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

https://doi.org/10.1016/j.soard.2016.11.029Get rights and content

Abstract

Background

Morbidly obese patients are affected by gastroesophageal reflux disease (GERD) and hiatal hernia (HH) more frequently than lean patients. Because of conflicting results, the indication to sleeve gastrectomy (SG) in patients with GERD is still debated.

Objectives

To evaluate the incidence of GERD on the basis of clinical, endoscopic, and histologic data in patients undergoing SG.

Settings

University hospital, Rome, Italy.

Methods

From July 2007 to January 2010, 162 patients underwent primary SG. Preoperatively all patients underwent visual analogue scale (VAS) evaluation of GERD symptoms, proton pump inhibitors (PPIs) consumption recording, and esophagogastroduodenoscopy (EGD). Stomach resection started 6 cm from pylorus on a 48Fr bougie. Staple line was reinforced by an oversewing suture. A postoperative clinical control with VAS evaluation, PPI consumption, and EGD was proposed to all patients. Three patients were excluded because of the occurrence of major postoperative complications.

Results

A total of 110 patients accepted to take part in the study (follow-up rate: 69.1%). At a mean 58 months of follow-up, incidence of GERD symptoms, VAS mean score, and PPI intake significantly increased compared with preoperative values (68.1% versus 33.6%: P<.0001; 3 versus 1.8: P = .018; 57.2% versus 19.1%: P<.0001) At EGD, an upward migration of the “Z” line and a biliary-like esophageal reflux was found in 73.6% and 74.5% of cases, respectively. A significant increase in the incidence and in the severity of erosive esophagitis (EE) was evidenced, whereas nondysplastic Barrett’s esophagus (BE) was newly diagnosed in 19 patients (17.2%). No significant correlations were found between GERD symptoms and endoscopic findings.

Conclusion

In the present series the incidence of EE and of BE in SG patients was considerably higher than that reported in the current literature, and it was not related to GERD symptoms. Endoscopic surveillance after SG should be advocated irrespective of the presence of GERD symptoms.

Section snippets

Study design

Study design is summarized in Fig. 1. From July 2007 to February 2010, 341 patients referred to our bariatric center for management of their morbid obesity. All patients underwent a multidisciplinary workup including history and physical examination, routine laboratory evaluation, EGD, abdominal ultrasonography, and nutritional and psychiatric evaluation. At EGD, biopsies of the gastro-esophageal (GE) junction were routinely taken. UGI was performed only in patients with endoscopic findings

Results

SG has been completed laparoscopically in all cases. HH repair (HHR) and cholecystectomy were performed in 16 and 4 patients, respectively (14.5% and 3.6%). Of the 162 patients with primary SG, 3 patients (1.7%) experienced major postoperative complications (1 leak, 1 bleeding, and 1 dysphagia) and were excluded from the study. A total of 110 SG patients agreed to take part in the study (follow-up rate: 69.1%) whereas 49 (30.9%) refused. After a mean follow-up of 58 months (range: 55–82), mean

Discussion

Literature data concerning the relationship between GERD and SG are conflicting. Reflux symptoms after this procedure improved in some studies and worsened in others [7]. However, in the Fourth International Consensus Summit on SG in 2012, postoperative GERD was the most frequently reported complication in a collective series of>46,000 SGs performed by 130 surgeons worldwide, with a mean incidence of 7.9% [14].

Competence of the so-called “antireflux barrier” is based on the proper arrangement

Conclusion

Because SG is performed in an increasing number of patients, postoperative occurrence of EE and or BE and its possible long-term sequelae should be carefully considered. Furthermore, it is particularly worrisome that the data of the present study suggest that there is no strict relationship between GERD symptoms and occurrence of EE and or of BE. As a consequence, routine careful endoscopic evaluation in the postoperative surveillance of SG patients should be encouraged, regardless of presence

Disclosures

Dr. Alfredo Genco reports that he is Consultant/Trainer of Apollo Endosurgery, Inc., Austin, Texas, since January 2015. The other authors have no commercial associations that might be a conflict of interest in relation to this article.

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    © 2016 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.