Predictive value of preoperative DeMeester score on conversion to Roux-en-Y gastric bypass for gastroeosophageal reflux disease after sleeve gastrectomy

Results of sleeve gastrectomy conversion to Roux-en-Y gastric bypass on gastroesophageal reflux disease symptoms and proton pump inhibitors use evolution over time

BACKGROUND

Although sleeve gastrectomy (SG) is associated with excellent results in the short term, it has been shown that it is plagued by weight regain and new onset or worsening of gastroesophageal reflux disease (GERD). These 2 clinical conditions are currently the 2 most frequent indications for revisional surgery. To date, only a few studies have focused exclusively on GERD. In a selected series of patients complaining of GERD symptoms after SG as a main complaint, we analyzed the efficacy of conversion to Roux-en-Y gastric bypass (RYGB), with a standardized surgical technique.

METHODS

This is a retrospective study including all consecutive cases of SG to RYGB conversion for GERD not controlled by medical treatment. We excluded all patients undergoing conversion for weight regain without GERD. Quality of life and GERD symptoms were evaluated at outpatient's clinic visits before and after surgery with 2 standardized questionnaires (Gastroesophageal Reflux Disease Questionnaire and Simplified Form 6).

RESULTS

This study showed that 70% of patients had complete resolution of GERD symptoms and 60% had completely discontinued proton pump inhibitors (PPIs). The conversion to RYGB resulted in a significant decrease in the rate of patients presenting daily symptoms of GERD and use of PPIs (10% and 16.6%, respectively; P < .019) and a dramatic increase in those without symptoms and no need for PPIs (70% and 60%, respectively; P < .001).

CONCLUSION

Conversion to RYGB is a good option for GERD complications after SG providing a high rate of symptom remission and PPI discontinuation. Conversion to RYGB in the setting of GERD complications after SG improves postoperative outcomes decreasing GERD symptoms and improving quality of life.

Conversion of Sleeve Gastrectomy to Roux-en-Y Gastric Bypass: Is Intrathoracic Migration of the Sleeve of High Incidence?

BACKGROUND

Conversion of SG to Roux-en-Y gastric bypass (RYGB) is increasing. Intrathoracic migration of the sleeve (ITM) often seems associated and is increasingly reported.

MATERIAL AND METHODS

Patients who underwent a conversion of SG to RYGB from August 2013 to December 2022 were included. Two groups were compared: patients operated on for weight loss failure (WLF gp) and those operated on for gastroesophageal reflux disease (GERD gp). Demographic data, the incidence of ITM, weight loss outcomes, resolution of symptoms, and morbidity were analyzed.

RESULTS

Fifty-nine patients were included with an average follow-up of 32 months: 46 patients in the GERD gp (78%) were compared to 13 patients (22%) in the WLF gp. Groups were comparable regarding age and gender, but BMI and commodities were significantly higher in the WLF gp. In the GERD gp, on preoperative gastroscopy, 30% had a esophagitis, 48% had an ITM which required a posterior crural closure versus no esophagitis (p=0.02) and 23% of ITM in the WLF gp (p=0.11). Conversion led to 93% of GERD symptom improvement. In the WLF gp, mean TWL% was 15.3%, significantly greater than in the GERD gp (TWL% = 4.6%, p = 0.01). The complication rate was 10% at 30 days and 3.4% after 30 days, not significantly different between groups.

CONCLUSION

The main indication of conversion of SG to RYGB was because of GERD: in these indications, the incidence of ITM was high requiring a surgical treatment with a very good efficacy on symptoms. Weight loss results were disappointing.

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

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

Impact on sleeve gastrectomy in patients with esophageal motor disorder

BACKGROUND

Gastroesophageal reflux disease (GERD) and esophageal motor disorders (EMD) are frequent conditions among patients with obesity. The effects of sleeve gastrectomy (SG) on esophageal function can worsen GERD, but little is known about its effects on EMD and the consequences of preexisting EMD on GERD after SG.

OBJECTIVES

To study the postoperative outcomes of SG in a population of patients displaying preexisting EMD.

SETTING

University Hospital, France.

METHODS

Patients with EMD confirmed by high-resolution manometry who underwent a laparoscopic SG between 2010 and 2019 were retrospectively included in this monocenter study. GERD symptoms and high-resolution manometry results were recorded before surgery and during follow-up. Conversion to gastric bypass were also recorded.

RESULTS

Thirty-seven patients were included. Mean age was 52.6 ± 12.9 years. Most patients were female (70%). EMD were achalasia (19% of patients), hypercontractile (22%), hypocontractile (30%) and nutcracker esophagus (22%), and ineffective esophageal motility (8%). GERD symptoms were present in 10 patients (27%) preoperatively and 18 (49%) postoperatively. Achalasia was not resolved after SG and was constantly associated with disabling food blockage or GERD symptoms after surgery, and 3 of 4 patients with nutcracker esophagus had postoperative GERD symptoms and underwent gastric bypass.

CONCLUSIONS

This study is the largest to describe the course of GERD and EMD after SG in patients displaying preoperative EMD. Achalasia and nutcracker esophagus are associated with poorer postoperative outcomes, and another procedure such as a gastric bypass should be performed.