Study of gastroesophageal reflux in patients submitted laparoscopic sleeve gastrectomy: correlation between symptoms and nuclear tests

Nelida Diaz, Juan Francisco Ruiz Rabelo, PhD, Elena Navarro Rodriguez, MD, Luisa Mena, Juan Antonio Vallejo, Antonio Membrives Obrero, Francisco Javier Briceno Delgado. Hospital Universitario Reina Sofia

Introduction: Gastroesophageal reflux after sleeve gastrectomy is a controversial issue. Sleeve gastrectomy has demonstrated great effectiveness. Nevetheless the posibility to develop “the novo” gastroesophageal reflux disease (GERD) due to the impact on esophagogastric union and its functionality is one of the major criticism of this technique. The aim of this study is to analyze the correlation between GERD symptoms and the study of gastroesophageal and bile reflux after sleeve gastrectomy.

Patients and methods: 34 consecutive patients were included in this study. Inclusion criteria were: age between 18 and 65 years old, BMI > 40 kg/m2.  It was discarded preoperative GERD or hiatal hernia by conducted interview, pHmetry, manometry and endoscopy. Patients were submitted sleeve gastrectomy by the same surgery team. Water-soluble contrast esophagogastric transit was done between 48 and 72 hours post surgery. Six months after surgery patients filled in GERD-Q and Rome III criteria questionaires, validated and adapted to be used in Spanish. After that they were performed a gastroesophageal reflux scintigraphy and biliar Tc99m-scintigraphy to evaluate both gastroesophageal and bile reflux.

Results. Preoperative median BMI was 52,37 kg/m2 and mean age was 41,18 years old. 41,1% of patients were man and 58,8% were women. A 11,8% of patients had GER in scintigraphy, and another 5,9% of them showed bile reflux at biliar Tc99m scintigraphy.. In respect of gastrointestinal symptoms, 10 patients presented symptoms of GERD  on the GERD-Q. Regarding ROME-III criteria, 6 patients had functional heartburn criteria and 5 had functional dispepsia criteria.

All patients that showed gastroesophagueal reflux in the scintigraphy had also clinical criteria for GERD on the GERD-Q (75% had criteria for severe GERD and 25% for GERD), in addition the severity of the symptoms was related to the number of reflux episodes during the examination. Respect ROME III criteria 1 (25%) patient fulfilled criteria for functional dispepsia and 3 of them (75%) for functional heartburn criteria.

Patients that showed biliary reflux did not have gastrointestinal symptoms for any of the diseases contained in ROME III criteria.

Conclusions: The integrity of the OG junction is a major factor for esophagitis and Barret’s esophagus. The correlation between GERD symptoms and follow-up testings may help us detect those patients with reflux, in order to recommend endoscopy monitoring. Our study showed good correlation between GERD symptoms and scintigraphy. Nevertheless we found some cases of biliary reflux without symptoms, which are difficult to interpret.