Proximal Gastric Pressurization After Sleeve Gastrectomy Associates With Gastroesophageal Reflux

Abstract

INTRODUCTION: Sleeve gastrectomy (SG) results in persistent or de novo reflux more often than Roux-en-Y gastric bypass (RYGB). We investigated pressurization patterns in the proximal stomach on high-resolution manometry (HRM) to determine associations with reflux after SG. METHODS: Patients undergoing HRM and ambulatory pH-impedance monitoring after SG and RYGB over a 2-year period (2019–2020) were included. For each included patient, 2 symptomatic control patients with HRM and pH-impedance monitoring for reflux symptoms were identified within the same time frame; 15 asymptomatic healthy controls with HRM studies were also studied. Concurrent myotomy and preoperative diagnosis of obstructive motor disorders were exclusions. Conventional HRM metrics, esophagogastric junction (EGJ) pressures, contractile integral (EGJ-CI), acid exposure time (AET), and reflux episode numbers were extracted. Intragastric pressure was sampled at baseline, during swallows, and with straight leg raise maneuver, and compared with intraesophageal pressure and reflux burden. RESULTS: Patient cohorts included 36 SG patients, 23 RYGB patients, 113 symptomatic controls, and 15 asymptomatic controls. While both SG and RYGB patients pressurized the stomach during swallows and straight leg raise, SG patients had higher AET (median 6.0% vs 0.2%), reflux episode numbers (median 63.0 vs 37.5), and baseline intragastric pressure (median 17.3 mm Hg vs 13.1 mm Hg) (P < 0.001). SG patients also had lower trans-EGJ pressure gradients when reflux episodes were >80 or AET was >6.0% (P = 0.018 and 0.08, respectively, compared with no pathologic reflux). On multivariable analysis, SG status and low EGJ-CI independently associated with AET and reflux episode numbers (P ≤ 0.04). DISCUSSION: Impaired EGJ barrier function and proximal gastric pressurization after SG are associated with gastroesophageal reflux, especially during strain maneuvers.

Current Management and Treatment Paradigms of Gastroesophageal Reflux Disease following Sleeve Gastrectomy

“…Greenan et al explored gastric pressurization using high-resolution manometry and reflux using pH impedance in patients post-SG and post-RYGB as well as in symptomatic and asymptomatic control groups. Patients in the SG group had higher acid exposure time (median 6.0% vs. 0.2%), reflux episode numbers (median 63.0 vs. 37.5) and baseline intragastric pressure (median 17.3 mmHg vs. 13.1 mmHg) compared to the RYGB group, p < 0.001 [ 37 ].…”

“…Complications of SG, including stenosis, angulation or kinking, are associated with increased intragastric pressure and GERD (Figure 1) [38]. Data regarding the optimal bougie size for weight loss and reduced reflux are mixed, but generally support a range of [36][37][38][39][40][41][42]. Overfilling of the gastric sleeve due to a large meal portion may result in reflux symptoms, and thus, patients should be counseled to gradually advance their diet from liquids to small portions of healthy, protein-rich foods.…”

Clinical efficacy and safety of double-channel anastomosis and tubular gastroesophageal anastomosis in gastrectomy

“…This study is the first to report the use of tubular gastroesophagostomy for the treatment of early proximal gastric cancer[ 25 ]. This procedure reduces the possibility of esophageal reflux by cutting the residual stomach into a tubular stomach, making it similar to the gastric fundus structure, which can temporarily store gastric juice and reduce gastric acid secretion.…”