Gastroesophageal Reflux Following Sleeve Gastrectomy: A Meta-Analysis

Christopher Crawford, MD, Daniel Lomelin, MPH, Kyle Gibbens, BS, Crystal Krause, PhD, Dmitry Oleynikov, MD. University of Nebraska Medical Center

INTRODUCTION: Symptomatic gastroesophageal reflux remains a persistent problem following sleeve gastrectomy (SG).  SG decreases the volume and compliance of the stomach.  Dissection performed at the angle of His can decrease the acute angle, allowing fluid to reflux into the esophagus.  The altered anatomy of the GE junction and conversion to a high-pressure system makes SG patients more likely to develop gastroesophageal reflux disease (GERD) than those with native anatomy or those undergoing gastric bypass.

METHODS: A meta-analysis of the literature was performed to identify studies of bariatric patients undergoing SG that evaluated the pre-operative and post-operative incidence of GERD.  If hiatal hernia repair (HHR) in addition to SG was described, that was analyzed as a separate characteristic.  This was reported in 3 studies with 210 total patients.  Descriptive statistics were calculated for change in GERD prevalence, pre and post-operatively, using SPSS v20.0.0.0 and with each study weighed by sample size.

RESULTS: A total of 29 studies were identified with at least 6 months of follow up, with a pooled sample size of 8,723 patients.  In patients who underwent SG alone, 78.4% of 2,474 patients with pre-operative GERD still had GERD post-operatively.  In patients who underwent SG and concurrent HHR, only 15.1% of 116 patients who had pre-operative GERD still had GERD post-operatively (p<0.001, odds ratio 20.4).

In studies that reported overall pre- and post-operative GERD (n=7,729), the pre-operative prevalence of GERD was 39.5%, and the post-operative prevalence was 30.1%, (p<0.001).  One large study did not include pre-operative incidence of GERD, only de novo onset, and was excluded from that portion of our analysis. 

Patients who did not have GERD pre-operatively did not typically develop GERD, regardless of the addition of a HHR.  The onset of GERD occurred in 9.5% of patients following SG and 10.6% of patients following SG+HHR, with no significant difference (p=0.708).

CONCLUSIONS: Despite awareness of GERD being a potential complication following SG, 78% of patients with GERD do not have symptom improvement or resolution with SG, with 30.5% of all patients experiencing GERD symptoms following SG.  Patients with GERD and a hiatal hernia show improvement in GERD following SG by including a HHR.  Proper patient selection as well as operative technique focused on limiting the prevalence of GERD should remain a paramount concern.

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