The effect of laparoscopic sleeve gastrectomy with or without hiatal hernia repair on gastroesophageal reflux disease in obese patients

doi:10.1016/j.soard.2013.09.006

Surgery for Obesity and Related Diseases

Volume 10, Issue 2, March–April 2014, Pages 250-255

https://doi.org/10.1016/j.soard.2013.09.006 Get rights and content

Abstract

Background

Obesity is an independent risk factor for gastroesophageal reflux disease (GERD), which is often associated with the presence of a hiatal hernia (HH). Despite increasing popularity of laparoscopic sleeve gastrectomy (LSG) in bariatric surgery, its effect on GERD is still unclear. The objective of this study was to evaluate the effect of LSG with or without hiatal hernia repair (HHR) on GERD in obese patients.

Methods

Seventy-eight patients with HH underwent LSG with concomitant HHR (LSG+HHR group). Their data were compared with that of 102 patients without HH, who underwent only LSG (LSG-group). All patients underwent a standardized questionnaire, a double-contrast barium swallow, and an upper-gastrointestinal endoscopy before the surgical procedure and at least 6 months later.

Results

At baseline, the prevalence of GERD symptoms and their frequency-intensity scores did not differ between groups. At follow up, there was a significant decrease in the prevalence of typical GERD symptoms only in the LSG-group (P = .003). LSG+HHR patients showed a significantly higher heartburn frequency-intensity score compared with LSG patients (P = .009).

Conclusion

This finding confirms that LSG has a beneficial effect on relieving GERD symptoms, although the underlying mechanisms are still unclear; conversely, the procedure of HHR did not produce any improvement in GERD symptoms.

Section snippets

Methods

From January 2007 to April 2011, 180 obese patients eligible for bariatric surgery [14] underwent LSG. Seventy-eight consecutive patients, in whom sliding HH was intraoperatively disclosed, underwent LSG with concomitant HHR (LSG+HHR group), and 102 obese patients, similar for age and gender distribution in whom no HH was intraoperatively disclosed, underwent only LSG (LSG-group). The study was approved by the institutional review board of the university hospital. Adherence to the ethical

Preoperative evaluation

Demographic characteristics of participants are shown in Table 1.

GERD symptoms assessment and HH detection

The prevalence of typical GERD symptoms did not differ between LSG+HHR and LSG patients (P = .9) (Fig. 1). Heartburn and regurgitation frequency-intensity scores were similar between the LSG+HHR and LSG groups (P = .5 and P = .5, respectively) (Fig. 2). The dc-BS showed a significantly higher presence of HH in LSG+HHR patients compared with LSG patients (28.9% versus6.4%) (P = .004). Using UGIE, no differences in the presence of

Discussion

Our results show that obese patients, who underwent LSG, achieved a significant postoperative decrease in the prevalence and intensity-frequency scores of typical GERD symptoms compared with patients who underwent LSG combined with HH repair. Moreover, after bariatric surgery the LSG patients with concomitant HHR had a significantly higher heartburn intensity-frequency score than patients who underwent LSG alone. To our knowledge, this is the first study to compare LSG to LSG combined with HHR

Conclusion

LSG has a beneficial effect on relieving GERD symptoms, although the underlying mechanisms are still unclear; conversely, the procedure of HHR did not produce any improvement in GERD symptoms. Further studies, with a complete assessment of GERD (i.e., using a standardized questionnaire, esophageal HRM, 24-hour pH-metry before and after surgery at scheduled long-term follow-up combined with an intraoperative assessment of the size of HH, are warranted to tailor the HH management and avoiding

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Gastroesophageal reflux after sleeve gastrectomy: The dimension of the problem
2023, Cirugia Espanola
La gastrectomía vertical (GV) es una técnica segura y eficaz que ha demostrado excelentes resultados en relación con la pérdida ponderal y la resolución o mejoría de las comorbilidades más comunes asociadas a la obesidad a largo plazo. Sin embargo, una de las mayores preocupaciones en torno a ella es su presumible condición reflujogénica, no del todo tipificada. Cuestiones como «¿cuál es la historia natural del reflujo gastroesofágico (RGE) en el paciente intervenido de un sleeve gástrico?», «¿cuántos pacientes tras una GV desarrollarán RGE?» y «¿cuántos empeoraran su reflujo previo tras la realización de esta técnica?» pretenden ser abordadas en el presente artículo. Se ha efectuado una revisión sistemática siguiendo las recomendaciones Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), utilizando diversas bases de datos, para intentar dar una respuesta a las anteriores preguntas.
Sleeve gastrectomy is a safe and effective bariatric surgery in terms of weight loss and long-term improvement or resolution of comorbidities. However, its achilles heel is the possible association with the development with the novo and/or worsening of pre-existing gastroesophageal reflux disease. The anatomical and mechanical changes that this technique induces in the esophagogastric junction, support or contradict this hypothesis. Questions such as «what is the natural history of gastroesophageal reflux in the patient undergoing gastric sleeve surgery?», «how many patients after vertical gastrectomy will develop gastroesophageal reflux?» and «how many patients will worsen their previous reflux after this technique?» are intended to be addressed in the present article.
Anti-reflux surgery vs. bariatric surgery as anti-GERD and hiatal hernia treatment in obese patient: New surgical proposals
2023, Cirugia Espanola
La persistencia de obesidad favorece el fracaso de la funduplicatura (FP) en el tratamiento del reflujo gastroesofágico (RGE). Sin embargo, la pérdida de peso obtenida con la realización de un bypass gástrico (BPG) permite una buena resolución de síntomas, sin incrementar la incidencia de complicaciones postoperatorias. Todo ello lleva a considerar que mientras la FP es la indicación en el paciente con IMC < 30, en aquellos pacientes con IMC > 35 el BPG se muestra como el procedimiento de elección. Pero todavía no existe un posicionamiento en el caso de pacientes con IMC entre 30 y 35, si bien deberemos tener en consideración que se ha descrito un aumento de recurrencia del RGE tras FP en pacientes con un IMC > 30. Aunque la gastrectomía vertical (GV) es uno de los procedimientos bariátricos más frecuentemente utilizado en los últimos años, su asociación a una tasa elevada de RGE postoperatorio ha llevado a varios autores a proponer su realización asociada a un procedimiento antirreflujo en aquellos pacientes con síntomas de RGE.
Así mismo, en caso de constatarse la existencia de una hernia de hiato, esta debe ser tratada mediante hiatoplastia, tanto durante la realización de un BPG como de una GV. Este tratamiento simultáneo no se asocia con un incremento de complicaciones.
The persistence of obesity favors the failure of the fundoplication (FP) in the treatment of gastroesophageal reflux (GER). However, the weight loss obtained with the performance of a gastric bypass (GBP) allows a good resolution of symptoms, without increasing the incidence of post-operative complications. All of this leads us to consider that while FP is the indication in patients with BMI < 30, in those patients with BMI > 35, GBP appears to be the procedure of choice. But there is still no position in the case of patients with a BMI between 30 and 35, although we must take into account that an increase in GER recurrence has been described after FP in patients with a BMI > 30. Although sleeve gastrectomy (SG) is one of the most frequently used bariatric procedures in recent years, its association with a high rate of post-operative GER has led several authors to propose its performance associated with an anti-reflux procedure in patients with GER symptoms.Likewise, if the existence of an hiatal hernia is verified, it must be treated by hiatoplasty, both during the performance of a GBP and a SG. This simultaneous treatment is not associated with an increase in complications.
Comparison of upper gastrointestinal series and symptom questionnaires with intraoperative diagnosis of hiatal hernia during sleeve gastrectomy
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Hiatal hernias are common in bariatric surgery patients, but the utility of preoperative hiatal hernia diagnosis prior to sleeve gastrectomy (SG) is debated.
This study compared preoperative and intraoperative hiatal hernia detection rates in patients undergoing laparoscopic SG.
University hospital, United States.
As part of a randomized trial evaluating the role of routine crural inspection during SG, an initial cohort was prospectively studied to assess the correlation between preoperative upper gastrointestinal (UGI) series, reflux and dysphagia symptoms, and intraoperative hiatal hernia diagnosis. Preoperatively, patients completed the Gastroesophageal Reflux Disease Questionnaire (GerdQ), the Brief Esophageal Dysphagia Questionnaire (BEDQ), and a UGI series. Intraoperatively, patients with an anteriorly visible defect underwent hiatal hernia repair followed by SG. All others were randomized to standalone SG or posterior crural inspection with repair of any hiatal hernia identified prior to SG.
Between November 2019 and June 2020, 100 patients (72 female patients) were enrolled. Preoperative UGI series identified hiatal hernia in 28% (26 of 93) of patients. Intraoperatively, hiatal hernia was diagnosed during initial inspection in 35 patients. Diagnosis was associated with older age, lower body mass index, and Black race but did not correlate with GerdQ or BEDQ. Using the standard conservative approach, compared with intraoperative diagnosis, sensitivity and specificity of the UGI series were 35.3% and 80.7%, respectively. Hiatal hernia was identified in an additional 34% (10 of 29) of patients randomized to posterior crural inspection.
Hiatal hernias are highly prevalent in SG patients. However, GerdQ, BEDQ, and a UGI series unreliably identify hiatal hernia in the preoperative setting and should not influence intraoperative evaluation of the hiatus during SG.
Independent association of preoperative Hill grade with gastroesophageal reflux disease 2 years after sleeve gastrectomy
2023, Surgery for Obesity and Related Diseases
The sleeve gastrectomy (SG) is associated with postoperative gastroesophageal reflux disease (GERD). Higher endoscopic Hill grade has been linked to GERD in patients without metabolic surgery. How preoperative Hill grade relates to GERD after SG is unknown.
To explore the relationship between preoperative Hill grade and GERD outcomes 2 years after SG.
Academic hospital, United States.
All patients (n = 882) undergoing SG performed by 5 surgeons at a single academic institution from January 2015 to December 2019 were included. Complete data sets were available for 360 patients, which were incorporated in analyses. GERD was defined as the presence of a diagnosis in the medical record accompanied by pharmacotherapy. Patients with GERD postoperatively (n = 193) were compared with those without (n = 167). Univariable and multivariable analyses were conducted to explore independent associations between preoperative factors and GERD outcomes.
The presence of any GERD increased at the postoperative follow-up of 25.2 (3.9) months compared with preoperative values (53.6% versus 41.1%; P = .0001). Secondary GERD outcomes at follow-up included de novo (41.0%), persistent (33.1%), resolved (28.4%), worsened (26.4%), and improved (12.2%) disease. Postoperative endoscopy and reoperation for GERD occurred in 26.4% and 6.7% of the sample. Patients with GERD postoperatively showed higher prevalence of Hill grade III–IV (32.6% versus 19.8%; P = .0062) and any hiatal hernia (HH) (36.3% versus 25.1%; P = .0222) compared with patients without postoperative GERD. Frequencies of gastritis, esophagitis A or B, duodenitis, and peptic ulcer disease were similar between groups. Higher prevalence of preoperative GERD (54.9% versus 25.1%; P < .0001), obstructive sleep apnea (66.8% versus 54.5%; P = .0171), and anxiety (25.4% versus 15.6%; P = .0226) was observed in patients with postoperative GERD compared with those without it. Baseline demographics, weight, other obesity-associated diseases, whether an HH was repaired at index SG, and follow-up length were statistically similar between groups. After adjusting for collinearity, preoperative GERD (odds ratio [OR] = 3.6; 95% confidence interval [CI], 2.2–5.7; P < .0001) and Hill grade III–IV (OR [95% CI]: 1.9 [1.1–3.1]; P = .0174) were independently associated with the presence of any GERD postoperatively. The preoperative presence of an HH >2 cm and whether an HH was repaired at index SG showed no independent association with GERD at follow-up.
More than 50% of patients experienced GERD 2 years after SG. Preoperative GERD confers the highest risk for GERD postoperatively. Hill grade III–IV is independently associated with GERD after SG. Whether a hiatal hernia repair was performed did not influence GERD outcomes. Preoperative esophagogastroduodenoscopy should be obtained before SG and Hill grade routinely captured and used to counsel patients about the risk of postoperative GERD after this procedure. Hill grade may help guide the choice of metabolic operation.
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A retrospective chart review was performed for 130 patients who underwent a routine endoscopic surveillance before and after LSG between January 2013 and October 2018. The diagnosis of GERD was determined by presence of symptoms, history of PPI treatment, and endoscopic findings. The esophagogastroduodenoscopy (EGD) was performed annually after LSG and/or when the patients complained of severe reflux symptoms.
The prevalence of GERD before surgery was 18.5%. At 1 year after LSG, GERD was present in 70 (53.8%) of the 130 patients. GERD consisted of 55 patients with newly developed GERD, and 15 with preexisting GERD. 9 (37.5%) out of pre-existing GERD patients were free of symptoms and abnormal finding at EGD following LSG. During the LSG, 66 (50.8%) patients with hiatal hernia underwent re-approximation of the diaphragmatic crura. There was no significant relationship between hiatal hernia repair and postoperative GERD (p = 0.39). Number of patients taking PPI medication before and after LSG were 34 (26.2%) and 49 (37.7%). Out of 56 (43.1%) patients with endoscopic lesions, LA grade A was 31 (23.9%), B = 15 (11.5%), C = 4 (3.1%), and D = 6 (4.6%).
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Management of Gastroesophageal Reflux Disease after Sleeve Gastrectomy: Effectiveness of Medical, Endoscopic, and Surgical Therapies
2024, Journal of Laparoendoscopic and Advanced Surgical Techniques

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Original articleThe effect of laparoscopic sleeve gastrectomy with or without hiatal hernia repair on gastroesophageal reflux disease in obese patients

Abstract

Background

Methods

Results

Conclusion

Section snippets

Methods

Preoperative evaluation

GERD symptoms assessment and HH detection

Discussion

Conclusion

Am J Gastroenterol

Surg Obes Relat Dis

Surg Obes Relat Dis

Am J Surg

Surg Obes Relat Dis

The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus

Am J Gastroenterol

Review article: the pathophysiology of gastro-oesophageal reflux disease

Aliment Pharmacol Ther

Gastro-oesophageal reflux symptoms, oesophagitis and Barrett’s oesophagus in the general population: the Loiano-Monghidoro study

Gut

Clinical significance of hiatal hernia

Gut Liver

Meta-analysis: obesity and the risk for gastroesophageal reflux disease and its complications

Ann Intern Med

Systematic review: the effects of conservative and surgical treatment for obesity on gastro-oesophageal reflux disease

Aliment Pharmacol Ther

Gastroesophageal pressure gradients in gastroesophageal reflux disease: relations with hiatal hernia, body mass index, and esophageal acid exposure

Am J Gastroenterol

Laparoscopic gastric banding and crural repair in the obese patient with a hiatal hernia

Obes Surg

Laparoscopic Roux-en-Y gastric bypass for recalcitrant gastroesophageal reflux disease in morbidly obese patients

JSLS

Laparoscopic hiatus hernia repair and simultaneous sleeve gastrectomy: a novel approach in the treatment of gastroesophageal reflux disease associated with morbid obesity

J Laparoendosc Adv Surg Tech A

Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults—the evidence report

Obes Res

Original article
The effect of laparoscopic sleeve gastrectomy with or without hiatal hernia repair on gastroesophageal reflux disease in obese patients