Gastroesophageal reflux disease and Barrett's esophagus after laparoscopic sleeve gastrectomy: a possible, underestimated long-term complication

Laparoscopic Toupet-Sleeve gastrectomy in morbid obese patients with preoperative gastro-esophageal reflux: a 4-year follow-up cohort study

AIM

To assess the 4-year outcomes after Toupet-Sleeve (TS) gastrectomy in morbid obese patients with concomitant preoperative gastro-esophageal reflux disease (GERD).

MATERIAL AND METHODS

The study group consisted of 19 consecutive patients operated on between August 2017 and February 2019. There were 5 men and 14 women with a mean body mass index (BMI) of 43 ± 5 kg/m2 and a mean age of 42 ± 15 years. A retrospective analysis of database and telephone interview of patients who defaulted clinic follow-up was conducted. The main study end-points were weight loss and success of surgery, defined as no need for conversion and %EWL > 50%. Resolution of GERD was a secondary end-point.

RESULTS

No patient was lost for follow-up. Nadir weight loss was reached after a follow-up of one year: mean BMI was 32 ± 5 kg/m2, %EWL 61 ± 21% and %TWL 24 ± 7%. Thereafter, we observed a progressive weight regain over time. With a mean follow-up of 51 ± 6 months, mean BMI was 36 ± 8 kg/m2, %EWL 43 ± 35% and %TWL 16 ± 12%. Two patients were converted to another bariatric procedure because of dysphagia and fundus dilatation or because of insufficient weight loss. The overall surgical success rate was 32% (6/19). Resolution of GERD without any PPI treatment was noted in 88% (15/17) of the non-converted patients.

CONCLUSION

In our experience, with a 4-year follow-up, TS is associated with a significant risk of conversion, a moderate weight loss and a poor surgical success rate.

Does the Repair of an Accidentally Discovered Hiatal Hernia and Gastropexy Affect the Incidence of De Novo Postoperative GERD Symptoms After Laparoscopic Sleeve Gastrectomy?

Background

The relationship between laparoscopic sleeve gastrectomy (LSG) and gastroesophageal reflux disease (GERD) is intricate. Hiatal hernia repair or gastropexy can have an impact on postoperative GERD.

Aim

To assess the effect of the repair of an accidentally discovered HH and/or gastropexy on the development of de novo postoperative GERD symptoms after LSG.

Methods

This retrospective study included all obese patients who underwent LSG at our hospital from January 2018 to June 2022. The data retrieved from patients' files comprised demographic and clinical data, including BMI, GERD symptoms, and comorbidities. Hiatal hernias, surgical technique, gastropexy, duration, and intraoperative complications were recorded. Postoperative data included early and late postoperative complications, weight loss, de novo GERD, and medication use.

Results

The study included 253 patients, 89 males (35.2%) and 164 females (64.8%), with a mean age of 33.3±10.04 years. De novo GERD was detected in 94 individuals (37.15%). HH was accidentally found and repaired in 29 patients (11.5%). Only 10.3% of LSG and HH repair patients had de novo GERD symptoms, compared to 40.6% of non-HH patients. 149 patients (58.9%) had gastropexy with LSG. Postoperative de novo GERD symptoms were comparable for LSG with gastropexy (40.5%) and LSG alone (40.9%).

Conclusion

After one year, concurrent hiatal hernia repair and LSG seem to be safe and beneficial in lowering postoperative de novo GERD symptoms. The inclusion of gastropexy with LSG had no significant impact on postoperative de novo GERD. Both HH repair and gastropexy lengthened the operation but did not increase its complications.

Modified One Anastomosis Gastric Bypass Following Sleeve Gastrectomy for Severe Reflux and Delayed Gastric Emptying: A Prospective Trial with Clinical and Physiological Outcome Measures

BACKGROUND

Gastro-esophageal reflux (GORD) following sleeve gastrectomy (SG) is a central challenge, and precise indications for revisional surgery or the physiology have not been precisely defined. We aimed to determine whether OAGB performed for reflux post-SG (1) accelerates gastric emptying half-time, (2) reduces the frequency and severity of reflux events, and (3) improves reflux symptoms.

METHODS

We undertook a prospective trial (ACTRN12616001089426). There were 22 participants who underwent measurement before and after revisional surgery with 29 optimal SG (patients with optimal outcome from their primary surgery) as controls. All participants underwent a protocolized nuclear scintigraphy, 24-h pH monitoring, and gastroscopy and completed objective questionnaires.

RESULTS

Trial patients were 90.9% female, age 44.4 years. Conversion from SG to OAGB was at a median of 45.2 ± 19.6 months. Scintigraphy showed an increased rate of gastric emptying post-OAGB 34 (IQR 14) vs 24 (IQR 10.3) min, p-value 0.008, with decreased number of reflux events post-prandially (39 (IQR 13) vs 26 (IQR 7), p-value 0.001). This data correlated with the pH analysis; total acid events substantially reduced post-OAGB 58.5 (IQR 88) vs 12 (IQR 9.4) events, p-value 0.017. Endoscopic findings indicated a reduction in incidence of bile stasis 72.7% vs 40.9% post-OAGB, p-value < 0.00010. Post-OAGB, patients experienced less frequent regurgitation (12 ± 4.1 vs. 5.5 ± 3, p-value 0.012) and reflux (37.1 ± 15.7 vs. 16.8 ± 12.6, p-value 0.003).

CONCLUSIONS

We found OAGB is an effective treatment for reflux associated with delayed gastric emptying post-SG. The likely mechanisms is by, an increase in the rate of gastric clearance and reduced reflux events and overall esophageal acid exposure. This suggests that some forms of post-SG reflux are driven by slower emptying of the residual stomach and are amenable to treatment with drainage above the incisura.

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.

Management of Gastroesophageal Reflux Disease after Sleeve Gastrectomy: Effectiveness of Medical, Endoscopic, and Surgical Therapies

Introduction: Sleeve gastrectomy (SG) has become the most frequently performed bariatric operation in the United States. One of the main disadvantages of this procedure is the risk of developing gastroesophageal reflux disease (GERD) after the operation. We aimed to analyze different approaches for the treatment of GERD after SG. Methods: A literature review was performed to identify all possible treatment options for post-SG GERD. All the studies were assessed for full eligibility by manual assessment of their aims, methodology, results, and conclusions. Records were individually reviewed by the authors comparing outcomes and complications between procedures. Results: Although some studies have shown improvement or even resolution of GERD symptoms after SG, most patients develop or worsen symptoms. Lifestyle modifications along with medical therapy should be started on patients with GERD after SG. For those who are refractory to medication, endoscopic and surgical therapies can be offered. Conversion to Roux-en-Y gastric bypass (RYGB) is consistently effective in treatment of GERD and is the ideal therapy in patients with associated insufficient weight loss. Endoscopic and alternative surgical procedures are also available and have shown acceptable short-term outcomes. Conclusions: Several treatment options exist for the treatment of GERD after SG. Although conversion to RYGB remains the most effective therapy, other emerging endoscopic and surgical procedures could avoid the potential morbidity of this procedure and should be further evaluated. An evidence-based algorithm for the management of GERD after SG is proposed to guide decision making.

Effectiveness of sleeve gastrectomy plus fundoplication versus sleeve gastrectomy alone for treatment of patients with severe obesity: a systematic review and meta-analysis

BACKGROUND

Laparoscopic sleeve gastrectomy (SG) is a widely performed bariatric surgery, but it is associated with an increased risk of gastroesophageal reflux (GERD) in the long term. The addition of fundoplication to laparoscopic SG may improve lower oesophageal sphincter function and reduce postoperative GERD.

OBJECTIVES

This systematic review and meta-analysis aims to compare the efficacy and safety of SG plus fundoplication (SG + F) versus SG alone for the treatment of patients with severe obesity (≥35 kg/m2).

SETTING

Meta-analysis.

METHODS

Three electronic databases were searched from inception until January 2023. Studies were included if they compared outcomes of SG + F versus SG in patients with severe obesity (≥35 kg/m2). The primary outcome was remission of GERD postoperatively. Secondary outcomes were the percentage of excess weight loss, percentage of total weight loss, postoperative complication rate, operative time, and length of stay.

RESULTS

A total of 5 studies with 539 subjects (212 SG + F and 327 SG alone) were included. The mean preoperative body mass index was 42.6 kg/m2. SG + F achieved higher remission of GERD compared with laparoscopic SG (odds ratio [OR] = 13.13; 95% CI, 3.54-48.73; I2 = 0%). However, the percentage of total weight loss was lower in the SG + F group (mean difference [MD] = -2.75, 95% CI, -4.28 to -1.23; I2 = 0%), whereas there was no difference in the percentage of excess weight loss (MD = -0.64; 95% CI, -20.62-19.34; I2 = 83%). There were higher postoperative complications in SG + F (OR = 2.56; 95% CI, 1.12-5.87; I2 = 0%) as well. There was no difference in operative time or length of stay between the 2 groups.

CONCLUSION

SG + F achieved better GERD remission but is associated with lesser weight loss and increased postoperative complications compared with SG alone. Further studies are required to ascertain the overall clinical benefit of SG + F for patients with severe obesity.

Sleeve Migration Following Sleeve Gastrectomy: A Systematic Review of Current Literature

Sleeve gastrectomy (SG) is the most frequently performed bariatric procedure worldwide. The incidence and consequences of sleeve migration (SM) are not clearly understood. There is no clear consensus on appropriate measures to reduce the risk of SM. This study systematically reviewed the literature and identified 405 cases of SM from 21 studies. Age ranged from 18 to 68 years. Thirty-two percent and 11% of patients were females and males respectively, while sex was not reported in 57%. Time to diagnosis ranged from 1 day to 5 years postoperatively. A total of 9.6% and 58.8% of patients had or had no previous hiatal hernia respectively. SM incidence, risk factors, proposed mechanisms, clinical presentation, diagnosis, management, and potential preventive strategies are described in this review.

Laparoscopic sleeve gastrectomy conversion to gastric bypass: conversion rate over time, predictors of conversion, and weight loss outcomes

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is the most common Bariatric procedure in the United States; however, the frequency of conversion to Roux-en-Y gastric bypass (RYGB) is unknown.

OBJECTIVES

The primary aim was to determine the conversion rate over time from LSG to RYGB. The secondary objectives were to evaluate factors associated with conversion and postconversion weight loss outcomes.

SETTING

Single Academic Institution, Center of Bariatric Excellence.

METHODS

A retrospective analysis of all LSG from 2011 to 2020 was done. Kaplan-Meier analysis was utilized to estimate the conversion rate over time after LSG. Cox regression was utilized to identify predictors of future conversion.

RESULTS

Of 875 LSGs, 46 were converted to RYGB from 2011 to 2020. Median follow-up was 2.6 years, and 7-year follow-up rate was 59.9%. The 1-year conversion rate was 1.4%, increasing to 3.8%, 9.0%, and 12.6% at 3, 5, and 7 years respectively. Female gender (hazard ratio [HR] = 4.2, P = .05) and age <55 (HR = 3.5, P = .04) were associated with greater chance of conversion. Preoperative asthma (HR = 1.7, P = .14) and gastroesophageal reflux disease (GERD) (HR = 1.5, P = .18) trended toward higher conversion but were not significant. Of those with body mass index (BMI) >35 at time of conversion, the mean total body weight loss (TBWL) was 13.0% at the time of conversion. This subgroup had additional 13.6% of TBWL 1-year after conversion.

CONCLUSIONS

Conversion of LSG to RYGB increased with time to 12.6% conversion rate at 7-years. Patients with GERD prior to LSG had a nonsignificant trend toward conversion, while younger patients and females had significantly higher rates of conversion. There may be additional weight loss benefit for patients converted to RYGB.

Gastro-esophageal diagnostic workup before bariatric surgery or endoscopic treatment for obesity: position statement of the International Society of Diseases of the Esophagus

Obesity is a chronic and multifactorial condition characterized by abnormal weight gain due to excessive adipose tissue accumulation that represents a growing worldwide challenge for public health. In addition, obese patients have an increased risk of hiatal hernia, esophageal, and gastric dysfunction, as well as gastroesophageal reflux disease, which has a prevalence over 40% in those seeking endoscopic or surgical intervention. Surgery has been demonstrated to be the most effective treatment for severe obesity in terms of long-term weight loss, comorbidities, and quality of life improvements and overall mortality decrease. The recent emergence of bariatric endoscopic techniques promises less invasive, more cost-effective, and reproducible approaches to the treatment of obesity. With the endorsement of the International Society for Diseases of the Esophagus, we started a Delphi process to develop consensus statements on the most appropriate diagnostic workup to preoperatively assess gastroesophageal function before bariatric surgical or endoscopic interventions. The Consensus Working Group comprised 11 international experts from five countries. The group consisted of gastroenterologists and surgeons with a large expertise with regard to gastroesophageal reflux disease, bariatric surgery and endoscopy, and physiology. Ten statements were selected, on the basis of the agreement level and clinical relevance, which represent an evidence and experience-based consensus of the International Society for Diseases of the Esophagus.

Treatment of esophageal adenocarcinoma in patients with a history of bariatric surgery

BACKGROUND

The relationship among obesity, bariatric surgery, and esophageal adenocarcinoma (EAC) is complex, given that some bariatric procedures are thought to be associated with increased incidence of reflux and Barrett's esophagus. Previous bariatric surgery may complicate the use of the stomach as a conduit for esophagectomy. In this study, we presented our experience with patients who developed EAC after bariatric surgery and described the challenges encountered and the techniques used.

METHODS

We conducted a retrospective review of our institutional database to identify all patients at our institution who were treated for EAC after previously undergoing bariatric surgery.

RESULTS

In total, 19 patients underwent resection with curative intent for EAC after bariatric surgery, including 10 patients who underwent sleeve gastrectomy. The median age at diagnosis of EAC was 63 years; patients who underwent sleeve gastrectomy were younger (median age, 56 years). The median time from bariatric surgery to EAC was 7 years. Most patients had a body mass index (BMI) score of >30 kg/m2 at the time of diagnosis of EAC; approximately 40% had class III obesity (BMI score > 40 kg/m2). Six patients (32%) had known Barrett's esophagus before undergoing a reflux-increasing bariatric procedure. Sleeve gastrectomy patients underwent esophagectomy with gastric conduit, colonic interposition, or esophagojejunostomy. Only 1 patient had an anastomotic leak (after esophagojejunostomy).

CONCLUSION

Endoscopy should be required both before (for treatment selection) and after all bariatric surgical procedures. Resection of EAC after bariatric surgery requires a highly individualized approach but is safe and feasible.

Surgical Aspects of Sleeve Gastrectomy Are Related to Weight Loss and Gastro-esophageal Reflux Symptoms

INTRODUCTION

A large variation in outcome has been reported after sleeve gastrectomy (SG) across countries and institutions. We aimed to evaluate the effect of surgical technique on total weight loss (TWL) and gastro-esophageal reflux disease (GERD).

METHODS

Observational cohort study based on data from the national registries for bariatric surgery in the Netherlands, Norway, and Sweden. A retrospective analysis of prospectively obtained data from surgeries during 2015-2017 was performed based on 2-year follow-up. GERD was defined as continuous use of acid-reducing medication. The relationship between TWL, de novo GERD and operation technical variables were analyzed with regression methods.

RESULTS

A total of 5927 patients were included. The average TWL was 25.6% in Sweden, 28.6% in the Netherlands, and 30.6% in Norway (p < 0.001 pairwise). Bougie size, distance from the resection line to the pylorus and the angle of His differed between hospitals. A minimized sleeve increased the expected total weight loss by 5-10 percentage points. Reducing the distance to the angle of His from 3 to just above 0 cm increased the risk of de novo GERD five-fold (from 3.5 to 17.8%).

CONCLUSION

Smaller bougie size, a shorter distance to pylorus and to the angle of His were all associated with greater weight loss, whereas a shorter distance to angle of His was associated with more de novo reflux.

Conversion of one-anastomosis gastric bypass (OAGB) to Roux-en-Y gastric bypass (RYGB) for gastroesophageal reflux disease (GERD): who is more at risk? A multicenter study

BACKGROUND

Although gastroesophageal reflux disease (GERD) affects 0.6% to 10% of patients operated on for one-anastomosis gastric bypass (OAGB), only about 1% require surgery to convert to Roux-en-Y gastric bypass (RYGB) [3-5]. The aim of the present study was to analyze the characteristics of OAGB patients converted to RYGB for GERD not responding to medical treatment.

METHODS

This retrospective multicenter study included patients who underwent conversion from OAGB to RYGB for severe GERD. The conversion was performed with resection of the previous gastro-jejunal anastomosis and the use of the afferent loop as a new biliary loop.

RESULTS

A total of 126 patients were included in the study. Of these patients, 66 (52.6%) had a past medical history of bariatric restrictive surgery (gastric banding, sleeve gastrectomy). A hiatal hernia (HH) was present in 56 patients (44.7%). The association between previous restrictive surgery and HH was recorded in 33 (26.2%) patients. Three-dimensional gastric computed tomography showed an average gastric pouch volume of 242.4 ± 55.1 cm3. Conversion to RYGB was performed on average 60 ± 35.6 months after OAGB. Seven patients (5.5%) experienced an early postoperative complication (4 patients grade IIIb and 3 grade IIb), and 3 (2.4%) a late complication. Patients showed further weight loss after RYGB conversion and an average of 24.8 ± 21.7 months after surgery, with a mean % of total weight loss (%TWL) of 6.9 ± 13.6 kg. From a clinical point of view, the problem of GERD was definitively solved in more than 90% of patients.

CONCLUSIONS

Situations that weaken the esogastric junction appear to be highly frequent in patients operated on for OAGB and converted to RYGB for severe reflux. Similarly, the correct creation of the gastric pouch could play an important role in reducing the risk of conversion to RYGB for GERD.

National trends in utilization and safety of gastric bypass, sleeve gastrectomy and conversion surgery in patients with GERD

BACKGROUND

While some studies have reported improvement in gastro-esophageal reflux disease (GERD) symptoms after sleeve gastrectomy (SG), others have reported higher incidence of de-novo GERD, worsening of prior GERD symptoms and erosive esophagitis post SG. Furthermore, GERD unresponsive to medical management is one of the most common indications for conversion of SG to Roux-en-Y gastric bypass (RYGB). Real-world data on safety of primary SG, primary RYGB and SG to RYGB conversion for obese patients with GERD would be helpful for informing surgeons and patient procedure selection. We sought to evaluate the trends in utilization and safety of primary RYGB and primary SG for patients with GERD requiring medications, and compare the peri-operative outcomes between primary RYGB and conversion surgery from SG to RYGB for GERD using the MBSAQIP database.

METHODS

A comparative analysis of post-operative outcomes within 30 days was performed for primary RYGB and primary SG after 1:1 nearest neighbor propensity score matching for patient demographics and preoperative comorbidities using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) registry from 2015 to 2021. This was followed by comparison of peri-operative outcomes between conversion surgery from SG to RYGB for GERD and primary RYGB using MBSAQIP 2020-2021 data.

RESULTS

Utilization of primary RYGB increased from 38% in 2015 to 45% in 2021, while primary SG decreased from 62% in 2015 to 55% in 2021 for bariatric patients with GERD. Post-operative outcomes including reoperation, reintervention, readmission, major complications, and death within 30 days were significantly higher for patients undergoing primary RYGB compared to primary SG. Increased readmissions and ED visits were seen with conversion surgery. However, there was no difference in rates of reoperation, reintervention, major complications, or death between primary RYGB and SG conversion to RYGB cohorts.

CONCLUSIONS

This data suggests that a strategy of performing a primary SG and subsequent SG-RYGB conversion for those with recalcitrant GERD symptoms is not riskier than a primary RYGB. Thus, it may be reasonable to perform SG in patients who are well informed of the risk of worsening GERD requiring additional surgical interventions. However, the impact of such staged approach (SG followed by conversion to RYGB) on long-term outcomes remains unknown.

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.

Post-bariatric Surgery Changes in Secondary Esophageal Motility and Distensibility Parameters

INTRODUCTION

Despite the increasing number of bariatric procedures over the recent years, the physiological changes in secondary esophageal motility and distensibility parameters after surgery remain unknown.

METHODS

This is a retrospective, single-center cohort study comparing esophageal planimetry and gastroesophageal junction (GEJ) distensibility in post-bariatric surgery patients (Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), and conversion/revisional patients (DH)) and native-anatomy patients with obesity (NAC). Distensibility refers to the area achieved with a certain amount of pressure, and secondary peristalsis represents the esophageal response to an intended obstruction. Patients with pre-surgical dysmotility symptoms were excluded from the study.

RESULTS

From November 2018 to January 2023, 167 patients were evaluated and eligible for this study (RYGB = 87, SG = 33, NAC = 22, DH = 25). In NAC cohort, 17/22 (77%) patients presented normal motility patterns compared to 35/87 (40%) RYGB, 12/33 (36%) SG, and 5/25 (20%) DH (p < 0.05 for all comparisons). The most common abnormal motility pattern for all three bariatric cohorts was absent contractions. DH patients generally had the highest mean maximum distensibility index averages, followed by SG, RYGB, and NAC.

CONCLUSION

Bariatric surgery affects esophageal and GEJ physiology, and it is associated with higher rates of secondary dysmotility. DH patients have even higher rates of dysmotility. Further studies assessing clinical data and their correlation with manometric and pH-metric findings are needed.

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.

Comparison of Sleeve Gastrectomy vs Roux-en-Y Gastric Bypass: A Randomized Clinical Trial

Importance

Laparoscopic sleeve gastrectomy (SG) and laparoscopic Roux-en-Y gastric bypass (RYGB) are widely used bariatric procedures for which comparative efficacy and safety remain unclear.

Objective

To compare perioperative outcomes in SG and RYGB.

Design, Setting, and Participants

In this registry-based, multicenter randomized clinical trial (Bypass Equipoise Sleeve Trial), baseline and perioperative data for patients undergoing bariatric surgery from October 6, 2015, to March 31, 2022, were analyzed. Patients were from university, regional, county, and private hospitals in Sweden (n = 20) and Norway (n = 3). Adults (aged ≥18 years) eligible for bariatric surgery with body mass indexes (BMIs; calculated as weight in kilograms divided by height in meters squared) of 35 to 50 were studied.

Interventions

Laparoscopic SG or RYGB.

Main Outcomes and Measures

Perioperative complications were analyzed as all adverse events and serious adverse events (Clavien-Dindo grade >IIIb). Ninety-day mortality was also assessed.

Results

A total of 1735 of 14 182 eligible patients (12%; 1282 [73.9%] female; mean (SD) age, 42.9 [11.1] years; mean [SD] BMI, 40.8 [3.7]) were included in the study. Patients were randomized and underwent SG (n = 878) or RYGB (n = 857). The mean (SD) operating time was shorter in those undergoing SG vs RYGB (47 [18] vs 68 [25] minutes; P < .001). The median (IQR) postoperative hospital stay was 1 (1-1) day in both groups. The 30-day readmission rate was 3.1% after SG and 4.0% after RYGB (P = .33). There was no 90-day mortality. The 30-day incidence of any adverse event was 40 (4.6%) and 54 (6.3%) in the SG and RYGB groups, respectively (odds ratio, 0.71; 95% CI, 0.47-1.08; P = .11). Corresponding figures for serious adverse events were 15 (1.7%) for the SG group and 23 (2.7%) for the RYGB group (odds ratio, 0.63; 95% CI, 0.33-1.22; P = .19).

Conclusions and Relevance

This randomized clinical trial of 1735 patients undergoing primary bariatric surgery found that both SG and RYGB were performed with a low perioperative risk without clinically significant differences between groups.

Trial Registration

ClinicalTrials.gov Identifier: NCT02767505.

Reduced risk of de novo Barrett esophagus after bariatric surgery: a national database study

BACKGROUND

Bariatric surgery is an effective treatment for obesity and may decrease the morbidity and mortality of obesity-associated cancers.

OBJECTIVE

We investigated the risk of a new diagnosis of Barrett esophagus (BE) following bariatric surgery compared to screening colonoscopy controls.

SETTING

Large national database including patients who received care in inpatient, outpatient, and specialty care services.

METHODS

A national healthcare database (TriNetX, LLC) was used for this analysis. Cases included adults (aged ≥18 yr) who had undergone either sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB). Controls included adults undergoing screening colonoscopy and an esophagoduodenoscopy on the same day and had never undergone bariatric surgery. Cases and controls were propensity-matched for confounders. The risk of de novo diagnosis of BE at least 1 year after bariatric surgery was compared between cases and controls. Secondary analyses examined the effect of bariatric surgery on metabolic outcomes such as weight loss and body mass index (BMI). The risk of de novo diagnosis of BE in SG was compared with RYGB. Odds ratios (OR) and 95% CI were used to report on these associations.

RESULTS

In the propensity-matched analysis, patients who had undergone a bariatric surgical procedure showed a significantly reduced risk of de novo BE when compared with screening colonoscopy controls (.67 [.48, .94]). There was substantial reduction in weight and BMI in the bariatric surgery group when compared with baseline. There was no significant difference in de novo BE diagnosis between the propensity-matched SG and RYGB groups (.77 [.5, 1.2]).

CONCLUSION

Patients who underwent bariatric surgery (RYGB or SG) had a lower risk of being diagnosed with BE compared with screening colonoscopy controls who did not receive bariatric surgery. This effect appears to be largely mediated by reduction in weight and BMI.

GERD-screening before bariatric surgery: the predictive value of the GERD-HRQL questionnaire score compared with preoperative EGD findings

BACKGROUND

There is an ongoing debate on how to best identify patients with gastroesophageal reflux disease (GERD) before bariatric surgery. The value of routine preoperative esophagogastroduodenoscopy (EGD) is questioned, and patient reported symptoms are commonly used for screening. The goal of this study is to determine if patient reported symptoms using a validated questionnaire correlate with preoperative EGD findings.

METHODOLOGY

A prospective cohort study at a single institution was performed. Patients undergoing bariatric surgery between December 2020 and March 2023 were required to report symptoms of reflux by completing a preoperative GERD. Health-Related Quality of Life (GERD-HRQL) questionnaire and undergo a mandatory preoperative screening EGD. Patients were stratified into two cohorts: (group A) asymptomatic (score = 0) and (group B) symptomatic (score > 0). Statistical analysis was conducted using Pearson's chi-squared test and Wilcoxon rank-sum test in RStudio version 4.2.2. The predictive value of the GERD-HRQL score was analyzed using Areas Under the Curve (AUC; AUC = 0.5 not predictive, 0.5 < AUC ≥ 6 poor prediction & AUC > 0.9 excellent prediction) calculated from Receiver Operating Characteristic (ROC) curves.

RESULTS

200 patients were included; median age was 42.0 years (IQR 36.0 to 49.2). There were 79 patients (39.5%) in Group A and 121 patients (60.5%) in Group B. There was no difference in the frequency esophagitis (27.8% vs 32.2%, p = 0.61) or hiatal hernias (49.4% vs 47.1%, p = 0. 867) between group A and group B, respectively. ROC analysis revealed that the total GERD HRQL scores, heartburn only scores and regurgitation only scores, were poor predictors of esophagitis found on EGD (AUC 0.52, 0.53, 0.52), respectively. In asymptomatic patients, higher BMI was significantly associated with esophagitis (OR 1.15, 95% CI 1.06-1.27, p = 0.002).

CONCLUSION

Symptoms, identified through the GERD-HRQL questionnaire, are a poor indicator of esophagitis or its severity in patients undergoing workup for bariatric surgery. Therefore, liberal screening upper endoscopy is recommended for pre-bariatric surgery patients to guide appropriate procedure selection.

One-anastomosis gastric bypass (OAGB) versus Roux-en-Y gastric bypass (RYGB) as revisional procedures after failed laparoscopic sleeve gastrectomy (LSG): systematic review and meta-analysis of comparative studies

INTRODUCTION

The aim of this study was to compare weight loss and gastroesophageal reflux disease (GERD) remission after one-anastomosis gastric bypass (OAGB) versus Roux-en-Y gastric bypass (RYGB) as revisional procedures after laparoscopic sleeve gastrectomy (LSG).

METHODS

In PubMed, Embase, and Cochrane Library, a search was performed using the terms "Roux-en-Y gastric bypass versus one anastomosis gastric bypass," "revisional surgery," and "sleeve gastrectomy." Only original articles in English language comparing OAGB and RYGB were included. No temporal interval was set. The primary outcome measure was weight loss (%TWL). The secondary endpoints were leak, bleeding, marginal ulcer, and GERD. PRISMA flowchart was used. Differences in continuous and dichotomous outcome variables were expressed as mean difference (MD) and risk difference (RD) with 95% CI, respectively. Heterogeneity was assessed by using I2 statistic.

RESULTS

Six retrospective comparative articles were included in the present meta-analysis. Weight loss analysis showed a MD = 5.70 (95% CI 4.84-6.57) in favor of the OAGB procedure with a statistical significance (p = 0.00001) and no significant statistical heterogeneity (I2 = 0.00%). There was no significant RD for leak, bleeding, or marginal ulcer after the two revisional procedures. After conversion to OAGB, remission from GERD was 68.6% (81/118), and it was 80.6% (150/186) after conversion to RYGB with a RD = 0.10 (95% CI -0.04, 0.24), no statistical significance (p = 0.19), and high heterogeneity (I2 = 96%). De novo GERD was 6.3% (16/255) after conversional OAGB, and it was 0.5% (1/180) after conversion to RYGB with a RD = -0.23 (95% CI -0.57, 0.11), no statistical significance (p = 0.16), and high heterogeneity (I2 = 92%).

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.

Long-Term Outcomes of Sleeve Gastrectomy: Weight Recurrence and Surgical Non-responders

INTRODUCTION

Sleeve gastrectomy (SG) is an effective procedure with remarkable weight loss and low complication rates. However, up to 30% of cases require revisional surgery in non-responders or patients who experience weight recurrence. We aim to report the rate of weight recurrence/non-responders (WR/NR) in patients who underwent SG and had more than 5 years of follow-up.

METHODS

We performed a multicenter retrospective study of patients who underwent initial SG from 2008 to 2017. Patient demographics and weight loss outcomes up to 12 years after SG were collected. Surgical non-responders were defined as 20% weight regain compared to maximum weight loss. A chi-square test for categorical variables and a two-sample t-test for continuous variables were used. Data are summarized as mean ± standard deviation.

RESULTS

From a total of 1263 patients, we included 339 patients (78% female, age 47.3 ± 11.2 years; baseline weight 125.8 ± 27.6 kg) with at least 5 years of follow-up (mean follow-up of 7.1 ± 1.8 years) (Table 1). Surgical non-response was demonstrated in 15.9% of patients (n=54) and 64.0% (n=217) had weight recurrence after SG (Fig. 1). There was a statistically significant difference in history of hypertension (p=0.046) and diabetes (p=0.032) as well as %TBWL at 1 year (p=0.005) and at longest follow-up (p<0.001) between patients who experienced WR/NR and those who did not.

CONCLUSIONS

Only 20% of patients who underwent SG and followed up for more than 5 years were able to maintain appropriate weight loss.

Gastroesophageal reflux management after vertical sleeve gastrectomy

VSG is the most used surgical procedure in the world. Among the main complications linked to this procedure is GERD. It is apparent that endoscopic control protocols should be undertaken in all patients recovering from a VSG procedure. This is particularly key when taking into account the large number of patients suffering from GERD that show no symptoms, a situation that in many cases leads to severe esophagitis or even adenocarcinoma. Once the pertinent diagnostic tests have been carried out, the specialist should seek a conservative medical treatment including PPI. In the event that this treatment should fail, the next step to be considered should be a surgical procedure. In this case, the ideal procedure would be a reconversion to gastric bypass due to its low-risk and its results. There are other alternatives such as the Stretta, Linx or ARMS procedures; however, further research is necessary to prove their reliability.

Barrett's esophagus and esophageal cancer after sleeve gastrectomy. Myth or reality?

Sleeve gastrectomy has become the most performed bariatric surgery technique in the world. This bariatric technique has been related to the appearance of gastroesophageal reflux and recently with de novo Barrett's esophagus. It is not clear that this leads to an increased incidence of esophageal adenocarcinoma. In this review we analyze the current scientific literature to try to answer the true incidence of Barrett's esophagus and adenocarcinoma after sleeve gastrectomy, and whether these data should make us change the indications for this technique.

Endoscopic Follow-Up Between 3 and 7 Years After Sleeve Gastrectomy Reveals Antral Reactive Gastropathy but no Barrett's Esophagus

BACKGROUND

The main concerns following sleeve gastrectomy (SG) include the risk of gastroesophageal reflux disease (GERD) and its complications, such as Barrett's esophagus (BE). However, there is conflicting data on esophageal conditions, and studies on alterations of gastric mucosa after SG are lacking, despite reported cases of gastric cancer. Our aim was to assess esophageal and gastric lesions after SG.

METHODS

From November 2017, an upper gastrointestinal endoscopy (UGE) was proposed at least 3 years after SG to all patients operated on in our institution. Endoscopic results and gastric histological findings were analyzed. BE was defined as endoscopically suspected esophageal metaplasia with histological intestinal metaplasia.

RESULTS

Between September 2008 and August 2018, 375 patients underwent SG at our institution, of which 162 (43%) underwent at least one UGE 3 years or more after SG (91% women, mean preoperative age: 43.3±10.3 years). Despite a significant increase in the prevalence of symptomatic GERD, hiatal hernia, and esophagitis after SG (p<0.001 vs. preoperatively), no cases of BE were detected. Gastric dysplasia was not found and the prevalence of gastric atrophy tended to decrease after SG. However, 27% of patients with gastric biopsies developed antral reactive gastropathy.

CONCLUSIONS

At a mean follow-up of 54 months after SG, no BE or gastric dysplasia was identified. However, reactive gastric lesions appeared, and their long-term consequences need to be further clarified. Thus, the timing of endoscopic follow-up, starting as early as 3 years after SG should be reevaluated to improve patient adherence with long-term endoscopies.

How to address weight regain after bariatric surgery in an individualized way

Bariatric surgery is the most effective obesity treatment. As a chronic and progressive disease, weight loss response to surgery will vary individually. Thus, insufficient weight loss or regain can happen after surgery, but they lack a standard definition. There are different mechanisms underlying weight regain and/or insufficient weight loss, such as genetics, maladaptive eating behaviors, and the inadequate choice of index operations, among others. Patients with weight regain or insufficient weight loss should be submitted to an individualized and comprehensive evaluation by a multidisciplinary team. This may help identify the causes and direct the appropriate treatment individually. Options for patients with insufficient weight loss and/or weight regain following bariatric surgery include repair of postoperative complications, conversion into another operation, endoscopic therapies with inconsistent outcomes, and dietary/behavioral counseling. Revision and conversion surgeries have higher complication rates than primary operations. Although there is no standard pharmacological regimen for that indication, the new agents seem efficient and safe to promote the loss of the regained weight and even be adjunctive to selected patients before they reach the plateau. This review aims to summarize the knowledge of the best approach for patients with weight regain/insufficient weight loss and suggests an algorithm to customize the approach and therapeutic options after bariatric surgery.

Possible technical aspects involved in the development of GERD after sleeve gastrectomy: Surgical technique considerations

Sleeve gastrectomy (SG) is the most common bariatric surgery worldwide and has shown to cause de novo or worsen symptoms of gastroesophageal reflux disease (GERD). Esophageal motility and physiology studies are mandatory in bariatric and foregut centers. The predisposing factors in post-SG patients are disruption of His angle, resection of gastric fold and gastric fundus, increased gastric pressure, resection of the gastric antrum, cutting of the sling fibers and pyloric spasm. There are symptomatic complications due to sleeve morphology as torsion, incisura angularis stenosis, kinking and dilated fundus. In this article, we present recommendations, surgical technique and patient selection flow diagram for SG and avoid de novo or worsening GERD.

Gastroesophageal reflux after sleeve gastrectomy: The dimension of the problem

Sleeve gastrectomy is a safe and effective bariatric surgery in terms of weight loss and longterm improvement or resolution of comorbidities. However, its achilles heel is the possible association with the development with the novo and/or worsening of pre-existing gastroesophageal reflux disease. The anatomical and mechanical changes that this technique induces in the esophagogastric junction, support or contradict this hypothesis. Questions such as «what is the natural history of gastroesophageal reflux in the patient undergoing gastric sleeve surgery?», «how many patients after vertical gastrectomy will develop gastroesophageal reflux?» and «how many patients will worsen their previous reflux after this technique?» are intended to be addressed in the present article.

Reflux and Barrett's esophagus after sleeve gastrectomy: analysis of a statewide database

BACKGROUND

Recent studies have suggested that sleeve gastrectomy (SG) is associated with the development of Barrett esophagus (BE) even in the absence of gastroesophageal reflux disease (GERD) symptoms.

OBJECTIVE

The aim of this study was to assess the rates of upper endoscopy and incidence of new BE diagnoses in patients undergoing SG.

SETTING

This was a claims-data study of patients who underwent SG between 2012 and 2017 while enrolled in a U.S. statewide database.

METHODS

Diagnostic claims data were used to identify pre- and postoperative rates of upper endoscopy, GERD, reflux esophagitis, and BE. Time-to-event analysis using a Kaplan-Meier approach was performed to estimate the cumulative postoperative incidence of these conditions.

RESULTS

We identified 5562 patients who underwent SG between 2012 and 2017. Of these, 1972 patients (35.5%) had at least 1 diagnostic record of upper endoscopy. The preoperative incidences of a diagnosis of GERD, esophagitis, and BE were 54.9%, 14.6%, and .9%, respectively. The predicted postoperative incidences of GERD, esophagitis, and BE, respectively, were 18%, 25.4%, and 1.6% at 2 years and 32.1%, 85.0%, and 6.4% at 5 years.

CONCLUSIONS

In this large statewide database, rates of esophagogastroduodenoscopy remained low after SG, but the incidence of a new postoperative esophagitis or BE diagnosis in patients who underwent esophagogastroduodenoscopy was higher than in the general population. Patients undergoing SG may have a disproportionately high risk of developing reflux complications including BE after surgery.

Role of Preoperative High-Resolution Manometry in the Identification of Patients at High Risk of Postoperative GERD Symptoms 1 Year After Sleeve Gastrectomy

PURPOSE

Sleeve gastrectomy (SG) has become the most common bariatric procedure, but it is often characterized by the onset of postoperative gastroesophageal reflux disease (GERD). High-resolution manometry (HRM) is a useful tool to detect risk factors for GERD. The aim of this study was to evaluate preoperative manometric parameters as possible predictors of postoperative GERD.

MATERIALS AND METHODS

This was a monocentric retrospective study. We analyzed 164 patients, with preoperative esophagitis/GERD symptoms who underwent preoperative HRM and were submitted to SG (July 2020-February 2022).

RESULTS

Postoperative GERD was observed in 60 patients (36.6%): 41 of them (68%) already had preoperative GERD symptoms, whereas the remaining 19 patients (32%) developed postoperative symptoms. Female patients developed postoperative GERD in a significantly higher fraction of cases as compared to male patients (82% versus 18%; p < 0.001). DCI (distal contractile integral) was identified as the only HRM parameter correlating with the presence of GERD. Patients with DCI ≤ 1623 mmHg*cm*s developed postoperative GERD in 46% of cases (n = 43/94), as compared to 24% of cases (n = 17/70) among patients with DCI > 1623 mmHg*cm*s (p = 0.005). At multivariable analysis, female sex (OR 3.402, p = 0.002), preoperative GERD symptoms (OR 2.489, p = 0.013), and DCI ≤ 1623 mmHg*s*cm (OR 0.335, p = 0.003) were identified as independent determinants of postoperative GERD.

CONCLUSION

All the patients with preoperative risk factors for reflux, such as GERD symptoms or esophagitis on EGDS (esophagogastroduodenoscopy), should be considered for an HRM. Moreover, when a DCI ≤ 1623 mmHg*s*cm is found, a bariatric procedure different from SG might be considered.

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.

Prevalence of Gastroesophageal Reflux Symptoms Post Sleeve Gastrectomy in Al-Qassim Region

BACKGROUND AND AIMS

After sleeve gastrectomy, heartburn sensation and regurgitation are frequent postoperative consequences. This study aimed to determine the prevalence and severity of heartburn sensation and regurgitation symptoms among patients who underwent sleeve gastrectomy, as well as the relationship between demographic variables and the presence and severity of these symptoms.

METHODOLOGY

This cross-sectional study included 290 patients who underwent sleeve gastrectomy in the Al-Qassim region, Saudi Arabia. Patients were asked to complete a questionnaire that assessed the presence and severity of heartburn and regurgitation symptoms. Demographic data, including age, gender, smoking status, and the date of bariatric surgery, were also collected.

RESULTS

The results showed that heartburn and regurgitation were common symptoms among patients who underwent sleeve gastrectomy, with 78% and 73.9% of patients reporting these symptoms, respectively. 11.5% of patients who experienced severe symptoms of regurgitation, and 6.4% of patients with severe heartburn reported serious symptoms that affected their lives by causing an inability to perform daily activities. Age and the date of bariatric surgery were significant factors associated with heartburn and regurgitation symptoms. Patients aged 25-35 years reported the highest prevalence of heartburn symptoms, and the more recent surgery; dated less than one year ago had the highest prevalence of heartburn symptoms.

CONCLUSION

Patients who have sleeve gastrectomy frequently experience heartburn and regurgitation, which can have a substantial influence on their quality of life. Routine evaluation and treatment of heartburn and regurgitation symptoms should be an integral component of postoperative care. Younger patients and those who undergo surgery in the early postoperative period may be at a greater risk for developing heartburn and regurgitation symptoms, necessitating more active measures to treat these symptoms.

Case report: Laparoscopic nissen-sleeve gastrectomy in a young adult with incidental finding of Morgagni-Larrey hernia

Laparoscopic sleeve Gastrectomy (LSG) is the most performed bariatric procedure worldwide but it is associated with an increased incidence of de-novo or recurrent GERD. Recently a new technique consisting in LSG with associated fundoplication has been described. Morgagni-Larrey hernia is very rare and there is a lack of evidences on its correct surgical treatment. There are only rare cases of a MLH incidental diagnosis in patients submitted to bariatric surgery. We present our experience of Morgagni-Larrey Hernia (MLH) incidentally found intraoperatively in a patient with Gastroesophageal Reflux Disease (GERD) with Hiatal Hernia (HH) undergoing a bariatric surgical procedure.

Post-gastric Sleeve Surgery Chronic Symptoms From a Sample of Patients in Saudi Community

BACKGROUND

A common bariatric procedure known as gastric sleeve surgery can cause significant weight loss and co-morbid condition alleviation. However, patients could experience persistent problems such as gastrointestinal, musculoskeletal/neural, and psychiatric disorders after surgery. This study aims to identify the most prevalent chronic symptoms following sleeve gastrectomy among a sample of Saudi patients and the impact these symptoms have on patients' lives.

METHODOLOGY

Patients who underwent gastric sleeve surgery at the Ensan Clinic, a facility specializing in gastroenterology, were the subjects of this retrospective cohort analysis. The study population consisted of patients who underwent gastric sleeve surgery, showed up for follow-up after the procedure, and met the inclusion and exclusion criteria. The data collection sheet is divided into seven sections. Sociodemographic information was required in the first section, gastric sleeve surgery information in the second, vital signs in the third, lab results in the fourth, past medical history in the fifth, current treatments in the sixth, and postoperative complications and chronic symptoms in the seventh and final sections.

RESULTS

In 117 patients, the study evaluated the effects of gastric sleeve surgery. Participants had an average age of 40.21 years, and 61.5% were female. Regarding persistent symptoms after surgery, a sizable percentage of patients mentioned digestive issues such as GERD (44.4%), dyspepsia (60.7%), vomiting (23.1%), nausea (39.3%), and abdominal distention (45.3%). A total of 34.2% of patients reported experiencing anxiety, compared to 11.1% who said they had depression or 2.6% who said they had social issues. A few patients reported experiencing neurological or musculoskeletal issues, including exhaustion (7.7%), faintness (5.1%), back or joint discomfort (7.7%), and shortness of breath (8.5%).

CONCLUSION

After undergoing gastric sleeve surgery, a sizable proportion of patients complained of various chronic symptoms and nutritional inadequacies, primarily gastrointestinal problems and musculoskeletal/neurological issues. The study's findings show a connection between these symptoms and surgery.

Prospective clinical cohort study: low incidence of Barrett esophagus but high rate of reflux disease at 5-year follow-up after sleeve gastrectomy versus Roux-en-Y gastric bypass

BACKGROUND

Gastroesophageal reflux disease seems more frequent after laparoscopic sleeve gastrectomy (LSG) than Roux-en-Y gastric bypass (LRYGB). Retrospective case series have raised concerns about a high incidence of Barrett esophagus (BE) after LSG.

OBJECTIVE

This prospective clinical cohort study compared the incidence of BE ≥5 years after LSG and LRYGB.

SETTING

St. Clara Hospital, Basel, and University Hospital, Zürich, Switzerland.

METHODS

Patients were recruited from 2 bariatric centers where preoperative gastroscopy is standard practice and LRYGB is preferred for patients with preexisting gastroesophageal reflux disease. At follow-up ≥5 years after surgery, patients underwent gastroscopy with quadrantic biopsies from the squamocolumnar junction and metaplastic segment. Symptoms were assessed using validated questionnaires. Wireless pH measurement assessed esophageal acid exposure.

RESULTS

A total of 169 patients were included, with a median 7.0 ± 1.5 years after surgery. In the LSG group (n = 83), 3 patients had endoscopically and histologically confirmed de novo BE; in the LRYGB group (n = 86), there were 2 patients with BE, 1 de novo and 1 preexisting (de novo BE, 3.6% versus 1.2%; P = .362). At follow-up, reflux symptoms were reported more frequently by the LSG group than by the LRYGB group (51.9% versus 10.5%). Similarly, moderate-to-severe reflux esophagitis (Los Angeles grade B-D) was more common (27.7% versus 5.8%) despite greater use of proton pump inhibitors (49.4% versus 19.7%), and pathologic acid exposure was more frequent in patients who underwent LSG than in patients who underwent LRYGB.

CONCLUSIONS

After at least 5 years of follow-up, a higher incidence of reflux symptoms, reflux esophagitis, and pathologic esophageal acid exposure was found in patients who underwent LSG compared with patients who underwent LRYGB. However, the incidence of BE after LSG was low and not significantly different between the 2 groups.

Medium Term Outcomes of Revision Laparoscopic Sleeve Gastrectomy after Gastric Banding: A Propensity Score Matched Study

PURPOSE

Revision bariatric surgery may be undertaken after weight loss failure and/or complications following primary bariatric surgery. This study aims to compare the efficacy and safety of revision laparoscopic sleeve gastrectomy (RLSG) after gastric banding (GB) to those of primary laparoscopic sleeve gastrectomy (PLSG).

MATERIALS AND METHODS

A retrospective, propensity-score matched study was conducted to compare between PLSG (control) patients and RLSG after GB (treatment) patients. Patients were matched using 2:1 nearest neighbor propensity score matching without replacement. Patients were compared on weight loss outcomes and postoperative complications for up to five years.

RESULTS

144 PLSG patients were compared against 72 RLSG patients. At 36 months, PLSG patients had significantly higher mean %TWL than RLSG patients (27.4 ± 8.6 [9.3-48.9]% vs. 17.9 ± 10.2 [1.7-36.3]%, p < 0.01). At 60 months, both groups had similar mean %TWL (16.6 ± 8.1 [4.6-31.3]% vs. 16.2 ± 6.0 [8.8-22.4)]%, p > 0.05). Early functional complication rates were slightly higher with PLSG (13.9% vs. 9.7%), but late functional complication rates were comparatively higher with RLSG (50.0% vs. 37.5%). The differences were not statistically significant (p > 0.05). Both early (0.7% vs 4.2%) and late (3.5% vs 8.3%) surgical complication rates were lower in PLSG patients compared to RLSG patients but did not reach statistical significance (p > 0.05).

CONCLUSION

RLSG after GB has poorer weight loss outcomes than PLSG in the short-term. Although RLSG may carry higher risks of functional complications, the safety of RLSG and PLSG are overall comparable.

Insights into the Paradox of the Weak Association Between Sleeve Gastrectomy and Barrett's Esophagus

Sleeve gastrectomy (SG) is deemed a refluxogenic operation but with a low incidence of postoperative Barrett´s esophagus (BE). We aimed to shed some light on the potential paradox of the weak association between SG, BE and esophageal adenocarcinoma (EAC). The high incidence of GERD after SG is not followed by an increased rate of BE and EAC, as these rates are similar to the general population. We hypothesized that this paradox may occur due to a difference in the gastro-esophageal reflux composition secondary to a lower content of bile, to a decrease in inflammation due to weight loss and hormonal changes, and to acquisition of healthier habits such as exercise, smoking cessation, and better eating behavior.

Weight loss specific to indication, remission of diabetes, and short-term complications after sleeve gastrectomy conversion to Roux-en-Y gastric bypass: a systematic review and meta-analysis

Laparoscopic sleeve gastrectomy (SG) is the most frequently performed bariatric procedure worldwide. Long-term complications such as insufficient weight loss (IWL) and gastroesophageal reflux disease (GERD) may necessitate SG conversion to Roux-en-Y gastric bypass (RYGB). The aim of this review was to determine the indication-specific weight loss and diabetes remission after SG conversion to RYGB (STOBY). Our objective was to extract all available published data on indication for conversion, weight loss, remission of diabetes, and short-term complications after STOBY. A systematic literature search was conducted to identify studies reporting outcomes following STOBY. A random effects model was used for meta-analysis. The search identified 44 relevant studies. Overall short-term (12-mo) excess weight loss (EWL) was 54.6% (95% confidence interval [CI], 46%-63%) in 23 studies (n = 712) and total weight loss (TWL) was 19.9% (95% CI, 14%-25%) in 21 studies (n = 740). For IWL, short-term (12-mo) pooled weight loss outcomes were 53.9% EWL (95% CI, 48%-59%) in 14 studies (n = 295) and 22.7% TWL (95% CI, 17%-28%) in 12 studies (n = 219), and medium-term (2-5 yr) outcomes were 45.8% EWL (95% CI, 38%-53%) in 7 studies (n = 154) and 20.6% TWL (95% CI, 15%-26%) in 9 studies (n = 206). Overall diabetes remission was 53% (95% CI, 33%-72%), and the perioperative complication rate was 8.2% (95% CI, 7.6%-8.7%). Revisional SG conversion to RYGB for IWL can achieve good weight loss outcomes and diabetes remission.

No Long-Term Mucosal Lesions in the Esophagus but More Gastric Mucosal Lesions after Sleeve Gastrectomy in Obese Rats

Sleeve gastrectomy (SG) often induces gastroesophageal reflux, with few and discordant long-term data on the risk of Barrett's esophagus (BE) in operated patients. The aim of this study was to analyze the impact of SG on esogastric mucosa in a rat model at 24 weeks postoperatively, which corresponds to approximately 18 years in humans. After 3 months of a high-fat diet, obese male Wistar rats were subjected to SG (n = 7) or sham surgery (n = 9). Esophageal and gastric bile acid (BA) concentrations were measured at sacrifice, at 24 weeks postoperatively. Esophageal and gastric tissues were analyzed by routine histology. The esophageal mucosa of the SG rats (n = 6) was not significantly different in comparison to that of the sham rats (n = 8), with no esophagitis or BE. However, there was more antral and fundic foveolar hyperplasia in the mucosa of the residual stomach 24 weeks after SG than in the sham group (p < 0.001). Luminal esogastric BA concentrations did not differ between the two groups. In our study, SG induced gastric foveolar hyperplasia but no esophageal lesions at 24 weeks postoperatively in obese rats. Therefore, long-term endoscopic esophageal follow-up that is recommended in humans after SG to detect BE may also be useful for detecting gastric lesions.

Outcomes of laparoscopic revisional conversion of sleeve gastrectomy to Roux-en-Y gastric bypass: Diff erent strategies for obese and non-obese Asian patients

BACKGROUND

Sleeve gastrectomy (SG) is the most performed bariatric procedure now. Some patients would necessitate a revision to Roux-en-Y gastric bypass (RYGB) as a salvage procedure for intractable gastroesophageal reflux disease (GERD). However, outcome of the revision in Asians with co-existed obesity and those non-obese is not clear.

METHODS

We retrospectively reviewed the data of patients who underwent revisional laparoscopic RYGB after SG between 2007 and 2019 for intractable GERD with data of one year follow-up. Pre-operative clinical data, perioperative outcomes, GERD symptoms, weight loss and medication details were analyzed. Patients were classified into those with body mass index (BMI) ≥ 25 and < 25 kg/m².

RESULTS

Fifty-five patients (44 women, 11 men; mean age 42.5 years) were included. Mean interval from the initial SG to revision surgery was 51.2 months (range, 5-132). Mean body mass index before SG was 34.6 kg/m², whereas that before revision surgery was 27.6 kg/m². All the patients required continue proton pump inhibitor (PPI) to control the GERD symptoms before surgery. Among them, 36 (65.4%) patients in the obese group received long BP limb (>100 cm) RYGB for associated obesity but the common channel was assured to ≥ 400 cm or 70% of small bowel length, the other 19 (34.6%) patients in the non-obese group received standard BP limb (<100 cm) RYGB. There was no difference in basic characters between the two groups before revision surgery except a higher mean BMI (30.0 vs. 22.2 kg/m², p < 0.001), blood pressure and triglyceride in obese group. One year after revision surgery, all the patients had improved GERD symptoms but only 33 (60%) can completely wave PPI, without difference between the 2 groups. Obese group with a long BP limb RYGB had a significant higher % total weight loss (TWL) than non-obese group (%TWL 9.1% vs. -3.1%, p = 0.005).

CONCLUSION

Laparoscopic revision to RYGB is a safe and effective treatment for patients with intractable GERD after SG but some patients may still have residual GERD symptoms. Using a modified RYGB technique in revision surgery may help in weight reduction for obese Asian patients.

Foregut Malignancy After Metabolic Surgery: a Literature Review

Obesity is known to be epidemiologically associated with malignancy. Although there is an increasing global number of bariatric surgeries, the relationship between bariatric surgery and esophagogastric cancers is not well understood. Diagnosis of esophagogastric cancers following bariatric surgery is challenging because the presentation tends to be nonspecific and may be perceived as usual postoperative symptoms in bariatric patients. Therefore, the early diagnosis requires a high index of suspicion. In addition, endoscopic investigation of the excluded stomach after a Roux-en-Y gastric bypass or a one-anastomosis gastric bypass is technically challenging, which further complicates the diagnosis. The aim of this study is to review the current evidence in the literature on esophagogastric cancers following bariatric surgery.

The Effects of the Staple Line Reinforcement Procedures on Gastrointestinal Symptoms and Its Early Results in Sleeve Gastrectomy

Background: The laparoscopic sleeve gastrectomy (LSG) procedure is the most common bariatric surgical technique worldwide, but controversy continues over staple line reinforcement (SLR) techniques. This prospective randomized study aimed to compare the effects of SLR methods on early postoperative complications and gastrointestinal symptoms in patients undergoing LSG for morbid obesity. Materials and Methods: Ninety patients who underwent LSG surgery for obesity between June 2019 and February 2020 in the Department of General Surgery of Bezmialem Vakıf University were included in our prospective randomized study. According to the SLR techniques, three groups were determined as Group 1: using fibrin sealant (Tisseel^®), Group 2: omentopexy, Group 3: no SLR, with each group having 30 randomly assigned patients. Gastrointestinal symptoms were assessed by performing the Gastrointestinal Symptom Rating Scale (GSRS) for all patients following the first week and first month. On the second postoperative day, all patients underwent swallow-graphy to investigate twists and fistula. Results: The test group included 90 patients totally, of which 17 are males and 73 are females with a mean age of 35.3 ± 11.6 years and a mean body mass index of 45.3 ± 7.7 kg/m². According to the GSRS, reflux and indigestion scores in Group 3 were significantly higher than those in the other groups in the first week (P < .001). There was no statistically significant difference in abdominal pain scores in the first week. Group 3's operation time was statistically significantly shorter than the other groups (Group 1 P = .005; Group 2 P = .001). In Group 3, 2 patients (2.2%) had bleeding. There was no mortality. There were no twists or fistulas found in swallow graphs. Symptomatic reflux was not observed in the first-year follow-up period. Conclusions: SLR methods reduce gastrointestinal system complaints in the early postoperative period. In our study, omentopexy and fibrin sealant used in LSG did not show a statistically significant difference in early postoperative complications.

Gastric Bypass Versus Sleeve Gastrectomy: Comparison of Patient Outcomes, Satisfaction, and Quality of Life in a Single-Center Experience

Background: Laparoscopic sleeve gastrectomy (LSG) is the most common primary bariatric operation performed in the United States. Its relative technical ease, combined with a decreased risk for anatomic and malabsorptive complications make LSG an attractive option compared to laparoscopic gastric bypass (LGB) for many patients and surgeons. However, emerging evidence for progressive gastroesophageal reflux disease (GERD) after LSG, and the inferior weight loss in many studies, suggests that the enthusiasm for LSG requires reassessment. We hypothesized that patient satisfaction and quality of life (QoL) may be lower after LSG compared to LGB because of these differences. Methods: We distributed a survey querying weight-loss outcomes, complications, foregut symptoms, QoL, and overall satisfaction to patients who underwent bariatric operations at our institution between 2000 and 2020 and who had electronic mail contact information available. Mean follow-up was 2.75 ± 2.41 years for LGB patients and 3.37 ± 2.18 (P = .021) years for LSG patients. We compared these groups for weight-loss outcomes, changes in foregut symptoms, gastrointestinal QoL, postbariatric QoL, and overall satisfaction using appropriate statistical tests. Results: Among 323 respondents, 126 underwent LGB and 197 underwent LSG. LGB patients had larger body mass index (BMI) reduction than LSG patients (-17.16 ± 9.07 kg/m² versus -14.87 ± 7.4 kg/m², P = .023). LGB patients reported less reflux (P = .003), with decreased heartburn (P < .0001) and regurgitation (P = .0027). However, a greater proportion of LGB patients reported at least one complication (P = .025). Despite this, more LGB patients reported satisfaction (92.86%) than LSG patients (73.6%). Conclusion: LGB patients are significantly more likely to be satisfied than LSG patients. Factors contributing to the higher level of satisfaction include less GERD and better BMI decrease.

A case-control comparative study between Toupet-Sleeve and conventional sleeve gastrectomy in patients with preoperative gastroesophageal reflux

INTRODUCTION

The aim of that study was to compare outcomes after Toupet-Sleeve (T-Sleeve) and sleeve gastrectomy (SG) as primary bariatric procedures in obese patients presenting with preoperative gastro-esophageal reflux disease (GERD).

MATERIAL AND METHODS

The outcomes of 19 consecutive patients operated between 2017 and 2019 by T-Sleeve were compared to the outcomes of 38 patients operated in 2014 by SG. The two groups were matched by age, sex, ASA classification, BMI, food habits and severity of esophagitis. Postoperative weight loss and evolution of GERD symptoms were the study end-points.

RESULTS

The preoperative BMI was 43 ± 5 in the T-Sleeve and 42 ± 5 in the SG group (NS). All the procedures were completed by laparoscopy. The operative time was higher in the T-Sleeve group: 89 ± 18 vs. 68 ± 12 min. (p < 0.001). A lower weight loss was observed in the T-Sleeve group. Respectively 1 and 2 years after surgery, the mean BMI were: 32 ± 6 and 34 ± 6 in the T-Sleeve vs. 28 ± 5 (p < 0.006) and 30 ± 6 (p < 0.05) in the SG group and the mean %EWL were: 61 ± 23 and 54 ± 26% in the T-Sleeve vs. 86 ± 25 (p < 0.002) and 75 ± 28% (p < 0.03) in the SG group. Better control of GERD was noted in the T-Sleeve group: the number of patients with complete resolution of GERD symptoms was 17 (89%) vs. 13 (34%) in the SG group (p < 0.001).

CONCLUSION

T-Sleeve was an effective procedure for GERD treatment but, the weight loss was significantly much lower than after conventional SG. Studies with longer follow-up are mandatory to validate the T-Sleeve procedure.