Do Abdominoplasties in Patients with Prior Sleeve Gastrectomy Impact De Novo Gastroesophageal Reflux Disorder and the Need for Conversion to Roux-en-Y Gastric Bypass?

Abstract

Introduction:

The sleeve gastrectomy (SG) often requires conversion to Roux-en-Y gastric bypass (RYGB) due to gastroesophageal reflux disorder (GERD). Many postbariatric patients seek body-contouring surgery such as abdominoplasty to remove unwanted skin and fat. Although the number of abdominoplasties performed in postbariatric patients is increasing each year, the number of conversion surgeries is increasing in accordance. This study evaluates the impact of abdominoplasties in patients with prior SG on the development of GERD and the need for conversion to RYGB.

Methods:

A retrospective study was conducted with 630 patients who underwent conversions from SG to RYGB at our institution between January 2014 and December 2023. Outcomes were stratified for comparison between patients with GERD as an indication for conversion and patients with inadequate weight loss as an indication for conversion. Between the two groups we compared the number of patients with post-SG abdominoplasty and the number of hiatal hernias (HH) seen during conversion surgery. A logistic regression analysis was performed to identify factors independently associated with GERD.

Results:

There was a statistically significant higher number of abdominoplasties in patients who underwent conversion to RYGB for GERD (29 patients, 8.6%) compared to inadequate weight loss (12 patients, 4.1%), P value .034. However, these patients also had statistically significantly more HH (98 patients, 28.9%) compared to patients with inadequate weight loss as an indication for conversion (46 patients, 15.8%), P value <.001. In the logistic regression comparing these two variables, only the presence of HH seen during surgery was found to be a significant predictor of GERD (odds ratio 2.7, confidence interval 1.7–4.1, P < .001).

Conclusion:

Our data shows that abdominoplasty surgery does not directly influence the development of GERD in post-SG patients. However, the presence of HH in this population significantly impacts the development of GERD, often necessitating conversion to RYGB.

Key Points

There is an increasing number of conversions from sleeve gastrectomy (SG) to Roux-en-Y gastric bypass (RYGB) secondary to gastroesophageal reflux disorder (GERD).

Many postbariatric patients seek body-contouring surgery such as abdominoplasty to remove excess skin and fat, which is a known cause of intra-abdominal pressure.

Although abdominoplasties were more commonly seen in post-SG patients with GERD, they were not found to be significantly associated with GERD on logistic regression.

There is an association between presence of hiatal hernias and de novo GERD that may lead to conversion to RYGB in post-SG patients.

Introduction

Bariatric surgery is an ever-evolving field of medicine, with an increasing number of weight loss procedures performed each year.¹ Although sleeve gastrectomy (SG) is still the most common weight loss procedure today, the number of conversions from SG to Roux-en-Y gastric bypass (RYGB) is growing.² Indications for SG to RYGB conversion in 2020 and 2021 included gastroesophageal reflux disorder (GERD) as the leading factor (55.3%), followed by weight regain (24.4%) and insufficient weight loss (12.7%).³ The chance of developing de novo GERD after SG can be as high as 48%.^3,4 The mechanism behind GERD after a SG is multifactorial and impacted by the shape of the sleeve, extent of disruption to the lower esophageal sphincter, and presence of any concomitant hiatal hernias (HH).⁵ Conversions to a low-pressure system like the RYGB in patients with a failed SG can offer resolution of GERD symptoms and a reduction in the use of proton pump inhibitors (PPI).^2,6

Weight loss after successful bariatric surgery is approximately 60% to 70% of one’s excess weight.⁷ This dramatic difference in weight can cause undesirable changes to a person’s appearance, including excess skin around areas of marked weight loss.^7,8 This has negative impacts on physical activity, sexual activity, self-esteem, and can ultimately lead to poor hygiene, infections, depression, and overall decreased quality of life.^7,8 Many patients seek body-contouring surgery after bariatric surgery to remove unwanted skin and fat.⁷ Abdominoplasty serves as a safe and effective means of resecting this excess tissue and has shown improvements in quality of life and bodily function.⁸ Nonetheless, the number of abdominoplasties performed each year has risen in accordance with the number of bariatric procedures performed each year.¹

It has been proven that abdominoplasties are correlated with increased intra-abdominal pressure.^1,9–11 In this operation, an incision is made in the suprapubic crease and a flap is created between fascia and subcutaneous fat. Once the flap is raised, it is repositioned to the desired effect and any excess skin is excised. A rectus muscle plication is then commonly performed, where the fascia of the rectus muscle is plicated together with suture to reinforce the abdominal wall. The reapproximated flap is sutured back down to the suprapubic incision to create a cosmetically improved tightened abdominal wall.¹² Postoperatively, there is a decrease in abdominal wall compliance, which can lead to increased intra-abdominal pressure. Several cases in plastic surgery literature have found rectus muscle plication to contribute to the sequela of intra-abdominal hypertension (HTN) including respiratory compromise and HH.⁹ Many of these studies have theorized that abdominoplasties are a risk factor for GERD through a similar manner.^9,10 However, after an extensive literary search, no studies have explored this relationship further, specifically in the context of bariatric patients. We aimed to investigate the hypothesis that patients with prior SG who undergo abdominoplasty may have an increased risk of developing GERD and may require conversion to RYGB. Additionally, we wanted to identify any confounding factors, such as the presence of HH.

Methods

Study design

In our study, we assessed our centers data for patients with a history of laparoscopic and robotic SG who underwent conversion to RYGB from January 2014 to December 2023. We included for analysis all female or male patients with morbid obesity (body mass index [BMI] >35 kg/m² with comorbidities or BMI >40 kg/m²) who underwent laparoscopic or robotic SG as well as laparoscopic conversion to RYGB. All patients undergoing conversion surgery at our institution have workup including esophagogastroduodenoscopy (EGD) and/or upper gastrointestinal series (UGIS). Although EGD is the gold standard for diagnosing GERD, some of our patients were unable to undergo this procedure for various reasons, and therefore underwent UGIS instead to assess for other signs of GERD or HH. Therefore, all patients in our study with symptoms of GERD had confirmatory studies, including either EGD and/or UGIS, that demonstrated reflux, esophagitis, gastritis, erythematous mucosa or erosions, or the presence of HH.

We excluded patients who were diagnosed with GERD before their SG or abdominoplasty, patients with abdominoplasty surgery before their SG, and patients with primary bariatric surgeries other than laparoscopic or robotic SG. Our hospital protocol for bariatric surgery does not mandate imaging before primary laparoscopic or robotic SG. Therefore, we excluded primary SG patients who did not undergo conversion surgery, since most of these patients lacked pre- and postoperative diagnostic studies to confirm de novo GERD or HH.

Operative notes were evaluated for all conversion surgeries to assess for diagnosis of HH intraoperatively. All HH greater than 2 cm in size were repaired during their SG to RYGB conversion surgery. This included HH diagnosed preoperatively with EGD and/or UGIS and HH diagnosed intraoperatively.

Data collection

Data collection included demographics, operative information, and perioperative outcomes based on indications for conversion to SG. Baseline demographics included age, BMI, sex, presence of post-SG abdominoplasty, diabetes mellitus (DM), smoking status, chronic obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA), HTN, use of anticoagulants, and American Society of Anesthesiologists (ASA) class. All patients in our study underwent preoperative EGD and/or UGIS, and data from these studies were collected to evaluate for presence of HH or signs of GERD. Patients were categorized based on indication for conversion to RYGB, which included GERD or insufficient weight loss and weight regain (termed “inadequate weight loss”). The following perioperative outcome data was collected for each group: mean operative time (OT), mean length of stay (LOS), presence of HH during conversion surgery, surgical site infection (SSI), deep SSI, pulmonary embolism (PE), and postoperative deep venous thrombosis (DVT).

Statistical analysis

Categorical variables were presented as frequencies and percentages. Continuous variables whose distribution approximated normality were reported as mean and standard deviation, and those with skewed distributions were reported as median and interquartile range. Univariate analyses were performed using Pearson’s chi-square test for categorical variables and the t-test for continuous variables. Multivariate predictors of GERD were estimated using multivariable logistic regression. A P value < .05 was considered significant. Data were analyzed using SPSS v.29 (Chicago: SPSS Inc). Approval for this study was obtained through the Institutional Review Board (IRB 2023–15572) and all Health Insurance Portability and Accountability Act procedures were followed.

Results

Our study included 630 patients with a history of SG who underwent conversion to RYGB at our academic institution between January 2014 and December 2023. Patients were divided into two groups for comparison: patients with GERD as an indication for conversion (339 patients, 53.8%) and patients with inadequate weight loss as an indication for conversion (291 patients, 46.1%). The mean age in the GERD group was 44.5 years (standard deviation [SD] 11) and the mean age in the inadequate weight loss group was 42.4 years (SD 10.4), P value .014. The inadequate weight loss group had a statistically significantly higher mean BMI of 39.6 (SD 7.7) than the GERD group, which had a mean BMI of 44.4 (SD 7.8), P value <.001. The majority of patients included in our study were female, with 309 (91.2%) in the GERD group and 260 (89.3%) in the inadequate weight loss group. Most patients were ASA III, with 219 in the GERD group (64.6%) and 213 in the inadequate weight loss group (73.2%).

There was a significantly higher number of post-SG abdominoplasties in the group of patients with GERD as the indication for conversion (29 patients, 8.6%) compared to the group of patients with inadequate weight loss as the indication for conversion (12 patients, 4.1%), P value .034. DM was present in 33 (9.7%) patients in the GERD group and 37 (12.7%) patients in the inadequate weight loss group. Out of the patients who underwent conversions due to GERD, 20 (5.9%) were current smokers. Out of the patients who underwent conversions due to inadequate weight loss, 19 (6.5%) were current smokers. COPD was present in 4 (1.2%) patients in the GERD group and 5 (1.7%) patients in the inadequate weight loss group. OSA was present in 59 (17.4%) patients with GERD as an indication for conversion and 66 (22.7%) patients with inadequate weight loss as an indication for conversion. HTN was present in 115 (33.9%) patients in the GERD group and 92 (31.6%) patients in the inadequate weight loss group. Use of anticoagulation was present in 8 (2.4%) patients with GERD as an indication for conversion and 6 (2%) patients with inadequate weight loss as an indication for conversion. Patients undergoing conversion for GERD had statistically significant more HH seen on EGD/UGIS (205 patients, 60.5%) compared to patients undergoing conversion for inadequate weight loss (152 patients, 52.2%), P value .044. Likewise, patients in the GERD group had statistically significantly more signs of GERD seen on EGD/UGIS (268 patients, 79.1%) compared to patients undergoing conversion for inadequate weight loss (168 patients, 57.7%), P value <.001. Patient characteristics are listed in Table 1.

Table 1.

Patient Characteristics

n = 630	GERD n = 339 (53.8%)	Inadequate weight loss n = 291 (46.1%)	P value
Mean age (SD)	44.5 (11)	42.4 (10.4)	.014
Mean BMI (SD)	39.6 (7.7)	44.4 (7.8)	<.001
Sex			.5
Female	309 (91.2%)	260 (89.3%)
Male	30 (8.8%)	31 (10.7%)
Abdominoplasty	29 (8.6%)	12 (4.1%)	.034
DM	33 (9.7%)	37 (12.7%)	.25
Current smoker	20 (5.9%)	19 (6.5%)	.74
COPD	4 (1.2%)	5 (1.7%)	.739
OSA	59 (17.4%)	66 (22.7%)	.109
HTN	115 (33.9%)	92 (31.6%)	.552
Anticoagulant	8 (2.4%)	6 (2%)	.8
ASA			.051
I	0 (0%)	1 (0.3%)
II	119 (35.1%)	75 (25.8%)
III	219 (64.6%)	213 (73.2)
IV	1 (.3%)	2 (2.1%)
EGD/UGIS showing HH	205 (60.5%)	152 (52.2%)	.044
EGD/UGIS showing GERD	268 (79.1%)	168 (57.7%)	<.001

ASA, American Society of Anesthesiologists; BMI, body mass index; COPD, chronic obstructive pulmonary disease; DM, diabetes mellitus; EGD, esophagogastroduodenoscopy; GERD, gastroesophageal reflux disorder; HH, hiatal hernia; HTN, hypertension; OSA, obstructive sleep apnea; SD, standard deviation; UGIS, upper gastrointestinal series.

When comparing perioperative outcomes between the two groups, there were significantly more HH seen during surgery in patients with GERD as an indication for conversion (98 patients, 28.9%) compared to patients with inadequate weight loss as an indication for conversion (46 patients, 15.8%), P value <.001. The mean OT and mean LOS in the GERD group was 124.7 (SD 45.8) minutes and 1.4 (SD 1.1) days, respectively. The mean OT and mean LOS in the inadequate weight loss group were 124.7 (SD 50.6) minutes and 1.6 (SD 2.4) days, respectively. Surgical site infections were present in 8 (2.4%) patients in the GERD group and 0 patients in the inadequate weight loss group. Postoperative PE was present in 1 (0.3%) patient in the GERD group and 0 patients in the inadequate weight loss group. Neither group had postoperative deep SSI or DVT. The perioperative outcomes for each group are listed in Table 2.

Table 2.

Perioperative Outcomes

n = 630	GERD n = 339 (53.8%)	Inadequate weight loss n = 291 (46.1%)	P value
Mean OT (SD)	124.7 (45.8)	124.4 (50.6)	.943
Mean LOS (SD)	1.4 (1.1)	1.6 (2.4)	.34
HH during surgery	98 (28.9%)	46 (15.8%)	<.001
SSI	8 (2.4%)	0 (0)	.009
Deep SSI	0 (0)	0 (0)
PE	1 (.3%)	0 (0)	.35
DVT	0 (0)	0 (0)

DVT, deep venous thrombosis; GERD, gastroesophageal reflux disorder; HH, hiatal hernia; LOS, length of stay; OT, operative time; PE, pulmonary embolism; SD, standard deviation; SSI, surgical site infection.

A multivariate logistic regression analysis was conducted to determine factors associated with GERD. The following variables were included in the regression model: sex, abdominoplasty, DM, smoking status, COPD, EGD/UGIS showing HH, and HH seen during conversion surgery. Of these, only HH seen during surgery (odds ratio [OR] 2.7, confidence interval [CI]: 1.7–4.1, P < .001) was associated with GERD. The logistic regression analysis is listed in Table 3.

Table 3.

Logistic Regression

Variables	OR	95 CI%	P value
Sex	1.2	0.7–2.2	.37
Abdominoplasty	1.7	0.8–3.3	.13
DM	0.6	0.4–1.1	.122
Smoker	1	0.5–2	.94
COPD	1.1	0.2–4.3	.92
EGD/UGIS showing HH	1.2	0.9–1.8	.14
HH during surgery	2.7	1.7–4.1	<.001

CI, confidence interval; COPD, chronic obstructive pulmonary disease; DM, diabetes mellitus; EGD, esophagogastroduodenoscopy; HH, hiatal hernia; OR, odds ratio; UGIS, upper gastrointestinal series.

Discussion

Our institution has noticed an anecdotally high trend of prior SG patients undergoing abdominoplasty surgery. This study aims to address the possible impact of abdominoplasties on de novo GERD and the need for conversion to RYGB. After reviewing the relevant literature, we have not found any similar studies analyzing intra-abdominal pressure and GERD after body-contouring surgery in postbariatric patients. After analyzing our hospital’s data, we did find a statistically significant higher number of abdominoplasties in patients who underwent conversion to RYGB for GERD as compared to inadequate weight loss. However, we also found a statistically significant higher number of HH in patients who underwent conversion to RYGB for GERD. Following logistic regression analysis, we identified that only HH, not abdominoplasty, showed a significant association with GERD. The novelty of our research not only reinforces the correlation between HH and GERD but can also provide patients and providers more informed decision-making when it comes to considering body contouring surgery after bariatric procedures. It is valuable to note that the increased abdominal pressure after abdominoplasty surgery is clinically insignificant, and has not shown to increase the risk of symptomatic GERD in postbariatric patients.

It is widely documented in literature that an increase in intra-abdominal pressure increases the risk of GERD.¹³ Numerous studies have proven the positive relationship between intra-abdominal pressure and GERD by analyzing the effects of straight leg raises, Valsalva maneuvers, and abdominal binders. Siboni et al.¹³ was a systematic review of 30 studies that described intra-abdominal pressure as a driving force in the disruption of the gastroesophageal junction, and ultimately, the development of GERD. They found that elevated intra-abdominal pressure specifically blunts the pressure dynamics of the lower esophageal sphincter, leading to an equalization of gastric and esophageal pressures which ultimately results in GERD.

The impact of abdominoplasties on intra-abdominal pressure has been studied as well.^9,14 Huang et al.⁷ was a prospective study with 22 patients which calculated intra-abdominal pressures intraoperatively through bladder pressure transduction and showed a significant increase in pressures after rectus muscle plication. Although they found a significant increase of about 2–4 mmHg from preoperative values, all measured intra-abdominal pressures were less than 20 mmHg and none were clinically significant (i.e., decreased urinary output or increased peak airway pressures). Al-Basti et al.¹⁴ evaluated intra-abdominal pressure in 43 morbidly obese (mean BMI 35.8) and multiparous female patients undergoing abdominoplasty with rectus muscle plication. Similar to the prior study, bladder pressures measured before and after surgery correlated with a statistically significant and clinically insignificant increase in intra-abdominal pressure.

Our study found a statistically significant higher number of HH within the group of patients with GERD as an indication for conversion. There is a well-established association between HH and GERD that has been proven in literature.^5,15–17 Kumar et al.¹⁶ was a cross-sectional observational analysis with 63 patients who underwent SG and concomitant hiatal hernia repair (HHR). They found that concomitant HHR led to improvement in reflux symptoms and a reduction in PPIs in over two-thirds of their patients. Schlottmann et al.¹⁷ studied 175 patients with GERD divided into groups based on presence and size of HH. They assessed patient symptoms, conducted high-resolution manometry, pH monitoring, and endoscopy to demonstrate a correlation between larger HH size and GERD.

Limitations of the study

Our study had several important limitations. First, this is a single center and retrospective cohort study, and we acknowledge any limited generalizability and potential for selection bias. Additionally, we must factor in the variability of documentation of GERD findings in EGD and UGIS. Due to the numerous radiologists who have interpreted and documented the studies over the years, we must consider variability in interpretation, which can lead to varying results. Therefore there might be a disparity in diagnosis of GERD in our study. Likewise, there was a fair amount of patients without symptoms of GERD in the inadequate weight loss group that had findings of GERD on imaging. It is difficult to prove in these patients that GERD was not a factor in their indication for conversion. Although our study excluded patients with GERD symptoms prior to SG and/or abdominoplasty, it remains uncertain whether these patients would have shown evidence of GERD or HH if they had undergone imaging beforehand, thus blunting the impacts of our results. Because our hospital protocol does not mandate imaging before primary laparoscopic or robotic SG, it is possible that some asymptomatic patients had undiagnosed GERD or HH on imaging. Because these patients, including those with post-SG abdominoplasty surgery, did not have EGD and/or UGIS to evaluate for findings of de novo GERD or HH, they were not included in our study. Future studies should explore the impact of abdominoplasty surgery on clinical symptoms of GERD in patients with primary SG only. There was also a lack of consistency in reporting rectus plication in operative notes for abdominoplasties. Therefore, it is hard to ascertain the importance of this technique on intra-abdominal pressure. Subsequent investigations should look specifically into this component of the operation to see if it has a direct impact on GERD in patients.

Conclusions

We found a statistically significant higher number of abdominoplasties in patients with GERD as the indication for conversion from SG to RYGB (29 patients, 8.6%) compared to inadequate weight loss as the indication for conversion from SG to RYGB (12 patients, 4.1%), P value .034. However, these patients also had statistically significantly more HH (98 patients, 28.9%) compared to patients with inadequate weight loss as an indication for conversion (46 patients, 15.8%), P value <.001. In the logistic regression comparing these two variables, only the presence of HH seen during surgery was found to be a significant predictor of GERD (OR: 2.7, CI: 1.7–4.1, P < .001). Our data shows that abdominoplasty surgery does not directly influence the development of GERD in post-SG patients. However, the presence of HH in this population significantly impacts the development of GERD, often necessitating conversion to RYGB.

Footnotes

Authors’ Contributions

D.C., R.B., D.L.L., and M.W.: Study design. R.B., D.L.L., M.W., M.P., J.S., C.E., and R.D.-P.: Data collection and analysis. R.B., M.W., D.L.L., and D.C.: Article preparation and editing.

Author Disclosure Statement

The authors have no conflicts of interest.

Funding Information

There was no funding for this project.

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