Surgery for Obesity and Related Diseases 10 (2014) 1013–1015
Letter to the Editor
Reply to “Gastroesophageal reflux disease in the bariatric population: when is a laparoscopic sleeve gastrectomy the right choice?” We thank Pescarus et al. for their interest in our paper [1] that aims to study whether laparoscopic sleeve gastrectomy (LSG) alone or combined with hiatal hernia (HH) repair (HHR), whenever HH was present, could improve gastroesophageal reflux disease (GERD) symptoms in obese patients diagnosed on the basis of a standard definition of GERD. First of all, we appreciate the authors’ acknowledgment of our high rate of followup. This reflects our concept of the “bariatric way.” We strongly believe that bariatric surgery is only 1 phase of a multistep process that includes a multidisciplinary preoperative evaluation and regular postoperative outpatient management. We invite patients for follow-up in every possible way: phone calls, e-mails, and messages via Whatsapp or Facebook. We believe that patients who are followed regularly by the bariatric center have a better likelihood of achieving and maintaining good long-term weight loss results compared to those who are lost to follow-up. The authors commented that we did not state in the study’s results what is a valid positive symptoms (a mild, moderate, severe, or any), and we did not report the usage of proton pump inhibitors (PPI) for the 2 study groups. According to our standardized questionnaire [2–4], in each participant the symptom frequency-intensity score was obtained by adding the frequency and the intensity score of each typical GERD symptoms ranging from 0 to a maximum of 6. Moreover, each symptom on the basis of the intensity-frequency score was defined as mild (1–2), moderate (3–4), and severe (5–6). In our paper [1], Fig. 2 showed the mean of frequency-intensity scores, rather than the percentages of patients with a mild, moderate, and severe symptoms’ score; however, in this reply to better explain our findings, we added Table 1 that reports the prevalence of patients with mild, moderate, and severe symptom frequency-intensity scores before and after surgery in the 2 groups. Eighteen/30 (60%) LSGþHHR versus 17/40 (42.5%) of LSG patients took a PPI preoperatively. There was a significant correlation between the percent of
patients with mild, moderate, and severe heartburn and/or regurgitation frequency-intensity scores and PPI treatment in LSGþHHR group (R Spearman ¼ 0.77 and 0.66, respectively, P o 0.01 in all cases) and in the LSG group (R Spearman ¼ 0.54 and 0.56, respectively, P o 0.01 in all cases). Pescarus et al. also pointed out the lack of objective data, such as esophageal acid exposure testing to support the subjective GERD questionnaire data. We agree and stated the limitations of our study [1] regarding the absence of reflux testing to quantify the effect of LSG on GERD. Furthermore in our previous reply [5], we underlined the need for future randomized, prospective studies with a complete assessment of GERD and HH (including esophageal manometry and 24-hr pH measurements) before and after LSG. However, according to the Montreal Consensus Conference [6], GERD is diagnosed based on typical symptoms alone, which in our study were assessed by a standardized questionnaire [2–4] and no further diagnostic tests for GERD were necessary, especially after exclusion of misdiagnoses and GERD complications by upper gastrointestinal endoscopy [7]. Although Burgerhart et al. [8] demonstrated a significant decrease in the lower esophageal sphincter (LES) pressure after LSG, current data about the effect of LSG on LES resting pressure are still controversial. Petersen et al. [9], in fact, described an increase of LES after LSG. The substantial differences in surgical techniques might explain these LES pressure differences. Moreover, Pescarus et al. stated, “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.” However, as reported by Pomp [10] and highlighted in our previous reply [5], the HHR combined with LSG is in no way a standardized procedure and substantial differences exist in the technique of hiatal dissection and the subsequent alterations in the sling fibers at the angle of His. These differences could explain the different postoperative outcomes reported in the literature of HHR combined with LSG on GERD symptoms and also the worse postoperative effect of GERD symptoms after HHR combined with LSG compared to LSG alone.
http://dx.doi.org/10.1016/j.soard.2014.06.017 1550-7289/r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
1014
A. Santonicola et al. / Surgery for Obesity and Related Diseases 10 (2014) 1013–1015
Table 1 Percent of mild, moderate, and severe symptom frequency-intensity scores before and after surgery in the laparoscopic sleeve gastrectomy (LSG) with concomitant hiatal hernia repair (LSGþHHR) and LSG only Baseline
Heartburn frequency-intensity score Mild (%) Heartburn frequency-intensity score Moderate (%) Heartburn frequency-intensity score Severe (%) Regurgitation frequency-intensity score Mild (%) Regurgitation frequency-intensity score Moderate (%) Regurgitation frequency-intensity score Severe (%) *
Follow-Up
LSGþHHR (n ¼ 30/78)
LSG (n ¼ 40/102)
36.7
*
P value
LSGþHHR (n ¼ 24/78)
LSG (n ¼ 20/102)
47.7
33.3
75
36.6
37.6
37.5
15
26.7
14.7
29.2
10
43.4
52.5
29.2
60
36.7
32.5
41.7
30
20
15
29.1
10
0.4
0.7
P value*
0.02
0.09
P o 0.05 chi square.
Although the alternative interpretation of our results offered by Pescarus et al. was not the aim of our study, we agree with the authors that there are controversial results in the outcome of GERD symptoms after LSG with and without HHR [11] including the new onset postoperative GERD [12]. Our conclusion that LSG “has a beneficial effect on relieving GERD symptoms” confirms the results of recent studies that showed a significant improvement in GERD [11,13] and of a systematic review in which 7 studies on 11 found a decreased prevalence of GERD after SG [14]. Hopefully, randomized studies in similarly obese patients with GERD and HH with a complete assessment of GERD and HH (i.e., using standardized questionnaires, esophageal manometry and 24-hr pH measurements) before and after surgery at scheduled long-term follow-up intervals, combined with an intraoperative assessment of the size of HH, are needed to compare. LSG and LSGþHHR to give us more insight on how to tailor HH management. Antonella Santonicola, M.D. Department of Clinical Medicine and Surgery “Federico II” University of Naples Naples, Italy, Luigi Angrisani, M.D. General and Endoscopic Surgery Unit S. Giovanni Bosco Hospital Naples, Italy, Paola Iovino, M.D. Medicine and Surgery Department University of Salerno Salerno, Italy
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. Surg Obes Relat Dis 2014;10:250–6. [2] Amato G, Limongelli P, Pascariello A, et al. Association between persistent symptoms and long-term quality of life after laparoscopic total fundoplication. Am J Surg 2008;196:582–6. [3] Iovino P, Angrisani L, Tremolaterra F, et al. Abnormal esophageal acid exposure is common in morbidly obese patients and improves after a successful lap-band system implantation. Surg Endosc 2002;16:1631–5. [4] Iovino P, Angrisani L, Galloro G, et al. Proximal stomach function in obesity with normal or abnormal oesophageal acid exposure. Neurogastroenterol Motil 2006;18:425–32. [5] Santonicola A, Angrisani L, Iovino P. Reply to “Comment on: the effect of laparoscopic sleeve gastrectomy with or without hiatal hernia repair on gastroesophageal reflux disease in obese patients.”. Surg Obes Relat Dis 2014;10:371–2. [6] Vakil N, van Zanten SV, Kahrilas P, Dent J, Jones R, Global Consensus Group. The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. Am J Gastroenterol 2006;101:1900–20. [7] Kahrilas PJ, Shaheen NJ, Vaezi MF, et al. American Gastroenterological Association medical position statement on the management of gastroesophageal reflux disease. Gastroenterology 2008;135: 1383–91. [8] Burgerhart JS, Schotborgh CA, et al. Effect of sleeve gastrectomy on gastroesophageal reflux. Obes Surg 2014;24:1436–41. [9] Petersen WV, Meile T, Küper MA, Zdichavsky M, Königsrainer A, Schneider JH. Functional importance of laparoscopic sleeve gastrectomy for the lower esophageal sphincter in patients with morbid obesity. Obes Surg 2012;22:360–6. [10] Pomp A. Comment on: sleeve gastrectomy and crural repair in obese patients with gastroesophageal reflux disease and/or hiatal hernia. Surg Obes Relat Dis 2013;9:361–2. [11] Daes J, Jimenez ME, Said N, Dennis R. Improvement of gastroesophageal reflux symptoms after standardized laparoscopic sleeve gastrectomy. Obes Surg 2014;24:536–40.
Letter to the Editor / Surgery for Obesity and Related Diseases 10 (2014) 1013–1015 [12] Del Genio G, Tolone S, Limongelli P, et al. Sleeve gastrectomy and development of “de novo” gastroesophageal reflux. Obes Surg 2014; 24:71–7. [13] Pallati PK, Shaligram A, Shostrom VK, Oleynikov D, McBride CL, Goede MR. Improvement in gastroesophageal reflux disease symptoms
1015
after various bariatric procedures: review of the Bariatric Outcomes Longitudinal Database. Surg Obes Relat Dis 2014;10:502–7. [14] Chiu S, Birch DW, Shi X, Sharma AM, Karmali S. Effect of sleeve gastrectomy on gastroesophageal reflux disease: a systematic review. Surg Obes Relat Dis 2011;7:510–5.
Letter to the Editor
Reply to “Gastroesophageal reflux disease in the bariatric population: when is a laparoscopic sleeve gastrectomy the right choice?” We thank Pescarus et al. for their interest in our paper [1] that aims to study whether laparoscopic sleeve gastrectomy (LSG) alone or combined with hiatal hernia (HH) repair (HHR), whenever HH was present, could improve gastroesophageal reflux disease (GERD) symptoms in obese patients diagnosed on the basis of a standard definition of GERD. First of all, we appreciate the authors’ acknowledgment of our high rate of followup. This reflects our concept of the “bariatric way.” We strongly believe that bariatric surgery is only 1 phase of a multistep process that includes a multidisciplinary preoperative evaluation and regular postoperative outpatient management. We invite patients for follow-up in every possible way: phone calls, e-mails, and messages via Whatsapp or Facebook. We believe that patients who are followed regularly by the bariatric center have a better likelihood of achieving and maintaining good long-term weight loss results compared to those who are lost to follow-up. The authors commented that we did not state in the study’s results what is a valid positive symptoms (a mild, moderate, severe, or any), and we did not report the usage of proton pump inhibitors (PPI) for the 2 study groups. According to our standardized questionnaire [2–4], in each participant the symptom frequency-intensity score was obtained by adding the frequency and the intensity score of each typical GERD symptoms ranging from 0 to a maximum of 6. Moreover, each symptom on the basis of the intensity-frequency score was defined as mild (1–2), moderate (3–4), and severe (5–6). In our paper [1], Fig. 2 showed the mean of frequency-intensity scores, rather than the percentages of patients with a mild, moderate, and severe symptoms’ score; however, in this reply to better explain our findings, we added Table 1 that reports the prevalence of patients with mild, moderate, and severe symptom frequency-intensity scores before and after surgery in the 2 groups. Eighteen/30 (60%) LSGþHHR versus 17/40 (42.5%) of LSG patients took a PPI preoperatively. There was a significant correlation between the percent of
patients with mild, moderate, and severe heartburn and/or regurgitation frequency-intensity scores and PPI treatment in LSGþHHR group (R Spearman ¼ 0.77 and 0.66, respectively, P o 0.01 in all cases) and in the LSG group (R Spearman ¼ 0.54 and 0.56, respectively, P o 0.01 in all cases). Pescarus et al. also pointed out the lack of objective data, such as esophageal acid exposure testing to support the subjective GERD questionnaire data. We agree and stated the limitations of our study [1] regarding the absence of reflux testing to quantify the effect of LSG on GERD. Furthermore in our previous reply [5], we underlined the need for future randomized, prospective studies with a complete assessment of GERD and HH (including esophageal manometry and 24-hr pH measurements) before and after LSG. However, according to the Montreal Consensus Conference [6], GERD is diagnosed based on typical symptoms alone, which in our study were assessed by a standardized questionnaire [2–4] and no further diagnostic tests for GERD were necessary, especially after exclusion of misdiagnoses and GERD complications by upper gastrointestinal endoscopy [7]. Although Burgerhart et al. [8] demonstrated a significant decrease in the lower esophageal sphincter (LES) pressure after LSG, current data about the effect of LSG on LES resting pressure are still controversial. Petersen et al. [9], in fact, described an increase of LES after LSG. The substantial differences in surgical techniques might explain these LES pressure differences. Moreover, Pescarus et al. stated, “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.” However, as reported by Pomp [10] and highlighted in our previous reply [5], the HHR combined with LSG is in no way a standardized procedure and substantial differences exist in the technique of hiatal dissection and the subsequent alterations in the sling fibers at the angle of His. These differences could explain the different postoperative outcomes reported in the literature of HHR combined with LSG on GERD symptoms and also the worse postoperative effect of GERD symptoms after HHR combined with LSG compared to LSG alone.
http://dx.doi.org/10.1016/j.soard.2014.06.017 1550-7289/r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
1014
A. Santonicola et al. / Surgery for Obesity and Related Diseases 10 (2014) 1013–1015
Table 1 Percent of mild, moderate, and severe symptom frequency-intensity scores before and after surgery in the laparoscopic sleeve gastrectomy (LSG) with concomitant hiatal hernia repair (LSGþHHR) and LSG only Baseline
Heartburn frequency-intensity score Mild (%) Heartburn frequency-intensity score Moderate (%) Heartburn frequency-intensity score Severe (%) Regurgitation frequency-intensity score Mild (%) Regurgitation frequency-intensity score Moderate (%) Regurgitation frequency-intensity score Severe (%) *
Follow-Up
LSGþHHR (n ¼ 30/78)
LSG (n ¼ 40/102)
36.7
*
P value
LSGþHHR (n ¼ 24/78)
LSG (n ¼ 20/102)
47.7
33.3
75
36.6
37.6
37.5
15
26.7
14.7
29.2
10
43.4
52.5
29.2
60
36.7
32.5
41.7
30
20
15
29.1
10
0.4
0.7
P value*
0.02
0.09
P o 0.05 chi square.
Although the alternative interpretation of our results offered by Pescarus et al. was not the aim of our study, we agree with the authors that there are controversial results in the outcome of GERD symptoms after LSG with and without HHR [11] including the new onset postoperative GERD [12]. Our conclusion that LSG “has a beneficial effect on relieving GERD symptoms” confirms the results of recent studies that showed a significant improvement in GERD [11,13] and of a systematic review in which 7 studies on 11 found a decreased prevalence of GERD after SG [14]. Hopefully, randomized studies in similarly obese patients with GERD and HH with a complete assessment of GERD and HH (i.e., using standardized questionnaires, esophageal manometry and 24-hr pH measurements) before and after surgery at scheduled long-term follow-up intervals, combined with an intraoperative assessment of the size of HH, are needed to compare. LSG and LSGþHHR to give us more insight on how to tailor HH management. Antonella Santonicola, M.D. Department of Clinical Medicine and Surgery “Federico II” University of Naples Naples, Italy, Luigi Angrisani, M.D. General and Endoscopic Surgery Unit S. Giovanni Bosco Hospital Naples, Italy, Paola Iovino, M.D. Medicine and Surgery Department University of Salerno Salerno, Italy
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. Surg Obes Relat Dis 2014;10:250–6. [2] Amato G, Limongelli P, Pascariello A, et al. Association between persistent symptoms and long-term quality of life after laparoscopic total fundoplication. Am J Surg 2008;196:582–6. [3] Iovino P, Angrisani L, Tremolaterra F, et al. Abnormal esophageal acid exposure is common in morbidly obese patients and improves after a successful lap-band system implantation. Surg Endosc 2002;16:1631–5. [4] Iovino P, Angrisani L, Galloro G, et al. Proximal stomach function in obesity with normal or abnormal oesophageal acid exposure. Neurogastroenterol Motil 2006;18:425–32. [5] Santonicola A, Angrisani L, Iovino P. Reply to “Comment on: the effect of laparoscopic sleeve gastrectomy with or without hiatal hernia repair on gastroesophageal reflux disease in obese patients.”. Surg Obes Relat Dis 2014;10:371–2. [6] Vakil N, van Zanten SV, Kahrilas P, Dent J, Jones R, Global Consensus Group. The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. Am J Gastroenterol 2006;101:1900–20. [7] Kahrilas PJ, Shaheen NJ, Vaezi MF, et al. American Gastroenterological Association medical position statement on the management of gastroesophageal reflux disease. Gastroenterology 2008;135: 1383–91. [8] Burgerhart JS, Schotborgh CA, et al. Effect of sleeve gastrectomy on gastroesophageal reflux. Obes Surg 2014;24:1436–41. [9] Petersen WV, Meile T, Küper MA, Zdichavsky M, Königsrainer A, Schneider JH. Functional importance of laparoscopic sleeve gastrectomy for the lower esophageal sphincter in patients with morbid obesity. Obes Surg 2012;22:360–6. [10] Pomp A. Comment on: sleeve gastrectomy and crural repair in obese patients with gastroesophageal reflux disease and/or hiatal hernia. Surg Obes Relat Dis 2013;9:361–2. [11] Daes J, Jimenez ME, Said N, Dennis R. Improvement of gastroesophageal reflux symptoms after standardized laparoscopic sleeve gastrectomy. Obes Surg 2014;24:536–40.
Letter to the Editor / Surgery for Obesity and Related Diseases 10 (2014) 1013–1015 [12] Del Genio G, Tolone S, Limongelli P, et al. Sleeve gastrectomy and development of “de novo” gastroesophageal reflux. Obes Surg 2014; 24:71–7. [13] Pallati PK, Shaligram A, Shostrom VK, Oleynikov D, McBride CL, Goede MR. Improvement in gastroesophageal reflux disease symptoms
1015
after various bariatric procedures: review of the Bariatric Outcomes Longitudinal Database. Surg Obes Relat Dis 2014;10:502–7. [14] Chiu S, Birch DW, Shi X, Sharma AM, Karmali S. Effect of sleeve gastrectomy on gastroesophageal reflux disease: a systematic review. Surg Obes Relat Dis 2011;7:510–5.
