drafted questionnaire comprised of 41 questions was sent to all experts via e-mail.

RESULTS

Forty-six experts responded (92%). Esophago-gastro-duodenoscopy was considered mandatory before (92%) and after (78%) surgery. No consensus was achieved as to time intervals after surgery and the role of specialized tests for GERD. Higher degrees of erosive esophagitis (94%) and Barrett's esophagus (96%) were viewed as contra-indications for LSG. Roux-en-Y gastric bypass was recommended in postoperative patients with uncontrolled GERD and insufficient (84%) or sufficient (76%) weight loss and Barrett's esophagus (78%). Hiatal hernia (HH) repair was deemed necessary even in asymptomatic patients without GERD (80% for large and 67% for small HH). LSG with fundoplication in patients with GERD was considered by 77.3% of panelists.

CONCLUSIONS

The importance of pre- and postoperative endoscopy has been emphasized. The role of specialized tests for GERD and the exact surveillance programs need to be further defined. LSG is viewed as contra-indicated in higher degrees of endoscopic and clinical GERD. LSG with anti-reflux fundoplication emerges as a new valid option in patients with GERD.

Reflux Disease and Adenocarcinoma of the Esophagus and Cardia: Global Management and Surgical Treatment

Introduction: Adenocarcinoma of the esophagus and cardia is a rare cancer, associated with chronic reflux disease. Its associated mortality is still very high, reflecting both aggressive biology and lack of adequate treatments. The aim of this article was to describe up to date management of these complex tumors. Materials and Methods: A systematic review of the literature was performed, using PubMed Central database. Articles published after the year 2000 were included, with no language exclusion. Results: Reflux disease and Barrett esophagus are strongly associated with esophageal adenocarcinoma. A strict surveillance should be initiated at diagnosis. Both proton pump inhibitors and antireflux surgery failed to influence the incidence of cancer. Surgery and multimodal therapies are keystones for curative treatment, but no clear consensus exists for the best option. A clear trend in standardization of the surgical approach is observed since last ten years. However, the optimal approach for the tumors of the cardia is still not completely set. Complication rate is still high, but real progresses are made, through the implementation of less invasive techniques. Conclusion: Progress has been made in the management of esophageal cancer. However, the multiplicity of choices failed to lead to standardization. The development of international consensus regarding multimodal treatment and surgical approaches is needed.

Preoperative Upper-GI Endoscopy Prior to Bariatric Surgery: Essential or Optional?

Introduction

The role of preoperative upper-gastrointestinal (GI) gastroscopy has been discussed with controversy in bariatric surgery. The aim of this study was to evaluate the incidence of upper-GI pathologies detected via endoscopy prior to bariatric surgery along with their clinical significance for patients’ management.

Material and Methods

In our single center prospectively established database of obese patients, who underwent bariatric surgery from January 2011 to December 2017, we retrospectively analyzed the perioperative endoscopic findings along with their influence on patients’ management.

Results

In total, 636 obese patients with median BMI (body mass index) of 49 kg/m² [range 31–92] received an upper-GI endoscopy prior to bariatric surgery. Among the surgical procedures, laparoscopic Roux-Y-gastric bypass (72.6%; n = 462) was the most frequent operation. Endoscopically detected pathological conditions were peptic ulcer 3.5% (22/636), Helicobacter pylori (Hp) gastritis 22.4% (143/636), and gastric or duodenal polyps 6.8% (43/636). Reflux esophagitis could be detected in 139/636 patients (21.9%). Barrett’s esophagus (BE) was histologically diagnosed in 95 cases (15.0%), whereas BE was suspected endoscopically in 75 cases (11.3%) only. Esophageal adenocarcinomas were detected in 3 cases (0.5%). Change of the operative strategy due to endoscopically or histologically detected pathologic findings had to be performed in 10 cases (1.6%).

Conclusion

Preoperative upper-GI endoscopy identifies a wide range of abnormal endoscopic findings in obese patients, which may have a significant impact on decision-making, particularly regarding the most suitable bariatric procedure and the appropriate follow-up. Therefore, preoperative upper-GI endoscopy should be considered in all obese patients prior to bariatric procedure.

Laparoscopic Adjustable Gastric Banding: an Underestimated Risk Factor for the Development of Esophageal Cancer?-a Nationwide Survey

BACKGROUND

Approximately 14% of Austria's 8.5 million inhabitants have a body mass index (BMI) > 30 kg/m². The laparoscopic adjustable gastric banding (LAGB) was introduced in Austria in 1994, where about 10.300 patients have received it so far. One of our LAGB patients developed an adenocarcinoma of the distal esophagus 13 years after implantation.

OBJECTIVES

In order to calculate whether after LAGB patients are at higher risk for carcinoma of the esophagus, we performed a nationwide survey.

METHODS

A questionnaire was sent to all surgical departments in Austria, primarily in order to detect cases with esophageal carcinoma after LAGB, but also to evaluate the policy in Austria concerning preoperative work-up, operation, and follow-up in LAGB patients.

RESULTS

Since 1994, 37 of the 119 surgical departments in Austria have performed a total of about 10.300 LAGB implantations. Six patients have been identified with esophageal cancer following LAGB. The WHO statistical report on esophageal cancer shows an incidence of 2.8/100.000 per year in Austria, about 1/3 of which cases are adenocarcinoma of the distal esophagus.

CONCLUSION

Following LAGB, the incidence of esophageal cancer might be up to fivefold higher than the aged standardized overall population of Austria.

Seven-Year Outcomes of Laproscopic Sleeve Gastectomy in Indian Patients with Different Classes of Obesity

BACKGROUND

The aim of the study was to assess the long-term outcome in terms of weight loss and remission of comorbidities among the patients who had undergone LSG in an Indian setting.

METHODS

This is a retrospective observational study of patients (BMI > 30 kg/m²) who underwent LSG having a minimum 6 months of follow-up data. Based on preoperative BMI, patients were grouped as class 1, 30 < BMI < 35 kg/m²; class 2, 35 < BMI < 40 kg/m²; and class 3, BMI > 40 kg/m². Data on BMI and %EWL between three classes and among genders at different follow-up points for 7 years were compared.

RESULT

Study included 95 patients (mean age of 33.7 ± 11 years), and the preoperative mean BMI was 40.2 ± 5.1 kg/m². At one year of surgery, 85.5% patients achieved > 50%EWL. The highest mean %EWL was found in class 1 (66.19%), followed by class 2 (56.73%) and class 3 (46.59%) at the sixth month follow-up. At the seventh year, %EWLs were 85.11% (class 1), 76.69% (class 2), and 62.98% (class 3) and the mean BMIs were 25.13 ± 3.09 kg/m² (class 1), 26.86 ± 2.12 kg/m² (class 2), and 31.07 ± 3.39 kg/m² (class 3) and were significantly different (p < 0.05). At the last follow-up, though, the males showed slight weight regain; however, there were no statistical differences between the genders (p = 0.065).

CONCLUSION

Outcome from LSG was better in patients with BMI < 40 kg/m² compared to the patients with BMI > 40 kg/m². Remission of obesity-related comorbidities was observed with LSG in all groups and gender did not influence the outcome significantly.

Hiatal Surface Area's CT scan measurement is useful in hiatal hernia's treatment of bariatric patients

INTRODUCTION

Hiatal surface area (HSA) measurement has been recently proposed as useful tool for tailored treatment of hiatal defects. Multidetector CT scan (MDCT) of the hiatal area was shown to be useful in hiatal hernia (HH) management.

PURPOSE

MDCT preoperative HSA measurements validation as a useful method in the surgical repair decision making process of hiatal defects in candidates to antireflux ± bariatric surgery.

MATERIAL AND METHODS

Twenty-five obese patients (group A), candidates to laparoscopic cruroplasty ± bariatric surgery, were prospectively evaluated preoperatively and after one year, using an original MDCT algorithm, compared with intraoperative HSA measurement. Twelve non-obese (group B) and 12 obese patients (group C), without GERD or HH, were used as control groups.

RESULTS

Median preoperative HSA was 7.9 cm², (interquartile IQR 5.97-9.80) while intraoperative median HSA was 6 cm² (6-9.5), p = .84. Postoperative median HSA was 3.8 cm² (3.21-4.8), showing the efficacy of cruroplasty, comparable with HSA calculated in the control groups (3.98 for B and 3.69 cm² for C, p = .8547). No statistically significant difference between MDCT preoperative measurement and intraoperative findings was observed.

CONCLUSIONS

Preliminary results demonstrate MDCT scan HSA measurements as a valid, non-invasive method to predict intraoperative findings. It allows the HSA monitoring in order to correlate the symptoms onset and failure of cruroplasty.

Systematic Endoscopy 5 Years After Sleeve Gastrectomy Results in a High Rate of Barrett's Esophagus: Results of a Multicenter Study

BACKGROUND

Recent evidence has indicated an increased risk of Barrett's esophagus (BE) in the long term after sleeve gastrectomy (SG).

AIM

The aim of the study is to investigate the spectrum of gastroesophageal reflux disease (GERD) symptoms as well as the prevalence of BE, at minimum 5 years after SG in patients who underwent SG in different bariatric centers of two countries: France and Italy.

PATIENTS AND METHODS

Five high volume outpatient centers dedicated to bariatric surgery that routinely perform upper GI endoscopy before any bariatric procedures were invited to participate in the study. From January 2017 to June 2018, each center during scheduled postoperative evaluation after surgery asked a minimum 10 consecutive patients, which had performed SG at least 5 years before and with no evidence of BE preoperatively, to undergo another upper GI endoscopy.

RESULTS

Ninety (66 F) consecutive patients were enrolled. The mean follow-up was 78 ± 15 months, and the mean total body weight loss was 25 ± 12%. The prevalence of BE was 18.8% with no significant difference among centers. Weight loss failure was significantly associated with BE (p < 0.01). The prevalence of GERD symptoms, erosive esophagitis, and the usage of PPIs increased from 22%, 10%, and 22% before the SG to 76%, 41%, and 52% at the time of follow-up, respectively (p < 0.05).

CONCLUSIONS

This multicenter study show a high rate of BE at least 5 years after SG. Weight loss failure was significantly associated with BE. We suggest to provide systematic endoscopy in these patients to rule out this condition.

Duodenogastric biliary reflux assessed by scintigraphic scan in patients with reflux symptoms after sleeve gastrectomy: preliminary results

BACKGROUND

Bile reflux is a factor in the appearance of severe esophagitis and Barrett's esophagus, which have been reported after sleeve gastrectomy (SG). Incompetent lower esophageal sphincter and increased gastroesophageal acid reflux have been demonstrated after this operation. Some reports have shown bile content in the antrum during endoscopic control, but no investigations objectively confirm the presence of duodenogastric bile reflux in these patients.

OBJECTIVES

To evaluate the presence of duodenogastric bile reflux (DGR) after SG in patients presenting reflux symptoms.

SETTING

University hospital.

METHODS

Prospective study of 22 patients presenting reflux symptoms who underwent SG for morbid obesity and who received endoscopic evaluation and scintigraphic study to confirm esophagitis and duodenogastric bile reflux.

RESULTS

Erosive esophagitis was observed in 11 patients and Barrett's esophagus in 2 patients. Seven patients (31.8%) presented positive DGR. Among them, 3 had type B and C esophagitis. The other 4 patients did not present esophagitis in spite of reflux symptoms.

CONCLUSION

DGR may be present in patients with gastroesophageal reflux after SG. This line of investigation requires further studies to confirm this hypothesis.