Rami R Mustafa, MD, PhD1, Adel Alhaj Saleh, MD2, Mujjahid Abbas, MD1, Leena Khaitan, MD, MPH1. 1Cleveland Medical Center , University hospitals, 2Texas Tech University Health Sciences Center | TTUHSC · Department of Surgery
Background: Laparoscopic sleeve gastrectomy (LSG) is one of the most common bariatric procedures worldwide. This has led to a new problem: gastroesophageal reflux disease (GERD) after sleeve. A common approach to this problem is conversion to gastric bypass, even in those who are no longer obese. This study aims to establish a new algorithm with multiple options to manage GERD after Sleeve Gastrectomy based upon patient physiology.
Methods: From January, 2012 to December, 2017, 602 patients underwent LSG and 53 underwent evaluation for persistent GERD after sleeve that did not respond to high dose of PPI’s. All patients had evaluation with EGD, esophagram, esophageal motility and pH monitoring. Demographic data, BMI and symptoms were evaluated and algorithm applied. Procedures, medication use and symptoms were followed for at least one year postoperatively. Patients with BMI>35 or abnormal sleeve morphology had conversion to gastric bypass (GB). Patients with normal sleeve morphology and hypotensive lower esophageal sphincter (LES) received LES augmentation. Those with normal LES pressure (LESP) and normal weight received radiofrequency energy delivery (RF). All hiatal hernias (HH) were fixed. The primary symptoms measured were heartburn and regurgitation. Data is analyzed by SPSS and reported.
Results: Mean age was 53 ±13 yrs, (82% white, 80 % female) and BMI was 36 ±9 kg/m2. 31 (58.4%) patients underwent conversion to GB with mean LES pressure of 25.25 mmHg ± 14 (24 also had hiatal hernia (HH) repair). 13 cases (24.5%) received LES augmentation and had mean LESP of 11.5 mmHg (SD± 7.7). 7 patients (13.2%) only had HH repair. 2 (3.7%) underwent RF and had mean LESP of 25 mmHg. 43 (81%) of patients had HH repair (24 of which were concomitant with GB and 12 with LES augmentation). 85% of patients in the GB group (BMI 46.26±14.9) had no symptoms of heartburn or regurgitation at 2.5 year follow up(BMI 33±8.9) In the LES augmentation group, 12/13 (92%) patients had resolution of symptoms and stopped PPI’s immediately after procedure. BMI at time of surgery 30± 7 kg/m2 and remained stable at 2 yr follow up (30.7±7.3). The RF ablation groups and hiatal hernia group all had resolution of symptoms at 1-3 year follow up.
Conclusions: Multiple options for management of reflux after LSG are available. Excellent outcomes can be achieved when procedures are chosen based on patient physiology and a thorough evaluation of the patient’s reflux disease.
Keywords: sleeve gastrectomy. GERD. PH monitoring.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 95093
Program Number: S137
Presentation Session: Bariatric V – GERD and Esophageal Physiology
Presentation Type: Podium