Impact of Sleeve Gastrectomy On Gastroesophageal Reflux Disease in a Morbidly Obese Population Undergoing Bariatric Surgery

LeShon Hendricks, MD, Emanuela Alvarenga, MD, Emanuele Lo Menzo, MD, PhD, FACS, Samuel Szomstein, MD, FACS, Raul Rosenthal, MD, FACS. Cleveland Clinic Florida

Objectives

To analyze the incidence of gastroesophageal reflux disease (GERD) after laparoscopic sleeve gastrectomy (LSG) and to compare the results in patients with preexisting and de novo GERD.

Methods

We performed a retrospective review of primary sleeve gastrectomy cases performed at Cleveland Clinic Florida from 2005-2013. We compared patients that had LSGs with preexisting and de novo GERD.

Results

A total of 919 patients underwent LSG. GERD was present in 38 patients (4%) of the LSG cohort. In this cohort we identified two groups: Group A consists of 25 patients (3%) with new onset of GERD and Group B with 13 patients (1%) that had GERD before LSG. The diagnosis of GERD in Groups A and B was derived by symptoms and history of Proton Pump Inhibitor (PPI) treatment and/ or Upper Gastrointestinal Endoscopy (UGI) and Esophagogastroduodenoscopy (EGD); 3 patients (8%) in addition also had pH manometry. In Group A, diagnosis based on: symptoms/ history of PPI treatment = 11 patients (44%), UGI= 3 patients (12%), EGD= 11 patients (44%) and pH Manometry= 0 patients (0%). In Group B, diagnosis based on: symptoms/ history of PPI treatment= 10 patients (77%), UGI= 0 patients (0%), EGD= 3 patients (23%) and pH Manometry= 3 patients (23%). Group A developed symptoms between 1 month and 60 months (mean of 24 months). In comparison, Group B had 6 patients (46 %) with worsening reflux symptoms at 12- 78 Months (mean of 48 months) and 7 patients (54%) reported no change of symptoms post LSG. In Group A, 1 patient (4%) underwent simultaneous hiatal hernia repair. In Group B, 3 patients (23%) underwent simultaneous hiatal hernia repair, with no proof of improvement of GERD. In the treatment for Group A, 1 patient (4%) was managed with over the counter drugs, 17 patients (68 %) were treated with low dose PPI, 6 patients (24%) with high dose PPI and 1 patient (4%) was lost to failure of follow up. The treatment for Group B consisted of 9 patients (69%) treated with low dose PPI and 4 patients (31%) with high dose PPI. When medical management was unsuccessful in Groups A and B, Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) was performed. In Group A 1 patient (4%) required LRYGB and Group B 3 patients (23%) required LRYGB. In looking at the outcome of surgical management, the 1 patient (4%) needing conversion in Group A did not have complete resolution of GERD symptoms after LRYGB. Of the 3 patients (23%) needing conversion in Group B, 2 patients (67%) had complete resolution of GERD symptoms after LRYGB.

Conclusion

In our study 3% of patients developed de novo GERD (Group A), but most responded to either low or high dose PPI with 4% needing conversion to LRYGB. Of the 1% of patients with preexisting GERD (Group B), 23% required conversion to LRYGB because of failure of medical treatment of which 67% was resolved after conversion. Repair of pre-existing hiatal hernia did not seem to have an impact on postoperative GERD symptoms.