Highlights
- •GERD prevalence increases after SG
- •Addition of HHR to SG did not influence GERD outcomes
- •Preoperative GERD, OSA, anxiety, HH, and Hill grade were associated with GERD postoperatively
- •Hill grade III-IV is an independent risk factor for GERD after SG
- •GERD, gastroesophageal reflux disease; SG, sleeve gastrectomy; HHR, hiatal hernia repair; OSA, obstructive sleep apnea; HH, hiatal hernia.
Abstract
Background
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.
Objective
To explore the relationship between preoperative Hill grade and GERD outcomes 2 years
after SG.
Setting
Academic hospital, United States.
Methods
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.
Results
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.
Conclusions
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.
Graphical abstract
Graphical Abstract
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Surgery for Obesity and Related DiseasesAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
Centers for Disease Control and Prevention (CDC) [homepage on the Internet]. Atlanta: The Centers; [reviewed May 17, 2022; cited 2021 Aug 23]. Adult Obesity Facts; [about 2 screens]. Available from: https://www.cdc.gov/obesity/data/adult.html.
World Health Organization (WHO) [homepage on the Internet]. Geneva, Switzerland: The Organization; [update 2021 Jun 9; cited 2021 Aug 23]. Obesity and Overweight; [about 10 screens]. Available from: https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight.
- Bariatric surgery versus intensive medical therapy for diabetes - 5-year outcomes.N Engl J Med. 2017; 376: 641-651
- American Society for Metabolic and Bariatric Surgery 2020 estimate of metabolic and bariatric procedures performed in the United States.Surg Obes Relat Dis. 2022; 18: 1134-1140
- Relationship between bariatric surgery and gastroesophageal reflux disease: a systematic review and meta-analysis.Obes Surg. 2019; 29: 4105-4113
- American Society for Metabolic and Bariatric Surgery Clinical Issues Committee. American Society for Metabolic and Bariatric Surgery updated position statement on sleeve gastrectomy as a bariatric procedure.Surg Obes Relat Dis. 2017; 13: 1652-1657
- (2018) GERD: presence and size of hiatal hernia influence clinical presentation, esophageal function, reflux profile, and degree of mucosal injury.Am Surg. 2018; 84: 978-982
- Hill classification is superior to the axial length of a hiatal hernia for assessment of the mechanical anti-reflux barrier at the gastroesophageal junction.Endosc Int Open. 2016; 4: E311-E317
- Clinical Issues Committee of the American Society for Metabolic and Bariatric Surgery. ASMBS position statement on the rationale for performance of upper gastrointestinal endoscopy before and after metabolic and bariatric surgery.Surg Obes Relat Dis. 2021; 17: 837-847
- The role of endoscopy in the bariatric surgery patient.Surg Obes Relat Dis. 2015; 11: 507-517
- Sleeve gastrectomy: surgical tips.J Laparoendosc Adv Surg Tech A. 2018; 28: 930-937
- Standardized outcomes reporting in metabolic and bariatric surgery.Surg Obes Relat Dis. 2015; 11: 489-506
- Body-mass index and symptoms of gastroesophageal reflux in women.N Engl J Med. 2006; 354: 2340-2348
- Update on the epidemiology of gastro-oesophageal reflux disease: a systematic review.Gut. 2014; 63: 871-880
- Prevalence of gastroesophageal reflux and risk factors for erosive esophagitis in obese patients considered for bariatric surgery.Dig Liver Dis. 2019; 51: 1375-1379
- Gastroesophageal reflux disease in the obese: pathophysiology and treatment.Surgery. 2016; 159: 475-486
- Impact of obesity treatment on gastroesophageal reflux disease.World J Gastroenterol. 2016; 22: 1627-1638
- Disruption of the gastroesophageal junction by central obesity and waist belt: role of raised intra-abdominal pressure.Dis Esophagus. 2015; 28: 318-325
- Obesity is associated with increased transient lower esophageal sphincter relaxation.Gastroenterology. 2007; 132: 883-889
- Obesity: a challenge to esophagogastric junction integrity.Gastroenterology. 2006; 130: 639-649
- Gastroesophageal pressure gradients in gastroesophageal reflux disease: relations with hiatal hernia, body mass index, and esophageal acid exposure.Am J Gastroenterol. 2008; 103: 1349-1354
- Impact of preoperative wireless pH monitoring in the evaluation of esophageal conditions prior to bariatric surgery in a severely obese patient population.Surg Obes Relat Dis. 2019; 15: 288-294
- Association of obesity with hiatal hernia and esophagitis.Am J Gastroenterol. 1999; 94: 2840-2844
- Accuracy of hiatal hernia diagnosis in bariatric patients: preoperative endoscopy versus intraoperative reference.JGH Open. 2020; 4: 1074-1078
- Hiatal hernia evaluation before bariatric surgery: should it be routinely done?.Obes Surg. 2021; 31: 1013-1020
- Hiatal hernia diagnosis prospectively assessed in obese patients before bariatric surgery: accuracy of high-resolution manometry taking intraoperative diagnosis as reference standard.Surg Endosc. 2020; 34: 1150-1156
- Preoperative versus intraoperative diagnosis of hiatal hernia in bariatric population.Surg Obes Relat Dis. 2019; 15: 1949-1955
- Prevalence of hiatal hernia in the morbidly obese.Surg Obes Relat Dis. 2013; 9: 920-924
- Efficiency of preoperative esophagogastroduodenoscopy in identifying operable hiatal hernia for bariatric surgery patients.Surg Obes Relat Dis. 2017; 13: 287-290
- In the eye of the beholder: surgeon variation in intra-operative perceptions of hiatal hernia and reflux outcomes after sleeve gastrectomy.Surg Endosc. 2021; 35: 2537-2542
- Gastroesophageal reflux in healthy subjects. Significance of endoscopic findings, histology, age, and sex.Scand J Gastroenterol. 1999; 34: 121-128
- Relationship between endoscopic hiatus hernia and gastroesophageal reflux symptoms.Scand J Gastroenterol. 1991; 26: 921-926
- Jet al. Gastro-oesophageal reflux symptoms, oesophagitis and Barrett’s oesophagus in the general population: the Loiano-Monghidoro study.Gut. 2008; 57: 1354-1359
- Hiatal hernia, reflux symptoms, body size, and risk of esophageal and gastric adenocarcinoma.Cancer. 2003; 98: 940-948
- Hiatal hernia size is the dominant determinant of esophagitis presence and severity in gastroesophageal reflux disease.Am J Gastroenterol. 2001; 96: 1711-1717
- Concomitant hiatal hernia repair is more common in laparoscopic sleeve gastrectomy than during laparoscopic Roux-en-Y gastric bypass: an analysis of 130,772 cases.Obes Surg. 2019; 29: 744-746
- Safety of concurrent sleeve gastrectomy and hiatal hernia repair: a propensity score-matched analysis of the MBSAQIP registry.Surg Obes Relat Dis. 2020; 16: 365-371
- Concurrent hiatal hernia repair and bariatric surgery: outcomes after sleeve gastrectomy and Roux-en-Y gastric bypass.Surg Obes Relat Dis. 2021; 17: 2-80
- Hiatal hernia repair during laparoscopic sleeve gastrectomy: systematic review and meta-analysis on gastroesophageal reflux disease symptoms changes.Pol Przegl Chir. 2021; 93: 1-5
- 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: 250-255
- Gastroesophageal reflux disease after laparoscopic sleeve gastrectomy with concomitant hiatal hernia repair: an unresolved question.Obes Surg. 2017; 27: 2898-2904
- A randomized trial comparing reflux symptoms in sleeve gastrectomy patients with or without hiatal hernia repair.Surg Obes Relat Dis. 2016; 12: 1681-1688
- Incidence of GERD, esophagitis, Barrett’s esophagus, and esophageal adenocarcinoma after bariatric surgery.Surg Obes Relat Dis. 2020; 16: 1828-1836
- Do preoperative esophageal pH monitoring and high-resolution manometry predict symptoms of GERD after sleeve gastrectomy?.Obes Surg. 2021; 31: 3490-3497
- Can lower preoperative 48-hour pH score predict reflux resolution after sleeve gastrectomy.Am J Surg. 2021; 221: 578-580
- Predictive factors for developing gerd after sleeve gastrectomy: is preoperative endoscopy necessary?.J Gastrointest Surg. 2022; 26: 1015-1020
- Obstructive sleep apnea and gastroesophageal reflux: a multivariate population-level analysis.Otolaryngol Head Neck Surg. 2016; 154: 390-395
- Obstructive sleep apnea is a risk factor for Barrett’s esophagus.Clin Gastroenterol Hepatol. 2014; 12: 583-588.e1
- Anxiety and depression in patients with gastroesophageal reflux disease and their effect on quality of life.World J Gastroenterol. 2015; 21: 4302-4309
- Do sleeve gastrectomy and gastric bypass influence treatment with proton pump inhibitors 4 years after surgery? A nationwide cohort.Surg Obes Relat Dis. 2017; 13: 951-959
- Gastroesophageal reflux disease and hiatal hernia after laparoscopic sleeve gastrectomy: a retrospective cohort study.Cureus. 2022; 14e23024
- Impact of laparoscopic sleeve gastrectomy on gastroesophageal reflux disease and risk factors associated with its occurrence based upon quality of life.Obes Surg. 2021; 31: 3065-3074
- Small hiatal hernia and postprandial reflux after vertical sleeve gastrectomy: a multiethnic Asian cohort.PLoS One. 2020; 15e0241847
- Effect of sleeve gastrectomy on gastroesophageal reflux disease: a systematic review.Surg Obes Relat Dis. 2011; 7: 510-515
- Manometric changes of the lower esophageal sphincter after sleeve gastrectomy in obese patients.Obes Surg. 2010; 20: 357-362
- laparoscopic sleeve gastrectomy: symptoms of gastroesophageal reflux can be reduced by changes in surgical technique.Obes Surg. 2012; 22: 1874-1879
- Increase in gastroesophageal reflux disease symptoms and erosive esophagitis 1 year after laparoscopic sleeve gastrectomy among obese adults.Surg Endosc. 2013; 27: 1260-1266
- Long-term results of laparoscopic sleeve gastrectomy for obesity.Ann Surg. 2010; 252: 319-324
- Sleeve gastrectomy and gastroesophageal reflux disease.J Obes. 2013; 2013741097
- Esophageal pathophysiologic changes and adenocarcinoma after bariatric surgery: a systematic review and meta-analysis.Clin Transl Gastroenterol. 2020; 11e00225
- Alterations of global gastrointestinal motility after sleeve gastrectomy: a prospective study.Ann Surg. 2013; 258: 976-982
- Development and validation of an artificial intelligence-based model to predict gastroesophageal reflux disease after sleeve gastrectomy.Obes Surg. 2022; 32: 2537-2547
- Impact of hiatal hernia repair technique on patient-reported gastroesophageal reflux symptoms following laparoscopic sleeve gastrectomy.Surg Endosc. 2022; 36: 6815-6821
Article info
Publication history
Published online: December 08, 2022
Accepted:
December 1,
2022
Received:
September 4,
2022
Publication stage
In Press Journal Pre-ProofIdentification
Copyright
© 2023 Published by Elsevier Inc. on behalf of American Society for Metabolic and Bariatric Surgery.
