Do we understand the pathophysiology of GERD after sleeve gastrectomy?

Significant and distinct impacts of sleeve gastrectomy and Roux-en-Y gastric bypass on esophageal acid exposure, esophageal motility, and endoscopic findings: a systematic review and meta-analysis

BACKGROUND

The lack of standardized objective assessment of esophageal physiology and anatomy contributes to controversies regarding the effects of sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) on gastroesophageal reflux disease. This study aimed to investigate esophageal acid exposure, esophageal motility, and endoscopic findings before and after SG and RYGB.

METHODS

This was a systematic review and meta-analysis of studies reporting at least 1 objective measure of esophageal physiology and/or esophagogastroduodenoscopy (EGD) at baseline and after SG or RYGB. The changes in pH test, manometry, and EGD parameters were summarized.

RESULTS

Acid exposure time (AET) and DeMeester score (DMS) significantly increased after SG (mean difference [MD]: 2.1 [95% CI, 0.3-3.9] and 8.6 [95% CI, 2.0-15.2], respectively). After RYGB, both AET and DMS significantly decreased (MD: -4.2 [95% CI, -6.1 to -2.3] and -16.6 [95% CI, -25.4 to -7.8], respectively). Lower esophageal sphincter resting pressure and length significantly decreased after SG (MD: -2.8 [95% CI, -4.6 to -1.1] and -0.1 [95% CI, -0.2 to -0.02], respectively). There were no significant changes in esophageal manometry after RYGB. The relative risks of erosive esophagitis were 2.3 (95% CI, 1.5-3.5) after SG and 0.4 (95% CI, 0.2-0.8) after RYGB. The prevalence rates of Barrett esophagus changed from 0% to 3.6% after SG and from 2.7% to 1.4% after RYGB.

CONCLUSION

SG resulted in the worsening of all objective parameters, whereas RYGB resulted in the improvement in AET, DMS, and EGD findings. Determining the risk factors associated with these outcomes can help in surgical choice.

Gut motility and hormone changes after bariatric procedures

PURPOSE OF REVIEW

Metabolic and bariatric surgery (MBS) and endoscopic bariatric therapies (EBT) are being increasingly utilized for the management of obesity. They work through multiple mechanisms, including restriction, malabsorption, and changes in the gastrointestinal hormonal and motility.

RECENT FINDINGS

Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) cause decrease in leptin, increase in GLP-1 and PYY, and variable changes in ghrelin (generally thought to decrease). RYGB and LSG lead to rapid gastric emptying, increase in small bowel motility, and possible decrease in colonic motility. Endoscopic sleeve gastroplasty (ESG) causes decrease in leptin and increase in GLP-1, ghrelin, and PYY; and delayed gastric motility.

SUMMARY

Understanding mechanisms of action for MBS and EBT is critical for optimal care of patients and will help in further refinement of these interventions.

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.

Challenges of Revisional Metabolic and Bariatric Surgery: A Comprehensive Guide to Unraveling the Complexities and Solutions of Revisional Bariatric Procedures

Revisional metabolic and bariatric surgery (RMBS) presents unique challenges in addressing weight loss failure or complications arising from initial bariatric procedures. This review aims to explore the complexities and solutions associated with revisional bariatric procedures comprehensively, offering insights into the evolving terrain of metabolic and bariatric surgery. A literature review is conducted to identify pertinent studies and expert opinions regarding RMBS. Methodological approaches, patient selection criteria, surgical techniques, preoperative assessments, and postoperative management strategies are synthesized to provide a comprehensive overview of current practices and advancements in the field, including institutional protocols. This review synthesizes key findings regarding the challenges encountered in RMBS, including the underlying causes of primary procedure failure, anatomical complexities, technical considerations, and assessments of surgical outcomes. Additionally, patient outcomes, complication rates, and long-term success are presented, along with institutional approaches to patient assessment and procedure selection. This review provides valuable insights for clinicians grappling with the complexities of RMBS. A comprehensive understanding of patient selection, surgical techniques, preoperative management, and postoperative care is crucial for enhancing outcomes and ensuring patient satisfaction in the field of metabolic bariatric surgery.

GERD after Bariatric Surgery: A Review of the Underlying Causes and Recommendations for Management

PURPOSE OF REVIEW

GERD after bariatric surgery is an ongoing concern for bariatric surgeons and their patients. This paper reviews the association of persistent or de novo GERD after multiple types of bariatric surgery, and focuses on the work up and management of GERD after SG.

RECENT FINDINGS

Two recent large, multicenter randomized clinical trials have shown stronger associations between SG and GERD compared to RYGB. A large group of internationally recognized bariatric surgeons collaborated on 72 consensus statements to help guide the bariatric community on the subject of redo surgeries after SG, including as it pertains to GERD. We present an algorithm that consolidates the best-practices recommendations of the work-up and management of GERD after sleeve gastrectomy, and mention areas of persistent controversy where future research is warranted.

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.

Reflux Symptoms Increase Following Sleeve Gastrectomy Despite Triage of Symptomatic Patients to Roux-en-Y Gastric Bypass

BACKGROUND AND AIMS

Bariatric surgical options in obese patients include sleeve gastrectomy (SG) and roux-en-Y gastric bypass (RYGB), which may not be equivalent in risk of postoperative reflux symptoms. We evaluated risk and predictive factors for postbariatric surgery reflux symptoms.

METHODS

Patients with obesity evaluated for bariatric surgery over a 15-month period were prospectively followed with validated symptom questionnaires (GERDQ, dominant symptom index: product of symptom frequency and intensity from 5-point Likert scores) administered before and after SG and RYGB. Esophageal testing included high-resolution manometry in all patients, and ambulatory reflux monitoring off therapy in those with abnormal GERDQ or prior reflux history. Univariate comparisons and multivariable analysis were performed to determine if preoperative factors predicted postoperative reflux symptoms.

RESULTS

Sixty-four patients (median age 49.0 years, 84% female, median BMI 46.5 kg/m 2 ) fulfilled inclusion criteria and underwent follow-up assessment 4.4 years after bariatric surgery. Baseline GERDQ and dominant symptom index for heartburn were significantly higher in RYGB patients ( P ≤0.04). Despite this, median GERDQ increased by 2 (0.0 to 4.8) following SG and decreased by 0.5 (-1.0 to 5.0) following RYGB ( P =0.02). GERDQ became abnormal in 43.8% after SG and 18.8% after RYGB ( P =0.058); abnormal GERDQ improved in 12.5% and 37.5%, respectively ( P =0.041). In a model that included age, gender, BMI, acid exposure time, and type of surgery, multivariable analysis identified SG as an independent predictor of postoperative heartburn (odds ratio 16.61, P =0.024).

CONCLUSIONS

Despite preferential RYGB when preoperative GERD was identified, SG independently predicted worsening heartburn symptoms after bariatric surgery.

Does One-Anastomosis Gastric Bypass Expose Patients to Gastroesophageal Reflux: a Systematic Review and Meta-analysis

This systematic review and meta-analysis aimed to investigate the incidence of new-onset gastroesophageal reflux, reflux change, esophagitis, Barrett's esophagus, and revision due to reflux, gastritis, and marginal ulcer after one-anastomosis gastric bypass (OAGB). We performed subgroup analyses based on primary and revisional OAGB and time of follow-up. Meta-analysis of 87 studies with 27,775 patients showed a 6% rate of new-onset reflux after OAGB. Preoperative reflux status did not change significantly after OAGB. The rate of esophagitis and Barrett's esophagus was 15% and 1%, respectively. The new-onset reflux rate after OAGB was significantly higher than gastric bypass but not different with sleeve gastrectomy. The current study showed a relatively low rate of reflux and its complications after OAGB, but it was significantly higher than Roux-en-Y gastric bypass.

The Role of Endoscopy in the Management of Adolescent Bariatric Patients: A Primer For Pediatric Gastroenterologists

PURPOSE OF REVIEW

The prevalence of childhood and adolescent obesity in the United States has reached alarming levels, necessitating effective interventions such as bariatric surgery. This article reviews the current state of bariatric surgery in the adolescent population, highlighting the common complications encountered in post-bariatric patients. Furthermore, it outlines the pivotal role of endoscopy in both the prevention and management of these bariatric complications.

RECENT FINDINGS

Though only a minority of eligible adolescent patients undergo bariatric surgery the number of cases continues to increase. Sleeve gastrectomy has emerged as the preferred type of surgery, with the best balance of safety and efficacy. However, only a small number of pediatric surgeons have additional bariatric training and a number of technical aspects of the surgery itself impact the risk for post-surgical complications. Gastric sleeve stenosis, anastomotic leaks and gastroesophageal reflux are the most common of these complications. Ability to perform dilation of sleeve stenosis, closure of anastomotic leaks and evaluation of reflux are critical tools in the endoscopic toolbox necessary for the management of these complicated patients. Bariatric surgery remains the most effective treatment available for management of morbid obesity in adolescents but has significant associated complications. Pediatric gastroenterologists must be familiar in the endoscopic management of these complications and are crucial in creating a high functioning adolescent bariatric program.

Long-term impact of gastropexy on use of acid-reducing medication, second operations for gastroesophageal reflux and subjective reflux symptoms after sleeve gastrectomy

We investigated whether adding gastropexy to sleeve gastrectomy (SG) reduced gastroesophageal reflux disease (GERD) in patients operated for severe obesity, assessed mainly by use of anti-reflux medication (ARM) and second operations due to GERD worsening. In a prospective non-randomized study, patients undergoing SG at two Norwegian hospitals were included from 2011 to 2015 and followed for 7 years. GERD was defined by regular use of ARM, and epigastric pain and heartburn were measured by the Rome II questionnaire. Gastropexy was done by suturing the gastrocolic ligament to the staple line. Patients undergoing SG only, mainly before gastropexia was introduced in 2013, were compared to those with additional gastropexy from 2013 onwards. Of 376 included patients (75% females, mean age 42.6 years and BMI 42.9 kg/m2 ), 350 (93%) and 232 (62%) were available for evaluation after 1 and 7 years, respectively. Baseline characteristics in the no-gastropexy (n = 235) and gastropexy groups (n = 141) were similar. In patients without ARM use before surgery, the use increased and in those that used ARM at baseline, the proportion decreased, with no difference in the no-gastropexy and gastropexy groups. With a combined endpoint of ARM use and/or second operation for GERD, there was no difference during follow-up between the two groups. With time, adding gastropexy did not reduce symptoms of GERD significantly. In this population, adding gastropexy to SG did not reduce use of ARM and/or second operation for uncontrolled GERD, epigastric pain or heartburn during the first 7 postoperative years.

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.

Risk of Malnutrition in Adults Who Have Undergone Sleeve Gastrectomy: A Retrospective Study

Sleeve gastrectomy achieves long-term weight control by reducing gastric volume. However, postoperative gastrointestinal symptoms and insufficient nutritional intake are likely to occur, which are not conducive to physical health. A retrospective study aimed to investigate changes in nutritional status and associated factors in patients after sleeve gastrectomy. Data were collected from the medical records of patients who underwent sleeve gastrectomy at a teaching hospital in Taiwan. Data from 120 patients who met the eligibility criteria were included in the analysis. The results show that sleeve gastrectomy has a strong weight loss effect. Within 12 months, the average body mass index of the patients decreased by 13.47 kg/m2. The number of morbidly obese patients decreased from 62 (51.7%) to 3 (2.5%). However, surgery is also associated with gastrointestinal symptoms and the threat of malnutrition. The number of patients with moderate to severe nutritional risk increased from 4 (3.3%) before surgery to 24 (20%) at 12-month follow-up. Likewise, the number of patients with anemia increased from 11 (9.2%) to 29 (24.17%). Gender, constipation, and diarrhea affected postoperative nutritional status. These findings suggest that patients after sleeve gastrectomy are at risk of malnutrition and require regular monitoring. Special attention should be given to women and patients with constipation or diarrhea, as they are at a particularly high risk of malnutrition.

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.

GERD as a Complication of Laparoscopic Sleeve Gastrectomy for the Treatment of Obesity: A Systematic Review and Meta-Analysis

INTRODUCTION

The incidence of obesity is increasing in developed societies, and surgical treatment is one treatment option. The most common surgical treatment for obesity is laparoscopic sleeve gastrectomy (LSG). Gastroesophageal reflux disease (GERD) is a complication of both obesity and the surgical treatment of obesity.

MATERIALS AND METHODS

In this study, the PubMed database was searched using the keywords "GERD" and "bariatric surgery", and 987 papers published between 1 July 2017 and 30 June 2022 were retrieved.

RESULTS

Nine papers met the inclusion criteria and were included in the meta-analysis. The articles were analyzed for the de novo occurrence of GERD after the treatment of its symptoms, the occurrence of erosive esophagitis, and Barrett's esophagus. In addition, interesting conclusions are presented from the papers that did not meet the inclusion criteria but shed light on the pathophysiology of GERD in obese patients undergoing LSG.

CONCLUSION

In conclusion, the authors draw attention to the need for endoscopic surveillance in patients undergoing LSG, even in the absence of clinical signs of GERD.

Preoperative esophageal testing predicts postoperative reflux status in sleeve gastrectomy patients

BACKGROUND

Patients who undergo vertical sleeve gastrectomy (VSG) are at risk of postoperative GERD. The reasons are multifactorial, but half of conversions to Roux-en Y gastric bypass are for intractable GERD. Our institution routinely performs preoperative pH and high-resolution manometry studies to aid in operative decision making. We hypothesize that abnormal pH studies in concert with ineffective esophageal motility would lead to higher rates of postoperative reflux after VSG.

METHODS

A single institution retrospective review was conducted of adult patients who underwent preoperative pH and manometry testing and VSG between 2015 and 2021. Patients filled out a symptom questionnaire at the time of testing. Postoperative reflux was defined by patient-reported symptoms at 1-year follow-up. Univariate logistic regression was used to examine the relationship between esophageal tests and postoperative reflux. The Lui method was used to determine the cutpoint for pH and manometric variables maximizing sensitivity and specificity for postoperative reflux.

RESULTS

Of 291 patients who underwent VSG, 66 (22.7%) had a named motility disorder and 67 (23%) had an abnormal DeMeester score. Preoperatively, reflux was reported by 122 patients (41.9%), of those, 69 (56.6%) had resolution. Preoperative pH and manometric abnormalities, and BMI reduction did not predict postoperative reflux status (p = ns). In a subgroup analysis of patients with an abnormal preoperative pH study, the Lui cutpoint to predict postoperative reflux was a DeMeester greater than 24.8. Postoperative reflux symptoms rates above and below this point were 41.9% versus 17.1%, respectively (p = 0.03).

CONCLUSION

While manometry abnormalities did not predict postoperative reflux symptoms, GERD burden did. Patients with a mildly elevated DeMeester score had a low risk of postoperative reflux compared to patients with a more abnormal DeMeester score. A preoperative pH study may help guide operative decision-making and lead to better counseling of patients of their risk for reflux after VSG.

Quantifying physiologic parameters of the gastroesophageal junction during robotic sleeve gastrectomy and identifying predictors of post-sleeve gastroesophageal reflux disease

BACKGROUND

Sleeve gastrectomy is among the most commonly-performed procedures for morbid obesity. However, patients occasionally develop post-sleeve gastroesophageal reflux disease (GERD). Identifying patients most at risk for this complication remains difficult. We aimed to correlate intra-operative physiologic measurements of the lower esophageal sphincter (LES) at the gastroesophageal junction (GEJ) during robotic sleeve gastrectomy in an attempt to identify predictors of post-sleeve GERD symptoms.

METHODS

A retrospective chart review of a prospectively maintained database identified 28 patients in whom robotic sleeve gastrectomy was performed utilizing EndoFLIP™ technology between January and September 2021. Intraoperative LES measurements at the GEJ including cross-sectional area (CSA), distensibility index (DI), intra-balloon pressure, and high-pressure zone (HPZ length) were correlated with post-operative GERD.

RESULTS

GEJ CSA, pressure, and DI increased over the course of the surgery (CSA pre-op: 31 (IQR 19.3-39.5) mm² vs. post-op: 67 (IQR 40.8-95.8) mm², p < 0.001; pressure: 25.8 (IQR 20.2-33.1) mmHg vs. 31.5 (IQR 28.9-37.0) mmHg, p = 0.007; DI 1.1 (IQR 0.8-1.8) mm²/mmHg vs. 2.0 (IQR 1.2-3.0) mm²/mmHg, p =  < 0.001), whereas HPZ length decreased (2.5 (IQR 2.5-3) cm vs. 2.0 (IQR 1.3-2.5) cm, p = 0.022). Twenty-three patients (82.1%) completed a post-operative GERD questionnaire. Fifteen (65.2%) had no GERD symptoms before or after surgery; 5 (21.7%) reported new post-sleeve GERD symptoms; 3 (13.0%) reported exacerbation of pre-existing GERD symptoms. Patients with new or worsening GERD symptoms had higher post-sleeve DIs (3.2 (IQR 1.9-4.5) mm²/mmHg vs. 1.5 (IQR 1.2-2.4) mm²/mmHg, p = 0.024) and lower post-sleeve LES pressures (29.9 (IQR 26.3-32.9) mmHg vs. 35.2 (IQR 31.0-38.0) mmHg, p = 0.023) than those without.

CONCLUSIONS

An increase in GEJ CSA, pressure, and DI, and a decrease in GEJ length can be expected during robotic sleeve gastrectomy. Patients with new or worsening post-sleeve GERD symptoms have higher post-sleeve DI and lower post-sleeve LES pressure than their asymptomatic counterparts.

Sleeve gastrectomy morphology and long-term weight-loss and gastroesophageal reflux disease outcomes

BACKGROUND

The relationship between sleeve gastrectomy (SG) morphology and long-term weight-loss and gastroesophageal reflux disease (GERD) outcomes is unknown.

METHODS

All patients (n = 268) undergoing SG performed by 3 surgeons at a single academic institution from January 1, 2010 to December 31, 2012 were included. Long-term weight-loss and GERD outcomes were available for 90 patients which were incorporated in analyses. SG morphology was determined from postoperative day 1 upper gastrointestinal series (UGIS) available from 50 patients. Images were independently categorized using previously published methodology as Dumbbell (38%), Lower Pouch (22%), Tubular (26%), or Upper Pouch (14%) by Radiologist and Surgeon. Radiologist categorization was used when disagreement occurred (8%). Univariable analyses were conducted to explore potential associations between SG morphology, weight loss, and GERD outcomes.

RESULTS

Follow-up was 8.2 ± 0.9 years. Population characteristics included age of 45.1 ± 10.8 years, female sex in 83.3%, and hiatal hernia repair (HHR) performed at index SG in 17.8%. Surgeons did not preferentially achieve a specific SG morphology. Changes from preoperative obesity and associated diseases comprised body mass index (BMI) (49.5 ± 7.6 vs. 39.2 ± 9.4 kg/m²; p < 0.0001), diabetes mellitus (30.0 vs. 12.2%; p = 0.0006), hypertension (70.0 vs. 54.4%; p = 0.0028), hyperlipidemia (42.2 vs. 24.2%;p = 0.0017), obstructive sleep apnea (41.1 vs. 15.6%; p < 0.0001), osteoarthritis (48.9 vs. 13.3%; p < 0.0001), back pain (46.5 vs. 28.9%; p = 0.0035), and medications (4.8 ± 3.3 vs. 3.7 ± 3.5; p < 0.0001). Dumbbell SG morphology was associated with lesser reduction in BMI at follow-up (--6.8 ± 7.2 vs. -12.4 ± 8.3 kg/m²; p = 0.0196) while greater BMI change was appreciated with Lower Pouch SG shape (-16.9 ± 9.9 vs. -8.4 ± 6.8 kg/m²; p = 0.0017). GERD was more prevalent at follow-up than baseline (67.8 vs. 47.8%; p < 0.0001). GERD-specific outcomes included de novo (51.1%), persistent (27.9%), worsened (58.1%), and resolved (14.0%) disease. Ten patients underwent reoperation for refractory GERD with SG morphology corresponding to Dumbbell (n = 5) and Upper Pouch (n = 1) for those with available UGIS. Univariable analyses showed that patients with GERD experienced a larger reduction in BMI compared with patients without GERD (-11.8 ± 7.7 vs. -7.0 ± 5.1 kg/m²; p = 0.0007). Patient age, surgeon, morphology category, and whether a HHR was done at index SG were not associated with the presence of any, de novo, or worsened GERD. Female sex was associated with worsened GERD (96.0 vs. 4.0%; p = 0.0455). Type of calibration device, distance from staple line to pylorus, and whether staple line reinforcement was used were not associated with SG morphology classification.

CONCLUSION

This is the first study assessing the impact of SG morphology on long-term weight loss and GERD. Our data suggest an association between SG morphology and long-term weight loss but not with GERD outcomes. Current technical standards may be limited in reproducing the same SG morphology. This information may help guide the technical optimization and standardization of SG. Surgeons did not favor a specific SG morphology (1). Our results signal to a relationship between radiographic assessment of SG morphology and long-term weight-loss outcomes with Dumbbell classification correlated with lesser reduction in BMI (2a) and Lower Pouch morphology associated with superior weight loss (2b). SG, sleeve gastrectomy; BMI, body mass index.

Feasibility and Efficacy of Magnetic Sphincter Augmentation for the Management of Gastroesophageal Reflux Disease Post-Sleeve Gastrectomy for Obesity

BACKGROUND

Patients with medically intractable GERD after laparoscopic sleeve gastrectomy (LSG) have limited surgical options. Fundoplication is difficult post-LSG. Roux-en-Y gastric bypass may be used as a conversion procedure but is more invasive with potential for serious complications. Magnetic sphincter augmentation (MSA) is a less invasive GERD treatment alternative. The objective of this study was to assess safety and efficacy outcomes of MSA after LSG.

METHODS

The primary outcome of this observational, multicenter, single-arm prospective study was the rate of serious device and/or procedure-related adverse events (AEs). The efficacy of the LINX device was measured comparing baseline to 12-month post-implant reductions in distal acid exposure, GERD-HRQL score, and average daily PPI usage.

RESULTS

Thirty subjects who underwent MSA implantation were followed 12 months post-implant. No unanticipated adverse device effects were observed. There were two adverse events deemed serious (dysphagia, pain, 6.7%) which resolved without sequelae. GERD-HRQL scores showed significant improvement (80.8%, P < 0.001), and reduction in daily PPI usage was seen (95.8%, P < 0.001). Forty-four percent of subjects demonstrated normalization or >  = 50% reduction of total distal acid exposure time (baseline 16.2%, 12 months 11%; P = 0.038).

CONCLUSIONS

Post-LSG, MSA showed an overall improvement of GERD symptoms, and reduction in PPI use with explants within anticipated range along with improvement in distal esophageal acid exposure time.

Long-term (11 + years) efficacy of sleeve gastrectomy as a stand-alone bariatric procedure: a single-center retrospective observational study

INTRODUCTION

Sleeve gastrectomy (SG) is currently the most commonly performed bariatric procedure worldwide. The aim of the present study was to evaluate the long-term efficacy of SG as a stand-alone bariatric procedure.

METHODS

A single-center retrospective analysis of 104 patients who underwent SG as a stand-alone bariatric procedure between January 2005 and December 2009. Weight loss, weight regain, remission or improvement of comorbidities and the new onset of comorbidities were the main outcomes of the study.

RESULTS

The percent excess body weight loss (%EBWL), percent excess body mass weight (BMI) loss (%EBMIL), and percent total body weight loss (%TBWL) were 59 ± 25, 69 ± 29, and 29 ± 12, respectively, after a mean follow-up of 13.4 years. At the last follow-up, nearly two thirds of patients (67.3%) had an %EBWL greater than 50. The percentage of patients who experienced significant weight regain ranged from 47 to 64%, depending on the definition used for weight regain. The rate of improvement or remission of hypertension, type 2 diabetes, dyslipidemia, obstructive sleep apnea, and degenerative joint disease at a mean follow-up of 13.4 years was 40%, 94.7%, 70%, 100%, and 42.9%, respectively. The new onset of gastroesophageal reflux disease (GERD) symptoms in the same period was 43%.

CONCLUSION

Our data supports that SG results in long-lasting weight loss in the majority of patients and acceptable rates of remission or improvement of comorbidities. Weight regain and GERD may be issues of particular concern during long-term follow-up after SG.

Impact of concurrent hiatal hernia repair during laparoscopic sleeve gastrectomy on patient-reported gastroesophageal reflux symptoms: a state-wide analysis

BACKGROUND

Concurrent hiatal hernia repair (HHR) during laparoscopic sleeve gastrectomy (LSG) may improve gastroesophageal reflux disease (GERD) symptoms. However, patient-reported outcomes are limited, and the influence of surgeon technique remains unclear.

OBJECTIVES

To assess patient-reported GERD severity before and after LSG with and without concomitant HHR.

SETTING

Teaching and non-teaching hospitals participating in a state-wide quality improvement collaborative.

METHODS

Using a state-wide bariatric-specific data registry, all patients who underwent a primary LSG between 2015 and 2019 who completed a baseline and 1 year validated GERD health related quality of life (GERD-HRQL) survey were identified (n = 11,742). GERD severity at 1 year as well as 30-day risk-adjusted adverse events was compared between patients who underwent LSG with or without HHR. Results were also stratified by anterior versus posterior HHR.

RESULTS

A total of 4015 patients underwent a LSG-HHR (34%). Compared to patients who underwent LSG without HHR, LSG-HHR patients were older (47.8 yr versus 44.6 yr; P < .0001), had a lower preoperative body mass index (BMI) (45.8 kg/m² versus 48 kg/m²; P < .0001) and more likely to be female (85.2% versus 77.6%, P < .0001). Patients who underwent a posterior HHR (n = 3205) experienced higher rates of symptom improvement (69.5% versus 64.0%, P = .0014) and lower rates of new onset symptoms at 1 year (28.2% versus 30.2%, P = .0500). Patients who underwent an anterior HHR (n = 496) experienced higher rates of hemorrhage and readmissions with no significant difference in symptom improvement.

CONCLUSIONS

Concurrent posterior hiatal HHR at the time of sleeve gastrectomy can improve reflux symptoms. Patients undergoing anterior repair derive no benefit and should be avoided.

Post Sleeve Reflux: indicators and impact on outcomes

INTRODUCTION

Post-operative gastroesophageal reflux disease (GERD) remains a significant morbidity following sleeve gastrectomy (SG). We aim to evaluate the incidence and impact within a single center experience.

MATERIALS AND METHODS

A retrospective review of a prospectively maintained database was performed identifying laparoscopic or robotic SG patients. Primary outcomes included weight loss, rates of post-operative GERD (de-novo or aggravated), and re-intervention. Subgroup analysis was performed between patients with (Group 1) and without (Group 2) post-operative GERD. De-novo GERD and aggravated was defined as persistent GERD complaints or new/increased PPI usage in GERD naive or prior GERD patients, respectively.

RESULTS

392 patients were identified between 2014 and 2019. Average demographics: age 42.3 (18-84) years, Charlson Comorbidity Index (CCI) 1.12 (0-10), and body mass index (BMI) 47.7 (28-100). 98% were performed laparoscopically. Average excess weight loss (EWL) was 51.0% and 46.4% at 1 and 2 years post-operatively. Average follow up was 516 (6-2694) days. 69 (17%) patients developed post operative de-novo or aggravated GERD. Group 1 had significantly higher EWL at 9 months (57% vs 47%, p 0.003). 13 (3%) patients required operative re-intervention for GERD and other morbidities: 4 RYGB conversions, 4 diagnostic laparoscopies, 3 HHR, 1 MSA placement. Group 1 had higher rates of post-operative intervention (14% vs 1%, p 0.0001). Subanalysis demonstrated that Group 1 had elevated preoperative DeMeester scores on pH testing (34.8 vs 18.9, p 0.03). De-novo GERD had an elevated post-operative total acid exposure when compared to aggravated GERD (12.7% vs 7.0% p 0.03). No significant differences were found between preoperative endoscopy findings, pre and postoperative total acid exposure, post-operative DeMeester scores, and high-resolution manometry values regarding de-novo/aggravated GERD development.

CONCLUSION

Preoperative DeMeester scores may serve as risk indicators regarding post-operative GERD. Outcomes such as reintervention remain elevated in post-operative GERD patients.

Gastroesophageal Reflux Disease as an Indication of Revisional Bariatric Surgery-Indication and Results-a Systematic Review and Metanalysis

This systematic review evaluates the indications and results of revisional bariatric surgery (RBS) in gastroesophageal reflux disease (GERD). A systematic literature search and meta-analysis was performed for articles published by April 1, 2021. After examining 722 papers involving 17,437 patients, 48 studies were included (n = 915 patients). RBS for GERD was mostly reported after sleeve gastrectomy (n = 796, 87%) and one anastomosis gastric bypass (n = 62, 6.8%) and was performed due to intractable GERD (71.6%), GERD and weight issues (16%), and biliary reflux (6.2%). Mean follow-up of the studies was 31.5 (3-84) months. Pooled estimation of a meta-analysis of studies reported 7% of GERD following primary surgery needing RBS, in which 99% of the patients experienced remission.

Late (≥5 y) Complications of Laparoscopic Vertical Sleeve Gastrectomy (LVSG) and Laparoscopic Roux-en-Y Gastric Bypass (LRYGB): A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

There is a paucity of data that compares the relative complication profiles of laparoscopic vertical sleeve gastrectomy (LVSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) at 5 years.

OBJECTIVES

The aim was to compare late complications of LVSG and LRYGB.

METHODS

We updated our previous systematic review and meta-analysis of randomized controlled trials of primary LVSG and LRYGB procedures in adults, to review late (5 years) complication outcomes (PROSPERO 112054). Electronic databases were searched from January 2015 to July 2021 for publications meeting inclusion criteria. The Hartung-Knapp-Sidik-Jonkman random effects model was utilized to estimate weighted mean differences where meta-analysis was possible. Bias and certainty of evidence was assessed using the Cochrane risk of bias tool and Grading of Recommendations, Assessment, Development and Evaluations.

RESULTS

Four randomized controlled trials met the inclusion criteria (n=531; LVSG=272, LRYGB=259). No late treatment-related mortality was reported with either procedure. A significant reduction in surgical reoperations (odds ratio: 0.47, 95% confidence interval: 0.27-0.82, P=0.01) and endoscopic interventions (odds ratio: 0.29, 95% confidence interval: 0.12-0.71, P=0.02) were reported at 5 years post-LVSG relative to LRYGB. Reoperations were more frequently performed for reflux management in LVSG and for internal hernia repairs in LRYGB. Complications requiring medical management were common following both procedures. Limitations included few eligible studies for inclusion, and varying definitions of medically managed complications.

CONCLUSIONS

LRYGB is associated with a higher proportion of surgical and endoscopic interventions at 5 years compared with LVSG. More high-quality, long-term studies are required to further elucidate both surgical and nutritional long-term outcomes post these procedures.

The Protective Effect of Transit Bipartition and Its Modification Against Sleeve Gastrectomy-Related Esophagitis in a Rodent Model

BACKGROUND

The protective effect of transit bipartition against esophagitis has not yet been proven. Thus, we investigate and compare the bariatric outcomes and esophagus' histological changes of sleeve gastrectomy (SG), SG with transit bipartition (SG-TB), and the proximal SG-TB (SG-PTB) in a rodent model.

METHODS

This study included 45 diabetic Sprague-Dawley rats assigned to one of the four groups, SG-PTB (n = 15), SG-TB (n = 12), SG (n = 10), and SHAM (n = 8). Eight surviving rats from each group were included for further investigation. Histological analysis of the gastroesophageal junction was performed. Body weight, food intake, glucose control, and hormonal changes (glucagon-like peptide-1 and insulin) were assessed before and after surgery in all groups.

RESULTS

Preoperatively, no significant differences were observed in food intake, body weight, and fasting blood glucose levels among the groups. Postoperatively, the SG-PTB and SG-TB groups showed significantly superior glucose control compared to the SG group following the gavage of glucose (p < 0.05). Postoperatively, the SG-PTB and SG-TB groups had higher postoperative GLP-1 levels than postoperative SG and SHAM groups. More severe esophageal hyperpapillomatosis (EHP) of the esophageal section was observed in the SG group. The mucosal height of the SG group was significantly higher than that of the SG-PTB, SG-TB, and SHAM groups (p < 0.05).

CONCLUSION

The transit bipartition procedure may protect the distal esophagus from histological changes associated with esophagitis. Clinical studies are needed to confirm the anti-reflux effects of transit bipartition.

Gastroesophageal reflux related changes after sleeve gastrectomy and sleeve gastrectomy with fundoplication: A retrospective single center study

BACKGROUND

The worsening of gastroesophageal reflux disease (GERD) and "de novo" GERD after laparoscopic sleeve gastrectomy (LSG) is a major concern as it affects the patient's quality of life; the incidence of GERD after LSG is up to 35%. Laparoscopic sleeve gastrectomy with fundoplication (LSGFD) is a new procedure which is considered to be better for patients with morbid obesity and GERD, but there is a lack of objective evidence to support this statement. This study aimed to assess the effectiveness, safety, and results of LSG and LSGFD on patients who were morbidly obese with or without GERD over an average of 34 months follow-up.

METHODS

Fifty-six patients who were classified as obese underwent surgery from January 2018 to January 2020. Patients who were obese and did not have GERD underwent LSG and patients who were obese and did have GERD underwent LSFGD. The minimum follow-up time was 22 months and there were 11 cases lost during the follow-up period. We analyzed the short-term complications and medium-term results in terms of weight loss, incidence of de novo GERD/resolution of GERD, and remission of co-morbidities with follow-up.

RESULTS

A total of 45 patients completed the follow-up and a questionnaire-based evaluation (GERD-Q), of whom 23 patients underwent LSG and 22 patients underwent LSGFD. We had 1 case of leak after LSGFD.No medium or long- term complications. The patient's weight decreased from an average of 111.6 ± 11.8 Kg to 79.8 ± 12.2 Kg (P = 0.000) after LSG and from 104.3 ± 17.0 Kg to 73.7 ± 13.1 Kg (P = 0.000) after LSGFD. The GERD-Q scores increased from 6.70 ± 0.5 to 7.26 ± 1.7 (P = 0.016) after LSG and decreased from 8.86 ± 1.3 to 6.45 ± 0.8 (P = 0.0004) after LSGFD. The incidence of de novo GERD after LSG was 12 (52.2%) at the 12 month follow-up and 7 (30.4%) at the mean 34 (22-48) month follow-up. The remission of reflux symptoms, for patients who underwent LSGFD, was seen in 19 (86.4%) of 22 patients at 12 months and 20 (90.9%) of 22 patients at the mean 34 (22-48) month follow-up. The two groups did not have any significant difference in the effect of weight reduction and comorbidity resolution.

CONCLUSION

The incidence of de novo GERD after LSG is high,LSG resulted in the same weight loss and comorbidity resolution as LSGFD, in patients who are morbidly obese and experience GERD, and LFDSG prevent the occurrence and development of GERD, combination of LSG with fundoplication (LSGFD) is a feasible and safe procedure with good postoperative results,which worthy of further clinical application.

Endoscopic Stent Placement Can Successfully Treat Gastric Leak Following Laparoscopic Sleeve Gastrectomy If and Only If an Esophagoduodenal Megastent Is Used

PURPOSE

Gastric staple line leakage (GL) is a serious complication of laparoscopic sleeve gastrectomy (LSG), with a specific mortality ranging from 0.2 to 3.7%. The current treatment of choice is stent insertion. However, it is unclear whether the type of stent which is inserted affects treatment outcome. Therefore, we aimed not only to determine the effectiveness of stent treatment for GL but also to specifically clarify whether treatment outcome was dependent on the type of stent (small- (SS) or megastent (MS)) which was used.

PATIENTS AND METHODS

A single-centre retrospective study of 23 consecutive patients was conducted to compare the outcomes of SS (n = 12) and MS (n = 11) for the treatment of GL following LSG. The primary outcome measure was the success rate of stenting, defined as complete healing of the GL without changing the treatment strategy. Treatment change or death were both coded as failure.

RESULTS

The success rate of MS was 91% (10/11) compared to only 50% (6/12) for SS (p = 0.006). An average of 2.3 ± 0.5 and 6.8 ± 3.7 endoscopies were required to achieve healing in the MS and SS groups respectively (p < 0.001). The average time to resumption of oral nutrition was shorter in the MS group (1.4 ± 1.1 days vs. 23.1 ± 33.1 days, p = 0.003).

CONCLUSIONS

Stent therapy is only effective and safe for the treatment of GL after LSG if a MS is used. Treatment with a MS may not only increase treatment success rates but may also facilitate earlier resumption of oral nutrition and shorten the duration of hospitalization.

Safety and effectiveness of reduced-port laparoscopic sleeve gastrectomy in Asian morbidly obese patients

Laparoscopic sleeve gastrectomy is the most frequently performed surgical intervention in patients with morbid obesity. Single-port sleeve gastrectomy (SPSG) and reduced-port sleeve gastrectomy (RPSG) are increasingly reported in the literature. This study compared the short-term outcomes of SPSG, RPSG, and conventional laparoscopic sleeve gastrectomy (CLSG). This is a single-center retrospective study of 238 morbidly obese patients, of whom 148 (62.2%) patients completed follow-up one year after surgery. Propensity score matching was performed on factors influencing the choice of approach, and fifty patients from the SPSG + RPSG and CLSG groups were successfully matched. The groups were comparable in postoperative weight loss, morbidity, pain, and resolution of obesity-related comorbidities. The percentage of excess weight loss after one year was 90.0% in the SPSG + RPSG group and 75.2% in the CLSG group (P < 0.001). Complication rates showed no significant difference. The CLSG group was superior in dyslipidemia remission (17 [37.0%] vs. 28 [63.6%], P = 0.018) in the total cohort; however, this difference disappeared after matching. Our results suggest that single-port and reduced-port approaches could be alternative choices for selected patients. As our study was limited by its retrospective nature and potential selection bias, further studies are necessary to set standardized guidelines for SPSG.

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%).

Current status of gastroesophageal reflux disease after sleeve gastrectomy: Still a long way to go

Obesity is a public health concern that is becoming increasingly more serious around the world. Bariatric surgery has become more prevalent due to the obesity epidemic worldwide. Sleeve gastrectomy (SG) is one of the most popular procedures which is safe and efficient. Despite all its favorable features, however, there is an increasing evidence from the literature that the long-term incidence of gastroesophageal reflux disease (GERD) is likely to represent the Achilles' heel of this procedure. Management of severe reflux after SG usually requires revisional surgery. The relationship between SG and GERD needs to be better ascertained in order to prevent related complications, such as esophageal adenocarcinoma. This review attempts to elucidate the effect of SG on GERD and the postoperative management of reflux disease according to recent literature in the hope of drawing the attention of clinicians to postoperative gastroesophageal reflux and guiding the optimal management strategy associated with this "troublesome complication".

Transhiatal Migration After Laparoscopic Sleeve Gastrectomy: Myth or Reality? A Multicenter, Retrospective Study on the Incidence and Clinical Impact

PURPOSE

Only anecdotally reported, intrathoracic migration (ITM) represents an unacknowledged complication after sleeve gastrectomy (LSG) contributing to gastroesophageal reflux disease (GERD) development, both recurrent and de novo. The primary endpoint of this study was to evaluate the incidence of postoperative ITM ≥ 2 cm; the secondary endpoint was to determine the relationships between ITM, GERD, endoscopic findings, and percentage of patients requiring surgical revision.

MATERIALS AND METHODS

A retrospective, multicenter study on prospective databases was conducted, analyzing LSGs performed between 2013 and 2018. Inclusion criteria consisted of primary operation; BMI ranging 35-60 kg/m²; age 18-65 years; minimum follow-up 24 months; and postoperative UGIE, excluding concomitant hiatal hernia repair. Esophageal manometry and 24-h pH-metry were indicated, based on postoperative questionnaires and UGIE; patients with GERD due to ITM, and non-responders to medical therapy, were converted to R-en-Y gastric bypass (RYGB).

RESULTS

An ITM ≥ 2cm was postoperatively diagnosed in 94 patients (7% of 1337 LSGs), after mean 24.16 ± 13.6 months. Postoperative esophagitis was found in 29 patients vs. 15 initially (p=0.001), while GERD was demonstrated in 75 (vs. 20 preoperatively, p< 0.001). Fifteen patients (16%) underwent revision to RYGB with posterior cruroplasty. Seventeen patients with severe GERD presented improvement of endoscopic findings and clinical symptoms as a result of conservative therapy.

CONCLUSIONS

ITM after LSG is not a negligible complication and represents an important pathogenic factor in the development or worsening of GERD. Postoperative UGIE plays a fundamental role in the diagnosis of esophageal mucosal lesions.