The effects of sleeve gastectomy on gastro-esophageal reflux and gastro-esophageal motility

Abstract

Sleeve gastrectomy is an increasingly performed bariatric procedure associated with low morbidity and good short to medium term effects on weight loss and comorbid conditions. Studies assessing the prevalence of post-operative gastro-esophageal reflux disease (GERD), show sleeve gastrectomy may provoke de novo GERD symptoms or worsening of pre-existing GERD. Pathophysiological mechanisms of GERD after sleeve gastrectomy include a hypotensive lower esophageal sphincter, increased gastro-esophageal pressure gradient and intra-thoracic migration of the remnant stomach. A reduction in the compliance of the gastric remnant may provoke an increase in transient lower esophageal sphincter relaxations. Time-resolved MRI suggests relative gastric stasis in the proximal remnant and increased emptying from the antrum. A lack of standardisation of technique, along with heterogeneity of studies assessing GERD may explain the wide variability in reported results. Simultaneous and careful repair of an associated hiatus hernia may result in a reduction in the prevalence of post-operative GERD.

Keywords::

• 24 h pH studies
• bariatric surgery
• esophageal motility
• gastric emptying
• gastro-esophageal reflux
• sleeve gastrectomy

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Wide variability of reported prevalence of gastro-esophageal reflux disease (GERD) after sleeve gastrectomy contributed to heterogeneity in studies.

• Lack of short- or long-term data using objective measures.

• De novo GERD or worsening GERD is a problem in a cohort of post-operative patients in most studies.

• Alteration in gastric emptying, either static, faster or slower with differences in motility in the sleeve and the antrum.

• Likely to provoke incompetence of the lower esophageal sphincter with an increase in gastric pressure.

• Incidence of post-operative GERD may be modified by altering technique (e.g., by concomitant hiatal hernia repair).