Does sleeve gastrectomy affect the geometry and tone of the gastroesophageal junction?

Silvana Perretta, MD, Antonio D’Urso, MD, Marius Nedelcu, MD, Michel Vix, MD, Bernard Dallemagne, MD, Didier Mutter, MD. Department of Digestive and Endocrine surgery, University of Strasbourg

Introduction: The role of sleeve gastrectomy (SG) in causing post­operative gastroesophageal reflux remains controversial. Whereas previous data has clearly demonstrated that intra­gastric pressure  increases significantly after SG, the effect of the procedure on the geometry and compliance of the gastroesophageal junction GEJ) has been studied to a lesser extent. In this study we sought to assess the opening and distensibility of the GEJ before and after the SG procedure, as part of an ongoing European multicenter collaborative project FFSI (Functional Foregut Surgery Imaging) which seeks to derive a better understanding the physiology of the SG procedure.

Methods and procedures: 15(8F) patients were studied with mean age  of 35 ± 10,04 years,  and BMI of 42,23 ± 4,82. No patient complained of GERD symptoms prior to SG, no patient was on proton pump inhibitor medication, and all patients had negative EGD and UGI series. No patient had a hiatal hernia greater than 1cm.  After establishment of pneumperitoneum, an EndoFLIP EF325N catheter (Crospon, Galway, Ireland) was placed so as to straddle the GEJ, and measurements of          diameter and distensibility were taken at balloon inflation diameters of 30ml and 40mL.The  measurement was repeated upon completion of the sleeve. A paired t­test comparing opening diameter and distensibility pre­ and post­procedure was conducted to assess the effect of the  SG procedure on the GEJ.

Results: At 30mL inflation (n=15), mean (SD) GEJ opening diameter was 8.4(1.0) mm pre­procedure versus 10.2(2.0) mm post­procedure, a mean increase of 1.7mm (P=0.005). At 40mL inflation (n=14), mean GEJ opening diameter was 10.7(1.8) mm before versus 11.7(2.4) mm post­procedure, a mean increase of 1.0 mm (P=0.11). At 30mL inflation (n=14), mean GEJ distensibility was 2.3(0.8) mm2/mmHg before versus 2.9(1.6) mm2/mmHg post­procedure, a mean increase of 0.6 mm2/mmHg (P=0.2). At 40mL inflation (n=12), mean GEJ distensibility was 2.7(1.2) mm2/mmHg before versus 3.2(1.5) mm2/mmHg post­procedure, a mean increase of 0.4 mm2/mmHg (P=0.34).

Conclusions: This preliminary data from the FFSI study strongly suggests that GEJ diameter is widened by the SG procedure, which would logically suggest  that the risk of gastroesophageal reflux is    increased. Whereas the data suggest that the GEJ is  more distensible after SG, a higher powered study with a larger sample size will be required to determine if the effect is statistically significant.

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