Sleeve Gastrectomy

Sleeve gastrectomy is becoming the most frequently used restrictive bariatric procedure. The stapling of the stomach from the prepyloric area to the angle of His creates a tubular stomach with decreased reservoir function. In addition, removal of a large part of the gastric fundus leads to decreased levels of ghrelin (Fig. 18.1) [27].

In 2011, Miguel et al. [28] reported the results of a nonrandomized, prospective, controlled clinical study including 65 patients with a 1-year follow-up, analyzing the influence of SG and RYGB on erosive esophagitis. At baseline, 6 of 33 (18%) patients in the SG group and 9 of 32 (28%) patients in the RYGB group had endoscopically visible esophageal erosions (P = NS). One year following the bariatric intervention, the percentage of patients with erosive esophagitis rose in the SG group to 14 of 31 (45%) and decreased in the gastric bypass group to 2 of 32 (6%) (p < 0.001). Based on these findings, the authors concluded that SG increases the incidence of erosive esophagitis, whereas RYGB improves the mucosal damage.

There is evidence that the SG not only worsens symptoms and esophagitis in patients with pre-existing GERD, but it also induces “de novo” GERD in many patients [29–32]. Probably, this is due to the effect that a SG has on the antireflux mechanism: development of a hypotensive LES (by damaging the sling fibers and angle of His), decreasing the gastric compliance, and increasing the intragastric pressure (secondary to creation of a narrow gastric tube). Mandeville et al. [29] analyzed 100 consecutive patients who underwent SG between 2005 and 2009, with a mean follow-up of 8.5 years. At the end of the study period, they noted that 52% of patients experienced reflux symptoms, 47% were using proton pump inhibitors, and 7 patients underwent secondary bariatric surgery (RYGB) due to GERD refractory to treatment, achieving complete resolution of symptoms. Gorodner et al. [30] analyzed 118 patients who underwent SG between 2012 and 2013. At 1-year follow-up, the DeMeester score increased from 12.6 in the preoperative period to 28.4 postoperatively (p < 0.05), 5 (36%) patients had de novo GERD, and in 3 patients (21%), GERD worsened. Genco et al. [31], in a large study with a 5-year follow-up, showed that the mean BMI decreased from 46 to 29, but postoperatively erosive esophagitis (Los Angeles [LA] grade C and D) developed in 21% of patients and Barrett’s metaplasia in 17%. Interestingly, GERD symptoms were experienced only by 33% of patients with LA grade C esophagitis and by 57% of patients with LA grade D esophagitis. Hence, as symptoms are not reliable to evaluate the presence/absence of GERD, SG patients should have a closer follow-up, including esophagogastroduodenoscopy (EGD) surveillance due to the risk of developing Barrett’s esophagus [32].

Recently, two randomized multicenter trials performed in Finland and in Switzerland, with 5-year follow-up, have confirmed that the RYGB and the SG are equivalent in terms of weight loss [33, 34]. Both trials highlighted that the most common reason for an operation after a SG was severe gastroesophageal reflux refractory to medical treatment, requiring conversion to a RYGB.

In summary, currently available data indicate an increased prevalence of esophageal erosions and de novo GERD in patients undergoing SG. Thus, morbidly obese patients with GERD should not undergo SG. In addition, SG patients with documented GERD should be considered for conversion to a RYGB if symptoms are poorly controlled by proton pump inhibitors and if esophagitis is present .

Roux-en-Y Gastric Bypass

RYGB involves creating a small gastric pouch, followed by a gastrojejunostomy between this pouch and a 100–150-cm-long Roux loop. The procedure is highly effective for weight loss [33, 34], as documented by initial studies in the mid-1970s (Fig. 18.2) [35].

RYGB is considered the preferred bariatric procedure to treat GERD in morbidly obese patients [36] because this operation does not disrupt the natural antireflux mechanism, creates a small gastric pouch with few parietal cells (decreasing acid output), and diverts bile from the stomach. In addition, gastric emptying seems to be accelerated after RYGB [37] and esophageal motility not altered, independent of weight loss occurrence [38, 39]. Braghetto et al. showed that RYGB reduces body weight and improves GERD and Barrett’s esophagus when compared to antireflux surgery [40].

Langer et al. [41] published a report on conversion from SG to RYGP. Eight of 73 (11%) patients with SG underwent conversion to RYGP because of severe reflux (N = 3) confirmed by pH monitoring or because of weight loss failure (N = 5) about 3 years after laparoscopic SG. At a median follow-up of 14 months, conversion led to a significant weight reduction (15 ± 8 kg) in patients reoperated for weight loss failure and improved reflux in the three patients who had severe reflux. Patients with reflux symptoms after SG were able to discontinue acid-suppressive medication after conversion to RYGP .

Mejia-Rivas et al. [42] investigated the effect of RYGB on GERD in 20 patients using manometry and 24-h pH monitoring, and they observed resolution of symptoms in 90% of the patients. On esophageal manometry, LES pressure was slightly increased postoperatively, being 18 ± 11 and 20.1 ± 5.6 mmHg before and after the RYGBP, respectively (p = NS). On pH monitoring, the DeMeester score significantly decreased from 48.3 to 7.7 (p < 0.001). Only one patient (5%) had persistent heartburn and abnormal esophageal acid. They concluded that weight reduction after a RYGBP improves reflux symptoms and esophageal exposure to acid.

Furthermore, Csendes et al. [43] performed preoperative and postoperative EGDs on 130 patients undergoing RYGB. Before surgery, distal erosive esophagitis was present in 23.8% of patients. Postoperative, at a mean follow-up of 92 months, EGDs showed that esophagitis had healed in 93% of these patients.

In summary, studies investigating gastroesophageal reflux in patients undergoing RYGB show significant improvement of erosive esophagitis and reflux symptoms. In addition, evidence suggest that conversion of SG to RYGB is successful in treating newly developed reflux symptoms and weight loss failure.

Hiatal Hernia and Bariatric Surgery

If a hiatal hernia is present, it should be addressed as this does not add morbidity or increase operative time significantly [44]. Hiatal hernia repair may help in controlling regurgitation in patients with this symptom preoperatively [45, 46].