The Causes of Gastroesophageal Reflux after Laparoscopic Sleeve Gastrectomy: Quantitative Assessment of the Structure an
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ORIGINAL CONTRIBUTIONS
The Causes of Gastroesophageal Reflux after Laparoscopic Sleeve Gastrectomy: Quantitative Assessment of the Structure and Function of the Esophagogastric Junction by Magnetic Resonance Imaging and High-Resolution Manometry Giuseppe Quero 1,2 & Claudio Fiorillo 1,2 Silvana Perretta 1,3,6
&
Bernard Dallemagne 3 & Pietro Mascagni 1,2 & Jelena Curcic 4 & Mark Fox 4,5 &
# Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Background The incidence of de novo gastroesophageal reflux disease (GERD) after LSG is substantial. However, an objective correlation with the structural gastric and EGJ changes has not been demonstrated yet. We aimed to prospectively evaluate the effects of laparoscopic sleeve gastrectomy (LSG) on the structure and function of the esophagogastric junction (EGJ) and stomach. Methods Investigations were performed before and after > 50% reduction in excess body weight (6–12 months after LSG). Subjects with GERD at baseline were excluded. Magnetic Resonance Imaging (MRI), high-resolution manometry (HRM), and ambulatory pH-impedance measurements were used to assess the structure and function of the EGJ and stomach before and after LSG. Results From 35 patients screened, 23 (66%) completed the study (age 36 ± 10 years, BMI 42 ± 5 kg/m2). Mean excess weight loss was 59 ± 18% after 7.1 ± 1.7-month follow-up. Esophageal acid exposure (2.4 (1.5–3.2) to 5.1 (2.8–7.3); p = 0.040 (normal < 4.0%)) and reflux events increased after surgery (57 ± 24 to 84 ± 38; p = 0.006 (normal < 80/day)). Esophageal motility was not altered by surgery; however, intrabdominal EGJ length and pressure were reduced (both p < 0.001); whereas the esophagogastric insertion angle (35° ± 11° to 51° ± 16°; p = 0.0004 (normal < 60°)) and esophageal opening diameter (16.9 ± 2.8 mm to 18.0 ± 3.7 mm; p = 0.029) were increased. The increase in reflux events correlated with changes in EGJ insertion angle (p = 0.010). Patients with > 80% reduction in gastric capacity (TGV) had the highest prevalence of symptomatic GERD. Conclusion LSG has multiple effects on the EGJ and stomach that facilitate reflux. In particular, EGJ disruption as indicated by increased (more obtuse) esophagogastric insertion angle and small gastric capacity were associated with the risk of GERD after LSG. clinicaltrials.gov: NCT01980420 Keywords Laparoscopic Sleeve Gastrectomy . GERD . Magnetic Resonance Imaging (MRI)
Introduction Laparoscopic Sleeve Gastrectomy (LSG) has gained popularity over the last 15 years, becoming a standard procedure in * Claudio Fiorillo [email protected] 1
IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France
2
Digestive Surgery, Fondazione Policlinico Universitario “A. Gemelli” IRCSS, Rome, Italy
3
IRCAD, Research Institute against Digestive Cancer, Strasbourg, France
the surgical treatment of morbid obesity [1, 2]. It is efficiently performed in a minimal access fashion [3] with similar morbidity and mortality rates as compared with the laparoscopic Roux-en-Y gas
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