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

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.

Surgical treatment strategies for gastroesophageal reflux after laparoscopic sleeve gastrectomy

Bariatric surgery has emerged as an effective therapeutic approach for combating obesity. As the most commonly performed bariatric surgery, laparoscopic sleeve gastrectomy (LSG) has a long-term and effective outcome in weight reduction. However, studies have reported an increased incidence of gastroesophageal reflux disease (GERD) among patients after LSG. For those who fail to respond to conventional oral acid-suppressing medication, surgical intervention comes into consideration. The most commonly performed revisional surgery for sleeve gastrectomy is the Roux-en-Y gastric bypass, which can effectively alleviate the symptoms of reflux in patients and also continues to promote weight loss in patients who have not achieved satisfactory results or have experienced weight regain. In addition to this established procedure, innovative techniques such as laparoscopic magnetic sphincter augmentation (MSA) are being explored. MSA is less invasive, has good reflux treatment outcomes, and its safety and efficacy are supported by the literature, making it a promising tool for the future treatment of gastroesophageal reflux. This article also explores the role of endoscopic interventions for GERD treatment of post-sleeve gastrectomy patients. Although these methods have shown some therapeutic effect, their efficacy still requires further study due to a lack of support from more clinical data. For patients with preoperative hiatal hernia or gastroesophageal reflux symptoms, some experts now consider performing LSG combined with hiatal hernia repair or fundoplication to alleviate or prevent postoperative reflux symptoms. Both of these surgical approaches have demonstrated favorable outcomes; however, the addition of fundoplication requires further investigation regarding its long-term effects and potential postoperative complications. This article gathers and examines the current laparoscopic and endoscopic treatments for refractory gastroesophageal reflux following LSG, as well as the concurrent treatment of LSG in patients with preoperative gastroesophageal reflux or hiatal hernia.

Upper Gastrointestinal Endoscopic Screening in Bariatric Surgery Candidates: Correlating the Findings with GERD symptoms

INTRODUCTION

The role of routine preoperative esophagogastroduodenoscopy (EGD) in bariatric surgery candidates is controversial. This study compares preoperative EGD outcomes with patient-reported gastroesophageal reflux disease (GERD) symptoms to determine if a case-based EGD is appropriate.

PATIENTS AND METHODS

A prospective cohort study was conducted from April 2022 through September 2023 in Mashhad, Iran. All patients underwent EGD. To assess GERD symptoms, we used the GERD-Health Related Quality of Life questionnaire. Patients were categorized into two groups: the asymptomatic group (GERD-HRQL = 0) and the symptomatic group (GERD-HRQL > 0).

RESULTS

A total of 165 patients were included, out of which 133 (80.6%) were in the symptomatic group and 32 (19.4%) were in the asymptomatic group. Esophagitis was present in 41 (24.8%) patients. There was no significant difference in the frequency of esophagitis (18.8% vs. 26.3%, p-value = 0.37), hiatal hernia (18.8% vs. 18.8%, p-value = 1.00), gastritis (56.3% vs. 63.9%, p-value = 0.42), and H. pylori infection (9.4% vs. 12.0%, p-value = 1.00) between the asymptomatic and symptomatic groups, respectively. None of the demographic factors or comorbidities of asymptomatic patients were associated with esophagitis, except for hiatal hernia (OR = 7.67, 95% CI 3.01-19.53, p-value < 0.001). Receiver operating characteristic (ROC) analysis showed that the GERD-HRQL total scores, as well as the heartburn and regurgitation subscales, were poor predictors of esophagitis (AUC 0.57, 0.51, and 0.56, respectively).

CONCLUSION

EGD findings were not associated with GERD symptoms in candidates for bariatric surgery.

Novel subtype of obesity influencing the outcomes of sleeve gastrectomy: Familial aggregation of obesity

BACKGROUND

Differences in the preoperative characteristics and weight loss outcomes after sleeve gastrectomy (SG) between patients with familial aggregation of obesity (FAO) and patients with sporadic obesity (SO) have not been elucidated.

AIM

To explore the impact of SG on weight loss and the alleviation of obesity-related comorbidities in individuals with FAO.

METHODS

A total of 193 patients with obesity who underwent SG were selected. Patients with FAO/SO were matched 1:1 by propensity score matching and were categorized into 4 groups based on the number of first-degree relatives with obesity (1SO vs 1FAO, 2SO vs 2FAO). The baseline characteristics, weight loss outcomes, prevalence of obesity-related comorbidities and incidence of major surgery-related complications were compared between groups.

RESULTS

We defined FAO as the presence of two or more first-degree relatives with obesity. Patients with FAO did not initially show significant differences in baseline data, short-term postoperative weight loss, or obesity-related comorbidities when compared to patients with SO preoperatively. However, distinctions between the two groups became evident at the two-year mark, with statistically significant differences in both percentage of total weight loss (P = 0.006) and percentage of excess weight loss (P < 0.001). The FAO group exhibited weaker remission of type 2 diabetes mellitus (T2DM) (P = 0.031), hyperlipidemia (P = 0.012), and non-alcoholic fatty liver disease (NAFLD) (P = 0.003) as well as a lower incidence of acid reflux (P = 0.038).

CONCLUSION

FAO patients is associated with decreased mid-to-long-term weight loss outcomes; the alleviation of T2DM, hyperlipidemia and NAFLD; and decreased incidence of acid reflux postoperatively.