Esophageal reflux common after sleeve gastrectomy

By Will Boggs MD

NEW YORK (Reuters Health) - 12/4/2019

About one in four patients will develop gastroesophageal reflux disease (GERD) after sleeve gastrectomy, but few will require conversion to gastric bypass for severe reflux, according to a systematic review and meta-analysis.

"The high rates of new GERD and worsening GERD after the very common procedure of sleeve gastrectomy" were surprising, said Dr. Hutan Ashrafian of Imperial College London.

"This operation is generally considered a relatively 'straightforward,' safe, and rapidly performed operation for obesity, though it seems to result in many of the complications of GERD and lower esophageal reflux conditions, such as esophagitis and even Barrett's esophagus," he told Reuters Health by email.

Sleeve gastrectomy is the most common bariatric procedure, yet there is disparity in the current literature about the development or worsening of GERD postoperatively.

To investigate, Dr. Ashrafian's team used data from 46 studies including more than 10,000 patients and with follow-ups ranging from three to 132 months.

Overall, there was a 19% increase in the prevalence of esophageal reflux following sleeve gastrectomy and a 23% rate of new-onset reflux, the researchers report in Annals of Surgery, online March 1.

The rate of postoperative esophagitis was 30%, which remained 28% at long-term follow-up, and the rate of Barrett's esophagus after sleeve gastrectomy was 6% (8% long-term).

Hiatus hernia developed after sleeve gastrectomy in 41% of patients, and 38% of patients required proton-pump inhibitors to manage symptoms; 4% of patients were converted to gastric bypass because of severe reflux.

"When selecting and, importantly, consenting patients for this procedure, surgeons and patients should be mindful of the risk of GERD, esophagitis, and Barrett's esophagus after sleeve gastrectomy," Dr. Ashrafian said. "Some patients may therefore benefit from anti-obesity procedures that are more protective of GERD and its symptoms, such as performing Roux-en-Y gastric bypass."

Dr. Dmitry Oleynikov of the University of Nebraska Medical Center, in Omaha, who recently reviewed techniques that can be used to mitigate the severity of reflex following sleeve gastrectomy, told Reuters Health by email, "There is no question among experts that around 20% to 30% of patients will develop de novo severe reflux after this operation. Because obesity is on the rise and because this is such a popular operation, patients and surgeons need to be aware of this risk. In our study, as well as many others, a great many of the patients, in fact the majority with obesity and reflux, will benefit from this operation."

"It's very important that patients who are high risk for developing reflux disease, including those with hiatal hernia, known severe reflux, and Barrett's esophagus, are not good candidates for this operation and should be offered other types of bariatric surgery," said Dr. Oleynikov, who was not involved in the new work. "Unfortunately, not every surgeon feels comfortable offering a multitude of bariatric procedures, so the patient is only given one choice. In high-risk patients, the consensus is that the patient should be receiving a Roux-en-Y gastric bypass."

"If one develops severe reflux after sleeve gastrectomy, the best option is to proceed to bypass surgery," Dr. Oleynikov said. "However, many insurance companies will not approve this."


Ann Surg 2019.

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