Reflux After Sleeve Gastrectomy: An Update

Abstract

Background:

Modifications of gastric anatomy, function, and of the esophagogastric junction secondary to sleeve gastrectomy (SG) can worsen the symptoms of gastroesophageal reflux disease (GERD). Its late diagnosis and poor treatment can lead to serious complications. In recent years, attempts have been made to optimize preoperative studies and improve surgical techniques to prevent this problem. The aim of this study was to update on the presence of GERD and their symptoms post-SG.

Methods:

A literature review of articles based on randomized clinical trials on the presence of GERD after SG was carried out, in a period of 10 years.

Results:

A result of 336 articles was obtained, of which 327 were discarded and 9 were included. The variables of GERD post-SG were analyzed according to their symptoms (“improved,” “worsened,” and “unchanged”), “remission,” or appearance “de novo.”

Conclusion:

GERD is a frequently associated pathology in obese patients. Several authors reported that symptoms worsen after SG, and has been diagnosed de novo. The application of exhaustive preoperative studies and a correct surgical technique could reduce its incidence.

Introduction

Obesity is an epidemic disease that affects millions of people in the world (1.1 billion adults are overweight and 312 million are obese).¹ It carries numerous comorbidities, such as arterial hypertension (high blood pressure), diabetes mellitus, dyslipidemia, gastroesophageal reflux disease (GERD), obstructive sleep apnea syndrome, traumatology, and psychological disorders, among others. Its resolution requires multidisciplinary work, which includes surgeries. Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) procedures are the most frequently used to treat these patients.^2,3

Surgery is the only effective treatment for morbid obesity and obtains the best long-term outcomes. It is indicated when body mass index (BMI) is >40, or BMI is >35 with significant associated comorbidities. Each bariatric procedure (restrictive or malabsorptive) is associated with a different balance of risks and benefits, in terms of surgical complications, excess weight loss (EWL), and resolution of GERD. The mortality rate in specialized centers is <0.3%.⁴ Since specific procedure guidelines are missing, surgical treatment for morbid obese patients must be selected according to the clinical characteristics of the patient, his eating habits, and patient willingness. It should be based on a preoperative workup with shared decision-making, with the double purpose of treating both GERD and obesity.⁵

Obese patients commonly develop GERD, with an incidence of 50%.⁶ Changes in gastric anatomy, function, and in the esophagogastric junction secondary to SG can worsen GERD, or trigger GERD de novo by 3%–20%.^7,8 Its late diagnosis and poor treatment can lead to serious complications (esophagitis, metaplasia, Barrett's esophagus [BE]; neoplasia, lung disease, and nutritional disorders).

Little is known about the evolution of pre-existing BE after bariatric surgery and the incidence of esophageal adenocarcinoma. To the best of our knowledge only a few cases of esophageal cancer after laparoscopic SG (LSG) have been reported; however, physicians should be aware of the increased prevalence of GERD given that the young age of patients could represent a risk.^9–11

This raises concern in surgeons who perform these procedures and in patients who undergo SG. For this reason, in recent years they have tried to optimize preoperative studies and improve surgical techniques to prevent this problem.

Objectives

The objective of this study was to update on the presence of GERD and their symptoms post-SG through a review of the current literature.

Materials and Methods

In this study, we analyze the relationship between GERD post-SG and other procedures (Table 1). An update on the presence of GERD after SG was carried out. The search engines “PubMed” and “Medline” were used. The time period covered the past 10 years (from 2011 to 2021). The terms used to perform the search were “reflux,” “gastroesophageal reflux disease,” “GERD,” “sleeve gastrectomy,” and “laparoscopic sleeve gastrectomy.” Boolean operators were applied to optimize the search, such as “[AND]” and “[WITH].” Only those articles based on randomized clinical trials were analyzed, focused on the results and complications after SG, especially GERD.

Table 1.

Presence of Gastroesophageal Reflux Disease in Obese Patients Undergoing Different Bariatric Surgery Techniques

	Comparison of SG versus other bariatric surgery techniques
	Postoperative symptoms of GERD
	Remission	Improved	Unchanged	Worsened	De novo	GerdQ	Follow-Up (years)
SG versus RYGB
Biter et al.²⁷	—	—	—	—	—	6.63 ± 2.26 versus 5.60 ± 1.07^a	1
Catheline et al.¹³	—	—	—	—	20.2% versus 8.3%^a	—	3
Peterli et al.³⁵	50% versus 75%^a	—	—	—	12.5% versus 4%	—	1
Peterli et al.³⁶	61% versus 77.6%	5.0% versus 14.3%	14.6% versus 6.1%	19.4% versus 2.0%^a	—	—	3
Peterli et al.¹²	25% versus 60.4%^a	9.1% versus 6.3%	34.1% versus 27.1%	31.8% versus 6.3%^a	31.6% versus 10.7%	—	5
SG versus OAGB
Shivakumar et al.¹⁴	—	—	—	—	3 versus 2	—	3
Seetharamaiah et al.¹⁵	—	—	—	—	3 versus 3	—	1
SG versus SGB
Fink et al.¹⁶	66.7% versus 36.4%	0% versus 18.2%	0% versus 27.3%	16.7% versus 0%	30.3% versus 20.8%	—	3
SG versus SG+HHR
Snyder et al.¹⁷	—	66% versus 65%	11% versus 17%	22% versus 17%	2.7% versus 7.3%	—	1

Statistically significant.

GERD, gastroesophageal reflux disease; GerdQ, gastroesophageal reflux disease questionnaire; OAGB, one anastomosis gastric bypass; RYGB, Roux-en-Y gastric bypass; SG, sleeve gastrectomy; SG+HHR, sleeve gastrectomy hiatal hernia repair; SGB, sleeve gastrectomy banded.

The reference list of the retrieved articles was also manually checked for relevant articles. The conference abstracts considered “gray literature” were not analyzed. No publication date or language limit was considered for our search strategy.

Our initial analysis included a prescreen to identify the clearly irrelevant reports by title, abstract, and keywords of the publication. Two other independent reviewers assessed the studies for relevance, inclusion, and methodological quality. The studies were classified as relevant (meeting all specified inclusion criteria); possibly relevant (meeting some but not all inclusion criteria); and rejected (not relevant to our review). Two reviewers independently reviewed the full-text versions of all studies classified as relevant or possibly relevant. Any disagreements were resolved by repeat extraction.

Results

A result of 336 articles was obtained, of which 21 were discarded due to duplication, 289 due to methodological aspects, and 17 due to other variables (languages, not available, and others). A total of nine studies were included (Fig. 1). The authors in their studies analyzed the GERD variable post-SG according to their symptoms (“improved,” “worsened,” and “unchanged”), “remission,” or “de novo” appearance.

FIG. 1.

Result of search in current literature. RCT = Randomized Clinical Trial; SG = Sleeve Gastrectomy; RYGB = Roux-en-Y Gastric Bypass; OAGB = One Anastomosis Gastric Bypass; SGB = Sleeve Gastrectomy Banded; SGHHR = Sleeve Gastrectomy Hiatal Hernia Repair.

Overall, patients underwent SG reported a lower remission of GERD, and a higher rate of worsening. GERD de novo was also higher in SG group. When SG versus RYGB was compared, the studies reported a GERD remission of 25% versus 60.4%, improvement 9.1% versus 6.3%, unchanged 34.1% versus 27.1%, worsening 31.8% versus 6.3%, and de novo 31.6% versus 10.7% (at 5 years) and 20.2% versus 8.3% (at 3 years).^12,13 Comparison of SG versus OAGB (one anastomosis gastric bypass) reported a de novo GERD index of 3 versus 2 (at 3 years), and 3 versus 3 (at 1 year).^14,15 The relationship between SG versus SGB (SG banded) demonstrated a GERD remission of 66.7% versus 36.4%, improvement 0% versus 18.2%, unchanged 0% versus 27.3%, worsening 16.7% versus 0%, and de novo 30.3% versus 20.8%, at 3 years.¹⁶ In those patients with hiatal hernia (HH), the comparison between SG versus SG+HHR (hiatal hernia repair) found an improvement of 66% versus 65%, unchanged 11% versus 17%, worsening 22% versus 17%, and de novo 2.7% versus 7.3%, in 1 year¹⁷ (Table 1).

Discussion

Bariatric surgery is one of the most popular procedures nowadays.¹⁸ It is a surgery that was perfectly adapted to the mini-invasive laparoscopic approach.¹⁹ The overall complication rate in bariatric area is 0%–10%.²⁰ The complication rate for SG is 1%–3%.^21–23 One of these complications is GERD, which has a post-SG incidence of 2.1%–47.2%.^24,25

The GERD is a complex diagnosis, especially in the era of bariatric surgery. There are teams that are considering the diagnosis only a clinical one, but GERD can also be asymptomatic and can be measured by pH-metrics. This additional examination makes it possible to measure the number of acid reflux per 24 hours, and it is extremely useful in morbid obese patients with clinical symptomatology of GERD and negative signs on upper endoscopy (not always relevant). Some authors find a close relationship between GERD and SG, and several studies have demonstrated its presence in the postoperative period.²⁶ Some cases are even classified as “de novo.” In those patients with GERD before surgery, this condition has worsened after surgery. All these data appear to be negative for SG in relation to GERD. But there are authors who also highlight that the majority of these patients present a mild disease, and that they respond very well to treatment with proton pump inhibitors (PPIs) and diet.²⁷ Furthermore, many patients with GERD before SG are asymptomatic, which could be concluded that the anatomical modifications secondary to the procedure would only express clinically the symptoms of an underlying disease. Asymptomatic patients with GERD were also observed after SG. Dimbezel et al. in a study on endoscopic findings after SG reported a significant number of asymptomatic patients with alterations at upper endoscopy.²⁸ For this reason, the use of endoscopy in the first 5 years after SG is highlighted for both symptomatic and asymptomatic patients. Sebastianelli et al., in a multicenter study, analyzed the prevalence of GERD and BE, at least 5 years after SG in patients who underwent SG, using systematic endoscopy.²⁹ The prevalence of GERD symptoms, erosive esophagitis, and PPIs use increased after SG (P < .05). They reported a BE presence of 18.8%. Weight loss failure was significantly associated with BE. These authors also suggest performing a systematic endoscopy in these patients to rule out this pathology.

GERD is a multifactorial disease.³⁰ It has an incidence of 15%–20% in adults, and 50% in the overweight patient.^6,31 Its causes are associated with anatomical variables (excess abdominal fat, modification of His angle angulation, and presence of HH), functional variables (lower esophageal sphincter defect, defect of esophageal clearance, and greater gradient transdiaphragmatic pressure), and environmental/behavior (type of diets rich in fats and sodas).^30,32–34

Although bariatric surgery has been successfully performed for several decades, the mechanism of action of each type of procedure is not completely understood both for the weight loss, GERD remission, or de novo GERD.

Regarding the results of SG versus RYGB, Biter et al. observed that patients in the SG group had a higher mean GerdQ (gastroesophageal reflux disease questionnaire) score after 12 months than those in the RYGB group. Since the %EWL (% excess weight loss) was similar in both groups, it is unlikely that this influenced the difference in GERD symptoms.²⁷ The appearance of GERD was greater in patients undergoing SG (SG 20.2% versus RYGB 8.3%, at 36 months).¹³ It should be considered that the majority of surgeons preferred to perform RYGB in those patients with a history of preoperative GERD. Peterli et al. compared SG versus RYGB in several trials.^12,35,36 In their 2018 publication, in a 5-year study they reported that GERD worsened in SG, and its remission was lower compared with RYGB. Other articles made the comparison between SG versus SGB. Fink et al. report a statistically significant increase in the presence of GERD in unbanded SG, but after 3 years.¹⁶ The comparison of SG versus OAGB showed that the presence of GERD in the postoperative period was higher in SG at 1 and 3 years.^14,15

It is not clear whether HH patients who are candidates for SG require crural repair during the bariatric procedure.^37–39 A review of the literature by Mahawar et al.⁴⁰ on the hiatal repair associated with SG involving >700 patients was performed. Of the 17 studies analyzed, only one did not show a satisfactory result on GERD. Soricelli et al.⁴¹ evaluated in 97 patients the repair of a concomitant hiatal hernia of a SG with a median follow-up of 18 months. 80.4% of these patients had remission of reflux, 12.1% had improved symptoms, 7.5% had persistent symptoms, and no de novo reflux.

Currently, some surgeons have chosen to perform N-Sleeve as a feasible and safe alternative in obese patients with reflux and HH to RYGB.³⁷ This technique appears to show similar results in terms of weight loss, effects on comorbidities, and a lower rate of leakage and GERD.³⁸ HH patients are a real challenge when undergoing bariatric surgery. By themselves they represent a pathology that requires surgical treatment.⁴² Fundoplication improves reflux symptoms, although it is controversial in obese patients.^43,44 When studying HH patients undergoing SG with and without repair (SG versus SG+HHR),¹⁷ the authors found that HHR during SG did not significantly reduce reflux symptoms compared with SG without this surgical gesture. Although it is believed that this maneuver could have some beneficial effect in patients with HH >4 cm. In addition, a greater number of patients presenting de novo symptoms undergoing HHR were reported. However, those patients with significant preoperative reflux symptoms had a more significant improvement in their symptoms after surgery compared with those patients who did not report severe symptoms.

Many surgeons prefer to perform RYGB to decrease the incidence of postoperative GERD.⁴⁵ Indeed, patients with post-SG reflux symptoms who underwent revisions and converted to RYGB had improved symptoms.⁴⁶ Different clinical trials tried to compare the results in quality of life (QoL) between RYGB and SG. Catheline et al., similar to other authors, conclude that the presence of GERD decreases after RYGB, and increases after SG.^13,47 When OAGB was compared with SG, the postoperative results and morbidities were similar. Although patients in the first group with comorbidities had a better QoL and BAROS score (bariatric analysis reporting and outcome system).¹⁴ Continuation of similar studies found that the incidence of GERD was similar in both groups.¹⁵ New procedures such as ESG (endoscopic sleeve gastroplasty) also reported better results with respect to SG, although the results with respect to %EWL were not good.⁴⁸

This study has some limitations. The main one is the small number of studies analyzed, and we cannot fail to highlight the heterogeneity of their participants. Although it should be noted that most of them reach similar conclusions. In contrast, a wide variability in terms of GERD was observed in patients underwent SG, which may be due to the different surgical teams and their technical variants.

Conclusion

GERD is a frequently associated pathology in obese patients. Several authors reported that symptoms worsen after SG. As well as, GERD has been diagnosed de novo in patients undergoing SG. The application of exhaustive preoperative studies and a correct surgical technique could reduce its incidence. We must emphasize the importance of a screening upper endoscopy between 1 and 5 years after LSG.

Footnotes

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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