Esophagitis After Bariatric Surgery: Large Cross-sectional Assessment of an Endoscopic Database

Update on esophageal function, acid and non-acid reflux after one-anastomosis gastric bypass (OAGB): high-resolution manometry, impedance-24-h pH-metry, and gastroscopy in a prospective mid-term study

BACKGROUND

One-anastomosis gastric bypass (OAGB) is the third most common metabolic/bariatric procedure worldwide. A point for discussion regarding OAGB is acid and non-acid reflux in mid- and long-term follow-up. The aim of this study was to objectively evaluate reflux and esophagus motility by comparing pre- and postoperative results of 24-h pH-metry, high-resolution manometry (HRM), and gastroscopy.

SETTING

Cross-sectional study and university hospital based.

METHODS

This study includes primary OAGB patients operated at the Medical University of Vienna before 31st December 2022. After a mean follow-up of 4.1 ± 2.9 years, the preoperative examinations were repeated. Additionally, history of weight, remission of obesity-related complications (ORC), and quality of life (QOL) were evaluated.

RESULTS

A total of 50 patients were included in this study and went through all examinations. Preoperative weight was 125.5 ± 21.0 kg with a BMI of 44.6 ± 5.4 kg/m2 and total weight loss after 4.1 ± 2.9 years was 37.1 ± 8.1%. Remission of ORC and QOL outcomes was successful in all categories. Gastroscopy showed anastomositis, esophagitis, Barrett's esophagus, and bile in the pouch in 38.0%, 34.0%, 6.0%, and 48.0%, respectively. In HRM, the postoperative lower esophageal sphincter pressure was 29.6 ± 15.1 mmHg (unchanged to preoperative). The total number of refluxes was equal to preoperative, whereas decreased acid refluxes were replaced by increasing non-acid refluxes. Impedance-24-h pH-metry showed that acid exposure time of the esophagus and DeMeester score decreased significantly to 1.6 ± 1.4% (p = 0.001) and 10.3 ± 9.6 (p = 0.046).

CONCLUSION

This study has shown decreased rates of acid reflux and increased rates of non-acid reflux after a mid-term outcome of primary OAGB patients. Gastroscopy showed significant signs of chronic reflux exposure of the anastomosis, the pouch, and the distal esophagus, even in asymptomatic patients. General follow-up visits in patients after OAGB should be considered.

Risk of De Novo Barrett's Esophagus Post Sleeve Gastrectomy: A Systematic Review and Meta-Analysis of Studies With Long-Term Follow-Up

BACKGROUND & AIMS

Sleeve gastrectomy (SG) is one of the most commonly performed bariatric procedures worldwide. Gastroesophageal reflux disease (GERD) is a major concern in patients undergoing SG and is a risk factor for Barrett's esophagus (BE). We conducted a systematic review and meta-analysis to assess the incidence of and analyze predictive factors for post-SG BE.

METHODS

A comprehensive literature search was conducted in April 2024, for studies reporting on incidence of BE, erosive esophagitis (EE), and hiatal hernia (HH) post-SG. Primary outcomes were post-SG pooled rates of de novo BE, EE, GERD symptoms, proton pump inhibitor use, and HH. Meta-regression analysis was performed to assess if patient and post-SG factors influenced the rates of post-SG BE.

RESULTS

Nineteen studies with 2046 patients (79% females) were included. Mean age was 42.2 years (standard deviation, 11.1) and follow-up ranged from 2 to 11.4 years. The pooled rate of de novo BE post-SG was 5.6% (confidence interval, 3.5-8.8). Significantly higher pooled rates of EE (risk ratio [RR], 3.37], HH (RR, 2.09), GER/GERD symptoms (RR, 3.32), and proton pump inhibitor use (RR, 3.65) were found among patients post-SG. GER/GERD symptoms post-SG positively influenced the pooled BE rates, whereas age, sex, body mass index, post-SG EE, and HH did not.

CONCLUSIONS

Our analysis shows that SG results in a significantly increased risk of de novo BE and higher rates of EE, proton pump inhibitor use, and HH. Our findings suggest that clinicians should routinely screen patients with SG for BE and future surveillance intervals should be followed as per societal guidelines.

Robotic or laparoscopic SLEEVE-DOR (sleeve gastrectomy with anterior Dor 180° fundoplication) for obesity: preliminary results of a series of 80 patients

Aims: Sleeve gastrectomy (SG) is currently the most performed bariatric surgery worldwide. For patients with obesity and symptomatic gastroesophageal reflux disease (GERD), the indication of SG is a matter of concern due to the possibility of worsening or de novo reflux in the postoperative follow-up. A new method, the combination of a 180-degree anterior fundoplication (SLEEVE-DOR) using only one barbed nonabsorbable suture, is proposed to allow the use of SG for this set of patients aiming to minimize the occurrence of de novo GERD. The study aims to evaluate the safety, feasibility and efficacy of SG with SLEEVE-DOR for the therapy of patients with obesity.

Methods: The study describes the largest series of SG combined with anterior hemifundoplication. Since June 2018, all patients with indications for bariatric surgery and having proton pump inhibitor (PPI) therapy for symptomatic reflux at least 6 months before surgery were prospectively documented. All operations were performed laparoscopically (45) or with a robotic DaVinci platform (35). Clinical data were collected from our bariatric center database. The primary outcomes included technical success, perioperative complications and mortality, and the resolution of symptomatic gastroesophageal reflux after the SLEEVE-DOR procedure.

Results: The procedure was successfully performed for all patients (n = 80). Mean operative time was 60.1 min. All patients started oral fluids one hour after the surgery and were discharged between 1st and 3rd postoperative day. Postoperative complications occurred in three patients, with one leak, one peritonitis due to colonic thermic lesion from adherences, and one postoperative death due to massive pulmonary embolism. Four patients claimed intractable reflux between 3 and 6 months and were later converted to a Roux-en-Y gastric bypass (RYGB). The remaining patients experienced complete resolution of reflux symptoms in the 6-month follow-up. The percentage of excess weight loss (%EWL) was 58.5% on postoperative 12 months.

Conclusions: SLEEVE-DOR with one nonabsorbable barbed suture is a safe, effective, and technically simple alternative procedure to allow the performance of SG for morbidly obese patients with preoperative mild symptomatic gastroesophageal reflux, especially for patients with severe obesity as the first step operation.

A Predictive Nomogram for the Occurrence of Gastroesophageal Reflux Disease After Sleeve Gastrectomy: A Study Based on Preoperative HERM

Purpose

Gastroesophageal reflux disease (GERD) is a common complication after laparoscopic sleeve gastrectomy (LSG); This study aimed to construct a model that can predict the incidence of GERD after LSG by exploring the correlation between the results of high-resolution esophageal manometry (HREM) and the incidence of GERD after LSG.

Patients and Methods

We collected the clinical data of patients who had undergone HREM before bariatric surgery from September 2013 to September 2019 at the bariatric center of our hospital. The Gerd-Q scores during the postoperative follow-up were collected to determine the incidence of GERD. A logistic regression analysis was performed to explore the correlation of the HREM results and general clinical data with the incidence of GERD after LSG.

Results

The percentage of synchronous contractions, lower esophageal sphincter (LES) resting pressure, and history of smoking were correlated with the development of GERD after LSG, with the history of smoking and percentage of synchronous contractions as risk factors and LES resting pressure as a protective factor. The training set showed an area under the ROC curve (AUC) of the nomogram model of 0.847. The validation set showed an AUC of 0.761. The decision and clinical impact curves showed a high clinical value for the prediction model.

Conclusion

The HREM results correlated with the development of GERD after LSG, with the percentage of synchronous contractions and LES resting pressure showing predictive value. Combined with the history of smoking, the predictive model showed a high confidence and clinical value.

Current Management and Treatment Paradigms of Gastroesophageal Reflux Disease following Sleeve Gastrectomy

Obesity is associated with serious comorbidities and economic implications. Bariatric surgery, most commonly Roux-en-Y gastric bypass and sleeve gastrectomy, are effective options for weight loss and the improvement of obesity-related comorbidities. With the growing obesity epidemic, there has been a concomitant rise in bariatric surgeries, particularly in sleeve gastrectomy, which has been the most widely performed bariatric surgery since 2013. Gastroesophageal reflux disease (GERD) is highly prevalent in obese individuals, can significantly impact quality of life and may lead to serious complications. Obesity and GERD both improve with weight loss. However, as the incidence of sleeve gastrectomy rises, recent data have revealed a risk of exacerbation of pre-existing GERD or the development of de novo GERD following sleeve gastrectomy. We performed a detailed review of GERD post-sleeve gastrectomy, including its overall incidence, pathophysiology and current treatment paradigms.

Incidence of Barrett's Esophagus Following Sleeve Gastrectomy in Southeast Asian Population

Background: Variable incidences (up to 18.8%) of Barrett's esophagus (BE) have been reported following sleeve gastrectomy (SG), however, there is no published data from the Southeast Asian population. Objective: To determine the incidence of BE following SG in Southeast Asians. Materials and Methods: In this cross-sectional observational study from a tertiary-care center, all patients who had undergone SG from 2008 to 2021 and completed a minimum of 1-year follow-up were contacted to participate. Preoperative data were retrieved from a prospectively maintained database. On recruitment, all patients underwent barium swallow and upper gastrointestinal endoscopy, and weight parameters and reflux symptoms were recorded. Results: One hundred fourteen patients with no preoperative evidence of BE were included. The mean follow-up duration was 5.4 ± 3.1 years. On follow-up endoscopy, Barrett's was suspected in 4 patients. However, 3 patients had columnar-lined epithelium and only 1 patient (0.87%) had evidence of intestinal metaplasia without dysplasia on histology. Reflux esophagitis (grade LA-A) resolved in 9 out of 11 patients, while the rate of de novo esophagitis was reported in 22.3%. The mean reflux Symptom Severity score increased from 0.6 ± 1.8 to 2.6 ± 5.4 (P = .002). The mean body mass index reduced from 44.1 ± 7.1 to 33.6 ± 6.9 kg/m2 (P < .0001), however, 23.7% of the patients experienced significant weight recidivism. Conclusions: Southeast Asians might have a low incidence of BE following SG. Hence, endoscopic surveillance for the sole purpose of diagnosing BE may not be advisable for these patients.

Revisional bariatric surgery for gastroesophageal reflux disease: characterizing patient and procedural factors and 30-day outcomes for a retrospective cohort of 4412 patients

INTRODUCTION

Gastroesophageal reflux disease (GERD) is a well-established potential consequence of bariatric surgery and can require revisional surgery. Our understanding of the population requiring revision is limited. In this study, we aim to characterize patients requiring revisional surgery for GERD to understand their perioperative risks and identify strategies to improve their outcomes.

METHODS

Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) registry, a retrospective cohort of patients who required revisional surgery for GERD in 2020 was identified. Multivariable logistic regression modelling was used to assess correlations between baseline characteristics and morbidity.

RESULTS

4412 patients required revisional surgery for GERD, encompassing 24% of all conversion procedures. In most cases, patients underwent sleeve gastrectomy (SG) as their original surgery (n = 3535, 80.1%). The revisional surgery for most patients was a Roux-en-Y gastric bypass (RYGB) (n = 3722, 84.4%). Major complications occurred in 527 patients (11.9%) and 10 patients (0.23%) died within 30 days of revisional surgery. Major complications included anastomotic leak in 31 patients (0.70%) and gastrointestinal bleeding in 38 patients (0.86%). Multivariable analyses revealed that operative length, pre-operative antacid use, and RYGB were predictors of major complications.

CONCLUSION

GERD is the second most common indication for revisional surgery in patients who have undergone bariatric surgery. Patients who underwent SG as their initial procedure were the primary group who required revisional surgery for GERD; most underwent revision via RYGB. Further inquiry is needed to tailor operative approaches and pre-operative optimization for revisional surgery patients.

Scientific and Public Interest in Bariatric Surgery for Obesity: The Italian Scenario

Background: Obesity is an escalating concern in our society. Bariatric surgery appears to be the only feasible alternative for severe obesity. This study aims to conduct an integrative analysis of the Italian context concerning bariatric surgery, with a specific focus on the surgical procedures of sleeve gastrectomy, mini-gastric bypass, and gastric bypass. Methods: The analysis is based on bibliometric data extracted from the Scopus database to find Italian publications in this field from 2012 to 2022. Along with scientific interest, it is essential to assess the level of public interest in these topics. Google Trends is the most extensively utilized free tool for the analysis of online behavior. Using Google Trends data, we analyzed the amount of internet volume searches (Relative Search Volume = RSV) for the Italian terms “sleeve gastrectomy”, “mini-gastric bypass” and “gastric bypass”, both temporally (from 2012 to 2022 years) and geographically. Furthermore, to illustrate the Italian landscape, we compared Google Trends data with data from the Italian registry “Società Italiana di Chirurgia dell’Obesità e delle malattie metaboliche” (SICOB), which includes information about bariatric surgery procedures performed in the country. Results: Over the past decade, there has been a significant increase in the scientific literature on sleeve gastrectomy, mini-gastric bypass, and gastric bypass surgeries in Italy. Google Trends data has shown an increase in online public interest in these surgical procedures, from 2012 to 2022. The examination of the Google Trends information combined with the SICOB data demonstrated a remarkable association between the two data sets. Conclusions: Bariatric surgery has increased quickly in Italy in terms of scientific research and surgical interventions. The analysis of Google Trends data in conjunction with data from SICOB has revealed an interesting correlation between the two datasets therefore, Google Trends can be useful for estimating the demand for bariatric surgical procedures.

Meta-analysis of Long-term De Novo Acid Reflux-Related Outcomes Following Sleeve Gastrectomy: Evidence Against the Need for Routine Postoperative Endoscopic Surveillance

OBJECTIVES

To evaluate the incidence of long-term de novo acid reflux-related complications following sleeve gastrectomy (SG) to determine whether routine postoperative surveillance endoscopy is necessary.

METHODS

A systematic search of Medline, Embase, CINAHL, CENTRAL, the Web of Science, and bibliographic reference lists was conducted. A proportion meta-analysis model was constructed to quantify the risk of the de novo gastro-oesophageal reflux disease (GORD), oesophagitis, and Barrett's oesophagus (BE) at least 4 years after SG. Random-effects modelling was applied to calculate pooled outcome data.

RESULTS

Thirty-two observational studies were included reporting a total of 7904 patients who underwent primary SG and were followed up for at least 4 years. The median follow-up period was 60 months (48-132). Preoperative acid-reflux symptoms existed in 19.1% ± 15.1% of the patients. The risk of development of de novo GORD, oesophagitis, and BE after SG was 24.8% (95% CI 18.6-31.0%), 27.9% (95% CI 17.7-38.1%), and 6.7% (95% CI 3.7-9.7%), respectively. The between-study heterogeneity was significant in all outcome syntheses. It was suspected that several of the included studies have not reported BE and oesophagitis because such events might not have happened in their cohorts.

CONCLUSIONS

Long-term risk of de novo GORD after SG seems to be comparable with those of the general population which questions the merit of surveillance endoscopy after SG in asymptomatic patients. De novo BE and oesophagitis after SG have not been reported by most of the available studies which may lead to overestimation of the rates of both outcomes in any evidence synthesis. We recommend endoscopic surveillance for symptomatic patients only.

Gastroesophageal Reflux Disease in Obesity: Bariatric Surgery as Both the Cause and the Cure in the Morbidly Obese Population

Gastrointestinal reflux disease (GERD) is a chronic, highly prevalent condition in the United States. GERD can significantly impact quality of life and lead to complications including aspiration pneumonia, esophageal stricture, Barrett's esophagus (BE) and esophageal cancer. Obesity is a risk factor for GERD, which often improves with weight loss and bariatric surgery. Though the incidence of bariatric surgery, in particular, minimally invasive sleeve gastrectomy, has risen in recent years, emerging data has revealed that the severity or new onset of GERD may follow bariatric surgery. We performed a literature review to provide a detailed analysis of GERD with an emphasis on bariatric surgery as both the cure and the cause for GERD in the morbidly obese population. We also describe the pathophysiological mechanisms, management approach and treatment strategies of GERD following bariatric surgery.

Sleeve-Dor Fundoplication - An Innovative Surgical Technique to Avoid the Epidemic Long Term de Novo Gastroesophageal Reflux and Barrett´s Esophagus After Sleeve Gastrectomy for Obesity

BACKGROUND

Sleeve gastrectomy (SG) in current literature showed an increased risk of "de novo" gastroesophageal reflux disease (GERD) and increased risk for Barrett's esophagus in longer follow-up series, with a possibility of esophageal adenocarcinoma in this population. Adding primarily an anterior Dor Fundoplication to SG (Sleeve-Dor) may protect the patient for future and can potentially avoid these chronic complications for patients with obesity.

METHODOLOGY

A standard SG is performed laparoscopically, and a small redundance of the fundus is maintained as a wrap, and this will be fixed to the right crura without dissection of the anatomy of the hiatus. The resulted anterior 180° Dor fundoplication is usually sufficient to relieve or to avoid reflux symptomatic.

DISCUSSION

Based on our preliminary and literature experiences, the SG with anterior Dor fundoplication (Sleeve-Dor) procedure could provide favorable safety profile, satisfactory reflux control and good bariatric outcomes. The complication rate is lower compared to published for Nissen Sleeve or Sleeve-Rossetti technique, with no leaks or major complications recorded to date. Sleeve-Dor procedure may be a potential primary and standard surgery for morbidly obese patients, especially for patients with preoperative GERD symptoms without major findings at endoscopy.

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

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

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Association between the body mass index, waist circumference, and body fat percentage with erosive esophagitis in adults with obesity after sleeve gastrectomy

Background: High anthropometric indexes before sleeve gastrectomy (SG) are associated with an increased risk of erosive esophagitis (EE) in bariatric surgery candidates. Reasons that explain how these indexes influence the development of esophageal pathology after surgery remains unclear. Objectives: To assess the association between the body mass index (BMI), waist circumference (WC), and body fat percentage (BFP) with the development of EE in adults with obesity three months after SG. Setting: Clínica Avendaño, Lima, Peru. Methods: Retrospective cohort using a database including adults with obesity who underwent SG during 2017-2020. All the patients included had an endoscopy before and after the surgery. Sociodemographic, clinical and laboratory characteristics were compared according to BMI, WC and BFP, as well as by the development of de novo esophagitis. The association was evaluated by crude and adjusted generalized linear models with the log-Poisson family. Results: From a total of 106 patients, 23 (21.7%) developed EE. We did not find significant differences in sociodemographic, clinical and laboratory characteristics between patients with de novo EE compared to those who did not develop EE. After adjustment, BMI (aRR = 0.59, 95% CI = 0.18-1.40), BFP (aRR = 0.41, 95% CI = 0.15-1.19) and WC (aRR = 0.91, 95% CI = 0.69-1.16) were not associated with the development of EE three months post SG. Conclusions: We found no association between preoperative anthropometric indexes and the development of de novo EE; therefore, morbid obesity should not be a criterion to exclude the patients to undergo SG as primary surgery because of the risk of developing EE.

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

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

Gastroesophageal Reflux Disease, Esophagitis, and Barrett's Esophagus 3 to 4 Years Post Sleeve Gastrectomy

BACKGROUND

Sleeve gastrectomy (SG) has become the most popular bariatric procedure worldwide. However, SG is associated with de novo gastroesophageal reflux (GERD) and esophagitis, with concerns for progression into Barrett's esophagus (BE). The purpose of this study is to assess the clinical and endoscopic progression of GERD, esophagitis, and BE 3 to 4 years after SG.

METHODS

Fifty-eight patients (pts) were assessed with endoscopy preoperative and at 3 to 4 years post SG, representing 44.9% follow-up. Endoscopy was offered to all SG pts regardless of symptoms. Outcomes including percent total weight loss (%TWL), PPI use, esophagitis progression, de novo reflux, and BE formation.

RESULTS

At post-op follow-up, the %TWL was 23%. The average BMI dropped from 49.07 to 37.5. De novo reflux developed in 13 pts (30.9%). Of the 16 pts with GERD pre-op, 37.5% improved, 25% had stable disease, and 37.5% had worsening symptoms. The rate of esophagitis nearly doubled from 37.9% pre-op to 70.6% post-op. A majority of post-op pts had mild esophagitis (87.8%), with 12.1% with LA classes C and D. Asymptomatic esophagitis was found in 68.2% of post-op pts. The incidence of BE was 12.7% post-op, with de novo BE developing in 4 pts, representing 7.2%.

CONCLUSION

SG is associated with increased rates of asymptomatic esophagitis and de novo reflux at 3 to 4 years post-op. De novo BE was detected as well, highlighting the importance of post-op screening. The majority of pts with GERD pre-op have stable disease or improve.

Management of gastric intestinal metaplasia in patients undergoing routine endoscopy before bariatric surgery

Routine preoperative endoscopic evaluation for bariatric surgery is controversial; however, for patients undergoing endoscopy, some findings may alter surgical management. Gastric intestinal metaplasia (GIM) is found in up to 11.7% of the general population. When associated with determined risk factors, GIM has a risk of progressing to gastric cancer. The aim of our study was to assess the prevalence of GIM and possible associated factors in those undergoing bariatric surgery. We performed a retrospective chart review of patients who underwent primary sleeve gastrectomy or Roux-en-Y gastric bypass at our institution between January 1, 2016 and June 30, 2020. Baseline characteristics and preoperative endoscopic findings were obtained from all patients. Histopathologic analysis of sleeve gastrectomy specimens was reviewed. We identified 753 patients. Mean (SD) age and body mass index were 49.0 (13.1) years and 43.9 (7.1) kg/m², respectively. Procedures consisted of 411 (54.6%) gastric bypasses and 342 (45.4%) sleeve gastrectomies. Esophagitis and Barrett esophagus were found in 18.1% and 5.0% of patients, respectively. Preoperative gastric biopsy identified Helicobacter pylori in 6.4% and GIM in 2.7%. Regression analysis found an association of Barrett esophagus (odds ratio 4.60; 95% CI 1.25-16.82) and age ≥ 60 years (odds ratio 2.67; 95% CI 1.04-6.90) with preoperative findings of GIM. Histopathologic analysis of sleeve gastrectomy specimens identified H. pylori in 1.8% and GIM in 0.9%. Older age and Barrett esophagus were associated with GIM in preoperative gastric biopsy. This association emphasizes the importance of a diligent examination during preoperative endoscopy.

Endoscopic Evaluation and Management of Late Complications After Bariatric Surgery: a Narrative Review

Despite ongoing evolution in technique and a low mortality rate, clinicians may care for patients who suffer late complications (> 90 days of surgery) after bariatric surgery. Endoscopic techniques are used to identify and manage many of the late complications of the two most commonly performed bariatric surgeries: sleeve gastrectomy and Roux-en-Y gastric bypass. Stenosis at the incisura angularis and gastroesophageal reflux disease may occur in patients who have undergone a sleeve gastrectomy. Patients who underwent a Roux-en-Y gastric bypass can suffer marginal ulceration, gastrojejunal anastomotic stricture, and gastro-gastric fistula. Clinicians may also encounter biliary pathologies such as choledocholithiasis, chronic abdominal pain, and weight regain. This narrative review provides an update on the endoscopic evaluation and management of patients with late complications after sleeve gastrectomy or Roux-en-Y gastric bypass.

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

PURPOSE

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

MATERIAL/METHODS

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

RESULTS

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

CONCLUSION

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

Indications and Outcomes of Conversion of Sleeve Gastrectomy to Roux-en-Y Gastric Bypass: a Systematic Review and a Meta-analysis

PURPOSE

Sleeve gastrectomy (SG) is the most performed bariatric procedure. Conversion to Roux-en-Y gastric bypass (RYGB) for SG-related complications such as gastroesophageal reflux disease (GERD), insufficient weight loss (ISWL), and weight regain (WR) is increasing. Our aim was to investigate the safety, efficacy, and outcomes of conversion from SG to RYGB.

METHODS

A literature search was performed from database inception to May 2020. Eligible studies must report indications for conversion, %total body weight loss (%TWL), and/or complications. The pooled mean or proportion were analyzed using a random-effects model.

RESULTS

Seventeen unique studies (n = 556, 68.7% female, average age at time of conversion 42.6 ± 10.29 years) were included. The pooled conversion rate due to GERD was 30.4% (95% CI 23.5, 38.3%; I² = 63.9%), compared to 52.0% (95% CI 37.0, 66.6%; I² = 85.89%) due to ISWL/WR. The pooled baseline BMI at conversion was 38.5 kg/m² (95% CI 36.49, 40.6 kg/m²; I² = 92.1%) and after 1 year was 32.1 kg/m² (95% CI 25.50, 38.7 kg/m²; I² = 94.53%). The pooled %TWL after 1 year was 22.8% (95% CI 13.5, 32.1%; I² = 98.05%). Complication rate within 30 days was 16.4% (95% CI 11.1, 23.6%; I² = 57.17%), and after 30 days was 11.4% (95% CI 7.7, 16.7%; I² = 0%).

CONCLUSION

This meta-analysis showed that conversion from SG to RYGB is an option for conversion at a bariatric care center that produces sufficient weight loss outcomes, and potential resolution of symptoms of GERD. Further indication-based studies are required to obtain a clearer consensus on the surgical management of patients seeking RYGB following SG.

Gastroesophageal Reflux After Sleeve Gastrectomy

Sleeve gastrectomy continues to be the most commonly performed bariatric operation worldwide. Development or worsening of pre-existing GERD has been recognized as a significant issue postoperatively. There is a paucity of information concerning the most appropriate preoperative workup and the technical and anatomical factors that may or may not contribute to the occurrence of reflux symptoms. Contemporary data quality is deficient given the predominantly retrospective nature, limited follow-up time, and heterogeneous outcome measures across studies. This has produced mixed results regarding the postoperative incidence and severity of GERD. Ultimately, better-constructed investigations are needed in order to offer evidence-based recommendations that may guide preoperative workup and improved patient selection criteria.

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.

Barrett's Oesophagus and Bariatric/Metabolic Surgery-IFSO 2020 Position Statement

The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) has been playing an integral role in educating both the metabolic surgical and the medical community at large about the importance of surgical and/or endoscopic interventions in treating adiposity-based chronic diseases. The occurrence of chronic conditions following bariatric/metabolic surgery (BMS), such as gastro-oesophageal reflux disease (GERD) and columnar (intestinal) epithelial metaplasia of the distal oesophagus (also known as Barrett's oesophagus (BE)), has long been discussed in the metabolic surgical and medical community. Equally, the risk of neoplastic progression of Barrett's oesophagus to oesophageal adenocarcinoma (EAC) and the resulting requirement for surgery are the source of some concern for many involved in the care of these patients, as the surgical alteration of the gastrointestinal tract may lead to impaired reconstructive options. As such, there is a requirement for guidance of the community.The IFSO commissioned a task force to elucidate three aspects of the presenting problem: First, to determine what the estimated incidence of Barrett's oesophagus is in patients presenting for BMS; second, to determine the frequency at which Barrett's oesophagus may develop following BMS (with a particular focus on the laparoscopic sleeve gastrectomy (LSG)); and third, to determine if regression of Barrett's oesophagus may occur following BMS given the close relationship of obesity and the development of BE/EAC. Based on these findings, a position statement regarding the management of this pathology in the context of BMS was developed. The following position statement is issued by the IFSO Barrett's Oesophagus task force andapproved by the IFSO Scientific Committee and Executive Board. This statement is based on current clinical knowledge, expert opinion and published peer-reviewed scientific evidence. It will be reviewed regularly.

The Impact of the Gastric Twist on Esophagitis Progression After Sleeve Gastrectomy: Mid-Term Endoscopic Findings

PURPOSE

To determine the real influence of the gastric twist on the progression of esophagitis after SG, evaluating pre- and late post-operative endoscopic findings.

MATERIAL AND METHODS

We retrospectively included 459 patients submitted to SG between 2009 and 2019. The sample comprised patients who performed esophagogastroduodenoscopy (EGD) at the pre-operative and late post-operative periods.

RESULTS

Patients were mainly female (85.6%), with a mean age of 40.4 years. Mean follow-up time was 20.8 months. In the pre-operative period, 1.1% of patients had non-erosive esophagitis, 24.2% of patients had grade A erosive esophagitis, and 1.5% of patients had grade B. In the post-operative evaluation, 3.3% had non-erosive esophagitis, 14.8% presented grade A erosive esophagitis, 8.9% had grade B, and 1.3% had grade C esophagitis. There were no cases of Barrett's esophagus. Forty-nine patients (10.7%) presented gastric twist. Comparing patients with and without gastric twist, it was possible to observe that the gastric twist group presented a higher incidence of grade C esophagitis (4.0% × 1.0%), p = 0.017. The correlation between the occurrence of gastric twist and esophagitis progression showed a prevalence ratio of 1.36 (95% CI 0.82-2.25).

CONCLUSIONS

SG is responsible for an increase in the prevalence of erosive esophagitis, and the occurrence of gastric twist definitely plays a role on it, expressing a risk of 36% for esophagitis progression and being related to a higher incidence of severe esophagitis.

Do we understand the pathophysiology of GERD after sleeve gastrectomy?

Gastroesophageal reflux disease (GERD), a prevalent problem among obese individuals, is strongly associated with obesity and weight loss. Hence, bariatric surgery effectively improves GERD for many patients. Depending on the type of bariatric procedure, however, surgery can also worsen or even cause a new onset of GERD. As a consequence, GERD remains a relevant problem for many bariatric patients, and especially those who have undergone sleeve gastrectomy (SG). Affected patients report not only a decrease in physical functioning but also suffer from mental and emotional problems, resulting in poorer social functioning. The pathomechanism of GERD after SG is most likely multifactorial and triggered by the interaction of anatomical, physiological, and physical factors. Contributing factors include the shape of the sleeve, the extent of injury to the lower esophageal sphincter, and the presence of hiatal hernia. In order to successfully treat post-sleeve gastrectomy GERD, the cause of the problem must first be identified. Therapeutic approaches include lifestyle changes, medication, interventional treatment, and/or revisional surgery.