Author's Accepted Manuscript
Gastroesophageal reflux disease in the bariatric population: when is a laparoscopic sleeve gastrectomy the right choice? Radu Pescarus MD, Kevin M. Reavis, Lee L. Swanströ m MD
www.elsevier.com/locate/buildenv
PII: DOI: Reference:
S1550-7289(14)00235-4 http://dx.doi.org/10.1016/j.soard.2014.05.032 SOARD2030
To appear in:
Surgery for Obesity and Related Diseases
Cite this article as: Radu Pescarus MD, Kevin M. Reavis, Lee L. Swanströ m MD, Gastroesophageal reflux disease in the bariatric population: when is a laparoscopic sleeve gastrectomy the right choice?, Surgery for Obesity and Related Diseases, http://dx.doi. org/10.1016/j.soard.2014.05.032 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Title Gastroesophageal reflux disease in the bariatric population: when is a laparoscopic sleeve gastrectomy the right choice? Authors Radu Pescarus, MD (1) Kevin M. Reavis (1,2) Lee L. Swanström, MD (1,2)
(1) Department of Surgery Providence Portland Medical Center 4805 NE Glisan St, Suite 6N60 Portland, OR 97213 Phone: 503-281-0561 Fax: (503) 281-0575 (2) Gastrointestinal and Minimally Invasive Surgery Division The Oregon Clinic 3805 NE Glisan St, Suite 6N60 Portland, OR 97213 Phone: 503-281-0561 Fax: (503) 281-0575 Corresponding Author: Radu Pescarus, MD FACS Providence Portland Medical Center 4805 NE Glisan St, Suite 6N60 Portland, OR 97213 Phone: 503-281-0561 Fax: (503) 281-0575
1
Title
Gastroesophageal reflux disease in the bariatric population: when is a laparoscopic sleeve gastrectomy the right choice?
To the editor,
We read with great interest the work of Dr Santonicola and colleagues entitled “The effect of laparoscopic sleeve gastrectomy with or without hiatal hernia repair on gastroesophageal reflux disease in obese patients’’ published in the April issue of the Journal (1).
We commend the authors for attempting to shed more light onto the issue of post-operative gastroesophageal reflux disease (GERD) symptoms incidence post sleeve gastrectomy in the bariatric population. The study compares 2 distinct patient populations, group I with 78 patients with an intra-operatively diagnosed type I hiatal hernia (HH) who underwent primary posterior crural repair and laparoscopic sleeve gastrectomy (LSG) and group II with 102 patients who underwent LSG in the absence of HH. GERD symptoms assessment was done using a standard questionnaire establishing a frequency-intensity score both preoperatively and at 6 months post-operatively.
It is admirable that 100% follow up with both pre and post-operative data is available in
2
this series. It is unclear however what is considered by the authors to be a valid positive symptom (a mild, moderate, severe or any) score and no PPI use data is available. Unfortunately, no objective data such as esophageal acid exposure testing is available to support the subjective GERD questionnaire data. It has been shown by our team and others that there is very poor correlation between post-operative GERD symptoms and actual reflux on pH study with symptoms having a sensitivity of 48% (2). Moreover, the comparison between the 2 groups is difficult to interpret, as a patient with a repaired HH should not have a different outcome than a patient without a HH.
The authors conclude that LSG ‘’has a beneficial effect on relieving GERD symptoms’’. One can however interpret the results of this study differently. Overall in the 180 patients, 70 patients (39%) had GERD symptoms pre-operatively and 44 patients (24 %) had GERD symptoms post-operatively with half of those (12%) presenting with new onset postoperative GERD (1). In a recent study, Burgerhart et al. presented objective pH study and manometry data in 20 patients before and 3 months post LSG (3). Interestingly, although no difference in typical symptoms was noted before and after the LSG, the lower esophageal sphincter pressure was significantly decreased and the esophageal acid exposure significantly increased after LSG (3). It is difficult, based on the results of these 2 studies, to recommend the LSG as a GERD-relieving operation.
We believe that a tailored approach is beneficial in the bariatric surgical decision algorithm and care should be exerted in differentiating the bariatric patient that has GERD as one of their comorbidities from the GERD patient that is obese. Although a LSG could be an
3
acceptable surgical option in the first case, the second category of patients can potentially be unsatisfied with the high rate of post-operative GERD. Indeed, the addition of a concomitant anti-reflux mechanism such as the Hill procedure might represent a solution to the high-risk GERD patient. We applaud the efforts of Dr Santanicola and colleagues in investigating the relationship of sleeve gastrectomy and GERD and hope that further objective data will increase our understanding of this important, still unresolved issue.
4
References
1. Santonicola A, Angrisani L, Cutolo P, Formisano G, Iovino P. The effect of laparoscopic sleeve gastrectomy with or without hiatal hernia repair on gastroesophageal reflux disease in obese patients. Surgery for Obesity and Related Diseases 10 (2014) 250–256 2. Khajanchee YS, O'Rourke RW, Lockhart B, Patterson EJ, Hansen PD, Swanstrom LL. Postoperative symptoms and failure after antireflux surgery. Arch Surg. 2002; 137:1008-1014. 3. Burgerhart JS, Schotborgh CA, Schoon EJ et al. Effect of sleeve gastrectomy on gastroesophageal reflux. ObesSurg. 2014 Mar 12.
5
Gastroesophageal reflux disease in the bariatric population: when is a laparoscopic sleeve gastrectomy the right choice? Radu Pescarus MD, Kevin M. Reavis, Lee L. Swanströ m MD
www.elsevier.com/locate/buildenv
PII: DOI: Reference:
S1550-7289(14)00235-4 http://dx.doi.org/10.1016/j.soard.2014.05.032 SOARD2030
To appear in:
Surgery for Obesity and Related Diseases
Cite this article as: Radu Pescarus MD, Kevin M. Reavis, Lee L. Swanströ m MD, Gastroesophageal reflux disease in the bariatric population: when is a laparoscopic sleeve gastrectomy the right choice?, Surgery for Obesity and Related Diseases, http://dx.doi. org/10.1016/j.soard.2014.05.032 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Title Gastroesophageal reflux disease in the bariatric population: when is a laparoscopic sleeve gastrectomy the right choice? Authors Radu Pescarus, MD (1) Kevin M. Reavis (1,2) Lee L. Swanström, MD (1,2)
(1) Department of Surgery Providence Portland Medical Center 4805 NE Glisan St, Suite 6N60 Portland, OR 97213 Phone: 503-281-0561 Fax: (503) 281-0575 (2) Gastrointestinal and Minimally Invasive Surgery Division The Oregon Clinic 3805 NE Glisan St, Suite 6N60 Portland, OR 97213 Phone: 503-281-0561 Fax: (503) 281-0575 Corresponding Author: Radu Pescarus, MD FACS Providence Portland Medical Center 4805 NE Glisan St, Suite 6N60 Portland, OR 97213 Phone: 503-281-0561 Fax: (503) 281-0575
1
Title
Gastroesophageal reflux disease in the bariatric population: when is a laparoscopic sleeve gastrectomy the right choice?
To the editor,
We read with great interest the work of Dr Santonicola and colleagues entitled “The effect of laparoscopic sleeve gastrectomy with or without hiatal hernia repair on gastroesophageal reflux disease in obese patients’’ published in the April issue of the Journal (1).
We commend the authors for attempting to shed more light onto the issue of post-operative gastroesophageal reflux disease (GERD) symptoms incidence post sleeve gastrectomy in the bariatric population. The study compares 2 distinct patient populations, group I with 78 patients with an intra-operatively diagnosed type I hiatal hernia (HH) who underwent primary posterior crural repair and laparoscopic sleeve gastrectomy (LSG) and group II with 102 patients who underwent LSG in the absence of HH. GERD symptoms assessment was done using a standard questionnaire establishing a frequency-intensity score both preoperatively and at 6 months post-operatively.
It is admirable that 100% follow up with both pre and post-operative data is available in
2
this series. It is unclear however what is considered by the authors to be a valid positive symptom (a mild, moderate, severe or any) score and no PPI use data is available. Unfortunately, no objective data such as esophageal acid exposure testing is available to support the subjective GERD questionnaire data. It has been shown by our team and others that there is very poor correlation between post-operative GERD symptoms and actual reflux on pH study with symptoms having a sensitivity of 48% (2). Moreover, the comparison between the 2 groups is difficult to interpret, as a patient with a repaired HH should not have a different outcome than a patient without a HH.
The authors conclude that LSG ‘’has a beneficial effect on relieving GERD symptoms’’. One can however interpret the results of this study differently. Overall in the 180 patients, 70 patients (39%) had GERD symptoms pre-operatively and 44 patients (24 %) had GERD symptoms post-operatively with half of those (12%) presenting with new onset postoperative GERD (1). In a recent study, Burgerhart et al. presented objective pH study and manometry data in 20 patients before and 3 months post LSG (3). Interestingly, although no difference in typical symptoms was noted before and after the LSG, the lower esophageal sphincter pressure was significantly decreased and the esophageal acid exposure significantly increased after LSG (3). It is difficult, based on the results of these 2 studies, to recommend the LSG as a GERD-relieving operation.
We believe that a tailored approach is beneficial in the bariatric surgical decision algorithm and care should be exerted in differentiating the bariatric patient that has GERD as one of their comorbidities from the GERD patient that is obese. Although a LSG could be an
3
acceptable surgical option in the first case, the second category of patients can potentially be unsatisfied with the high rate of post-operative GERD. Indeed, the addition of a concomitant anti-reflux mechanism such as the Hill procedure might represent a solution to the high-risk GERD patient. We applaud the efforts of Dr Santanicola and colleagues in investigating the relationship of sleeve gastrectomy and GERD and hope that further objective data will increase our understanding of this important, still unresolved issue.
4
References
1. Santonicola A, Angrisani L, Cutolo P, Formisano G, Iovino P. The effect of laparoscopic sleeve gastrectomy with or without hiatal hernia repair on gastroesophageal reflux disease in obese patients. Surgery for Obesity and Related Diseases 10 (2014) 250–256 2. Khajanchee YS, O'Rourke RW, Lockhart B, Patterson EJ, Hansen PD, Swanstrom LL. Postoperative symptoms and failure after antireflux surgery. Arch Surg. 2002; 137:1008-1014. 3. Burgerhart JS, Schotborgh CA, Schoon EJ et al. Effect of sleeve gastrectomy on gastroesophageal reflux. ObesSurg. 2014 Mar 12.
5
