Resolution of Erosive Esophagitis After Conversion from Vertical Sleeve Gastrectomy to Roux-en-Y Gastric Bypass

Abstract

Background Laparoscopic sleeve gastrectomy (LSG) has become the preferred bariatric procedure in many countries. However, there is one shortcoming of LSG in the long-term follow-up, and this is the onset of gastro-esophageal reflux disease (GERD) and erosive esophagitis (EE). Conversion to Roux-en-Y gastric bypass (RYGB) is considered an option in patients unresponsive to medical therapy. Currently, there is no evidence of EE improvement or resolution after conversion surgery. In this study, we objectively evaluate the effectiveness of RYGB in management of EE with upper endoscopy (EGD) to identify the significant variables in patients with GERD symptoms post LSG refractory to medical therapy and require conversion surgery. Methods Over a period of 11 years (2008–2019) at Singapore General Hospital, we retrospectively reviewed a prospectively collected database of a cohort of patients whom had conversion surgery to RYGB for refractory GERD and EE after LSG. Patient’s endoscopic findings and demographic and anthropometric data were analyzed. Results We identified a total of 14 patients who underwent LSG to RYGB conversions for endoscopic proven erosive esophagitis in our unit during the study period. Eight patients (57.1%) had concurrent hiatal hernia repaired. Nine (64.3%) patients were females. The median age of patients in this cohort was 44 (range 30–61) years. Mean weight and BMI were 87.7 kg (± 19.2) and 32.8 (± 3.09) kg/m2, respectively, on the day of conversion surgery. The median time between LSG and revision to RYGB was 36 (range 6–68) months. Seven patients (50%) had complete resolution of GERD symptoms after conversion, and 6 patients (42.9%) had partial resolution. Six out of 7 patients had complete resolution of EE. There were 4 anastomotic strictures (28.6%). Older patients, Indian ethnicity, present of hiatal hernia and lower weight loss after initial LSG were more likely to undergo conversion surgery. Conclusion Conversion to RYGB after LSG is clinically relevant and may be a feasible solution if patients have ongoing GERD refractory to medical therapy. Ninety-three percent of our patients achieved complete resolution of their GERD symptoms and significant improvement of erosive esophagitis with significant weight loss after conversion. This study has important implications as LSG is increasingly being performed and a proportion of these will need revision surgery for various reasons, particularly GERD which is extremely prevalent.

Gastroesophageal Symptoms After Laparoscopic Gastric Bypass: Mistakes in Performing the Procedure?

“…The reported main symptoms are pain (27.3-44.7%), dysphagia (12.5%), respiratory symptoms (17%), and vomiting (12.5%). EE and Barrett´s esophagus have been observed in a wide range of percentage (2.4-10.6% and 0-17.6%, respectively) 5 , 7 , 13 , 20 , 23 , 27 , 28 , 29 , 31 , 33 , 34 , 39 , 40 , 41 , 44 .…”

Conversión de gastrectomía vertical a bypass gástrico por enfermedad por reflujo gastroesofágico

“…Entre un 2% y un 12% de pacientes intervenidos de GV requerirán una segunda intervención por RGE severo. (1) Es frecuente que los pacientes obesos mórbidos presenten patología esofagogástrica como la gastritis o el reflujo gastroesofágico; que no siempre es sintomática y que puede afectar a la evolución tras la intervención (3). Por ello, el papel de la endoscopia y el tránsito baritado en el preoperatorio de la cirugía bariátrica es algo controvertido.…”

“…La aplicación de una técnica quirúrgica adecuada es probablemente el factor modificable más importante en la prevención de esta complicación (3). El BPG es en el momento actual la técnica de cirugía revisional más adecuada y ampliamente aceptada para tratar a los pacientes con ERGE severo tras gastrectomía vertical (3).…”

Small hiatal hernia and postprandial reflux after vertical sleeve gastrectomy: A multiethnic Asian cohort

“…Although our unit’s questionnaire was not validated but was more relevant to post-sleeve gastrectomy subjects, it takes into account smoking and alcohol history, symptoms related to meals, PPI usage, overeating and differentiation between acid reflux versus volume reflux [ 25 ]. We found that commonly used validated questionnaires, such as GERD-Q and GERD health-related quality of life (GERD-HRQL), may be useful in correlating symptoms to presence of esophagitis, but extremely impractical to assess progression or response of symptoms over time.…”