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Surgery for Obesity and Related Diseases ] (2014) 00–00
Editorial comment
Comment on: Evaluation of gastroesophageal reflux before and after laparoscopic sleeve gastrectomy using symptom scoring, scintigraphy and endoscopy Received February 16, 2014; accepted February 20, 2014
The authors of this study [1] have to be commended for their attempt at shedding some light on our understanding of the relationship between sleeve gastrectomy (SG) and gastroesophageal reflux disease (GERD). They assessed reflux and its consequences using endoscopy, scintigraphy, and 2 different symptom scores both preoperatively and up to 1-year postoperatively, with 2 main findings: Reflux is by far more common 6 months after SG than before, and this massive increase in reflux does not translate into worsening of GERD-associated symptoms (in fact the latter are even improved), nor does it result in significantly more esophagitis during the first postoperative year. Based on these results, the authors conclude that the presence of GERD related symptoms or of reflux esophagitis may not represent a contraindication to SG. GERD is commonly associated with obesity. In a large study involving candidates for bariatric surgery [2], results of a 24-hour pH study were abnormal in 450% of the patients, and reflux esophagitis was present in nearly one third of them. There was also a clear association between the importance of reflux and the presence of a hiatus hernia and esophagitis. Despite this frequent association and the numerous studies on the effects of various bariatric procedures on GERD, controversy persists as to which operation is best suited for morbidly obese patients with GERD. During the last International Consensus Meeting, 57% of attendants considered GERD as a relative contraindication to SG, although 480% thought that a hiatus hernia should be aggressively identified and repaired. On the other hand, 81% considered Barrett’s esophagus, the ultimate stage of GERD, as an absolute contraindication to SG [3]. Most surgeons, therefore, have some concern regarding the appropriateness of SG in GERD patients. There are substantial data showing the positive effects of Roux-en-Y gastric bypass (RYGB) on GERD [4,5], but results regarding the effects of other bariatric procedures are controversial. Despite SG being the only nonreversible
bariatric procedure, it is preferred by some surgeons because it leads to acceptable weight loss and avoids the risks associated with a foreign body, exclusion of a digestive segment, or gastrointestinal anastomoses. By its design, however, SG creates a high-pressure system in the remaining stomach. Furthermore, SG may reduce the efficacy of the lower esophageal sphincter (LES) by transecting some of the sling fibers. Both of these effects, intuitively, are likely to enhance reflux. The present study clearly confirms this impression, with 78% of the patients having objective reflux as assessed by scintigraphy 6 months after SG compared to only 6% before surgery. Does reflux always lead to GERD? The answer is obviously no, since many patients with proven reflux have no symptoms or esophagitis. How much reflux is necessary to cause GERD and for how long? The chemical content of the refluxate also plays a role. SG reduces the parietal cell mass and acid secretion so that reflux, even if increased in volume, may be less acidic, hence less harmful, after SG than with a normal anatomy. This is especially true early after surgery when the sleeve is not yet dilated. Six or 12 months of mild acid reflux may not be sufficient to cause symptoms and/or complications. This may explain why symptom scores, on average, decreased during the first postoperative year, despite the fact that the proportion of patients with abnormal scores did not change significantly. Unfortunately, 24-hour pH studies, the gold standard for GERD, were not used in the present study. Endoscopy was performed only 6 months after surgery, showing improvement in some patients, but also worsening in others, without significant changes overall. There was, however, a positive correlation with improved symptom scores in patients in whom endoscopic findings were improved. The small sample size and the short duration of follow-up certainly play a role in these nonconclusive results. Several papers have reported GERD to be 1 of the longterm complications of SG, sometimes requiring conversion
http://dx.doi.org/10.1016/j.soard.2014.02.020 1550-7289/r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
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M. Suter / Surgery for Obesity and Related Diseases ] (2014) 00–00
to RYGB because of intractable symptoms [6,7]. This clearly indicates that there is a relationship between SG and GERD. It is complex in nature, sometimes with improvement, other times with worsening of symptoms or de novo GERD. The surgical technique likely plays a role in this relationship. Not all sleeves are alike: a narrow sleeve creates more pressure and a large sleeve more acid. The distance at which the sleeve ends proximally may change its effects on the LES. The role of hiatal closure when a hernia is present remains to be better defined. Hiatal closure alone is not an accepted treatment for GERD, but only part of fundoplication, the gold standard that cannot be offered with SG. In fact, the only possible conclusion of the present study is that SG significantly increases reflux during the first postoperative year without causing early reflux associated complications (GERD). Whether this increased reflux will result in GERD and its related problems over time remains to be answered. More studies, using endoscopy and pH studies, with much longer follow-up and ideally larger groups of patients are urgently needed. Because their data do not support it, I therefore strongly disagree with the authors’ conclusion that GERD and esophagitis may not represent a contraindication to SG. Morbidly obese candidates for bariatric surgery should be informed that SG is likely to increase reflux, although we do not know whether this will translate into symptoms/complications or not. They need to know that a subset of patients develop severe GERD after SG, and may require conversion to RYGB. They must be informed not only that redo surgery is associated with greater operative risks, but also that RYGB represents the treatment of choice for morbidly obese patients with GERD until proven otherwise, obviating the risk for redo surgery and providing at least
equivalent weight loss. Only a fully informed patient can make the appropriate choice regarding the procedure he/she elects to have and the risks he/she is willing to accept. In my opinion, GERD remains at least a relative contraindication to SG. Michel Suter* Department of Surgery Hôpital du Chablais Aigle, Switzerland References [1] Evaluation of Gastroesophageal reflux before and after laparoscopic sleeve gastrectomy using Symptom Scoring, scintigraphy and endoscopy. Surg Obes Relat Dis 2014: xxxxxxx2. [2] Suter M, Dorta G, Giusti V, Calmes JM. Gastro-esophageal reflux and esophageal motility disorders in morbidly obese patients. Obes Surg 2004;14:959–66. [3] Rosenthal RJ. International sleeve gastrectomy expert panel consensus statement: best practice guidelines based on experience of 412000 cases. Surg Obes Relat Dis 2012;8:8–19. [4] Smith SC, Edwards CB, Goodman GN. Symptomatic and clinical improvement in morbidly obese patients with gastroesophageal reflux disease following Roux-en-Y gastric bypass. Obes Surg 1997;7: 479–84. [5] Madalosso CA, Gurski RR, Callegari-Jacques SM, Navarini D, Thiesen V, Fornari F. The impact of gastric bypass on gastroesophageal reflux disease in patients with morbid obesity: a prospective study based on the Montreal Consensus. Ann Surg 2010;251:244–8. [6] Gautier T, Sarcher T, Contival N, Le Roux Y, Alves A. Indications and mid-term results of conversion from sleeve gastrectomy to Roux-en-Y gastric bypass. Obes Surg 2013;23:212–5. [7] Mahawar KK, Jennins N, Balupuri S, Small PK. Sleeve gastrectomy and gastro-oesophageal reflux disease: a complex relationship. Obes Surg 2013;23:987–91.
* Correspondence: Michel Suter, Hôpital du Chablais, Chemin du Grand Chene, Aigle 1860, Switzerland. E-mail: [email protected]
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Surgery for Obesity and Related Diseases ] (2014) 00–00
Editorial comment
Comment on: Evaluation of gastroesophageal reflux before and after laparoscopic sleeve gastrectomy using symptom scoring, scintigraphy and endoscopy Received February 16, 2014; accepted February 20, 2014
The authors of this study [1] have to be commended for their attempt at shedding some light on our understanding of the relationship between sleeve gastrectomy (SG) and gastroesophageal reflux disease (GERD). They assessed reflux and its consequences using endoscopy, scintigraphy, and 2 different symptom scores both preoperatively and up to 1-year postoperatively, with 2 main findings: Reflux is by far more common 6 months after SG than before, and this massive increase in reflux does not translate into worsening of GERD-associated symptoms (in fact the latter are even improved), nor does it result in significantly more esophagitis during the first postoperative year. Based on these results, the authors conclude that the presence of GERD related symptoms or of reflux esophagitis may not represent a contraindication to SG. GERD is commonly associated with obesity. In a large study involving candidates for bariatric surgery [2], results of a 24-hour pH study were abnormal in 450% of the patients, and reflux esophagitis was present in nearly one third of them. There was also a clear association between the importance of reflux and the presence of a hiatus hernia and esophagitis. Despite this frequent association and the numerous studies on the effects of various bariatric procedures on GERD, controversy persists as to which operation is best suited for morbidly obese patients with GERD. During the last International Consensus Meeting, 57% of attendants considered GERD as a relative contraindication to SG, although 480% thought that a hiatus hernia should be aggressively identified and repaired. On the other hand, 81% considered Barrett’s esophagus, the ultimate stage of GERD, as an absolute contraindication to SG [3]. Most surgeons, therefore, have some concern regarding the appropriateness of SG in GERD patients. There are substantial data showing the positive effects of Roux-en-Y gastric bypass (RYGB) on GERD [4,5], but results regarding the effects of other bariatric procedures are controversial. Despite SG being the only nonreversible
bariatric procedure, it is preferred by some surgeons because it leads to acceptable weight loss and avoids the risks associated with a foreign body, exclusion of a digestive segment, or gastrointestinal anastomoses. By its design, however, SG creates a high-pressure system in the remaining stomach. Furthermore, SG may reduce the efficacy of the lower esophageal sphincter (LES) by transecting some of the sling fibers. Both of these effects, intuitively, are likely to enhance reflux. The present study clearly confirms this impression, with 78% of the patients having objective reflux as assessed by scintigraphy 6 months after SG compared to only 6% before surgery. Does reflux always lead to GERD? The answer is obviously no, since many patients with proven reflux have no symptoms or esophagitis. How much reflux is necessary to cause GERD and for how long? The chemical content of the refluxate also plays a role. SG reduces the parietal cell mass and acid secretion so that reflux, even if increased in volume, may be less acidic, hence less harmful, after SG than with a normal anatomy. This is especially true early after surgery when the sleeve is not yet dilated. Six or 12 months of mild acid reflux may not be sufficient to cause symptoms and/or complications. This may explain why symptom scores, on average, decreased during the first postoperative year, despite the fact that the proportion of patients with abnormal scores did not change significantly. Unfortunately, 24-hour pH studies, the gold standard for GERD, were not used in the present study. Endoscopy was performed only 6 months after surgery, showing improvement in some patients, but also worsening in others, without significant changes overall. There was, however, a positive correlation with improved symptom scores in patients in whom endoscopic findings were improved. The small sample size and the short duration of follow-up certainly play a role in these nonconclusive results. Several papers have reported GERD to be 1 of the longterm complications of SG, sometimes requiring conversion
http://dx.doi.org/10.1016/j.soard.2014.02.020 1550-7289/r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110
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M. Suter / Surgery for Obesity and Related Diseases ] (2014) 00–00
to RYGB because of intractable symptoms [6,7]. This clearly indicates that there is a relationship between SG and GERD. It is complex in nature, sometimes with improvement, other times with worsening of symptoms or de novo GERD. The surgical technique likely plays a role in this relationship. Not all sleeves are alike: a narrow sleeve creates more pressure and a large sleeve more acid. The distance at which the sleeve ends proximally may change its effects on the LES. The role of hiatal closure when a hernia is present remains to be better defined. Hiatal closure alone is not an accepted treatment for GERD, but only part of fundoplication, the gold standard that cannot be offered with SG. In fact, the only possible conclusion of the present study is that SG significantly increases reflux during the first postoperative year without causing early reflux associated complications (GERD). Whether this increased reflux will result in GERD and its related problems over time remains to be answered. More studies, using endoscopy and pH studies, with much longer follow-up and ideally larger groups of patients are urgently needed. Because their data do not support it, I therefore strongly disagree with the authors’ conclusion that GERD and esophagitis may not represent a contraindication to SG. Morbidly obese candidates for bariatric surgery should be informed that SG is likely to increase reflux, although we do not know whether this will translate into symptoms/complications or not. They need to know that a subset of patients develop severe GERD after SG, and may require conversion to RYGB. They must be informed not only that redo surgery is associated with greater operative risks, but also that RYGB represents the treatment of choice for morbidly obese patients with GERD until proven otherwise, obviating the risk for redo surgery and providing at least
equivalent weight loss. Only a fully informed patient can make the appropriate choice regarding the procedure he/she elects to have and the risks he/she is willing to accept. In my opinion, GERD remains at least a relative contraindication to SG. Michel Suter* Department of Surgery Hôpital du Chablais Aigle, Switzerland References [1] Evaluation of Gastroesophageal reflux before and after laparoscopic sleeve gastrectomy using Symptom Scoring, scintigraphy and endoscopy. Surg Obes Relat Dis 2014: xxxxxxx2. [2] Suter M, Dorta G, Giusti V, Calmes JM. Gastro-esophageal reflux and esophageal motility disorders in morbidly obese patients. Obes Surg 2004;14:959–66. [3] Rosenthal RJ. International sleeve gastrectomy expert panel consensus statement: best practice guidelines based on experience of 412000 cases. Surg Obes Relat Dis 2012;8:8–19. [4] Smith SC, Edwards CB, Goodman GN. Symptomatic and clinical improvement in morbidly obese patients with gastroesophageal reflux disease following Roux-en-Y gastric bypass. Obes Surg 1997;7: 479–84. [5] Madalosso CA, Gurski RR, Callegari-Jacques SM, Navarini D, Thiesen V, Fornari F. The impact of gastric bypass on gastroesophageal reflux disease in patients with morbid obesity: a prospective study based on the Montreal Consensus. Ann Surg 2010;251:244–8. [6] Gautier T, Sarcher T, Contival N, Le Roux Y, Alves A. Indications and mid-term results of conversion from sleeve gastrectomy to Roux-en-Y gastric bypass. Obes Surg 2013;23:212–5. [7] Mahawar KK, Jennins N, Balupuri S, Small PK. Sleeve gastrectomy and gastro-oesophageal reflux disease: a complex relationship. Obes Surg 2013;23:987–91.
* Correspondence: Michel Suter, Hôpital du Chablais, Chemin du Grand Chene, Aigle 1860, Switzerland. E-mail: [email protected]
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