Erosive Esophagitis after Bariatric Surgery: Banded VerticalGastrectomy versus Banded Roux-en-Y Gastric Bypass Gustavo Peixoto Soares Miguel & João Luiz Moreira Coutinho Azevedo &Paulo Henrique Oliveira de Souza & João de Siqueira Neto & Felipe Mustafa &Évelyn Saiter Zambrana & Perseu Seixas de Carvalho # Springer Science+Business Media, LLC 2010 the SRSG group to 14 (45.2%) and a decrease in the SRGB Background Obesity is associated with gastroesophageal group to two (6.3%), giving a total of 16 patients with EE reflux disease. Roux-en-Y gastric bypass is the most performed bariatric procedure in the world, whereas sleeve Conclusions After 1 year of follow-up, we observed a gastrectomy is an emerging procedure. Both can be worsening evolution of EE in the SRSG group, but combined with the use of a Silastic® ring. The aim of this study was to compare the evolution of erosive esophagitis(EE) in patients who underwent Silastic® ring gastric Keywords Bariatric surgery. Erosive esophagitis . Roux-en-Y bypass (SRGB) and Silastic® ring sleeve gastrectomy gastric bypass . Sleeve gastrectomy . Morbid obesity (SRSG) after a 1-year postoperative period.
Methods We carried out a non-randomized, prospective,controlled clinical study. Sixty-five patients were enrolled based on the following inclusion criteria: female gender,age 20–60 years old, BMI 40–45 and written informed Obesity is a multifactorial disease with a growing preva- consent. The exclusion criteria were secondary obesity, lence worldwide. Surgical treatment of morbid obesity has alcohol or drug use, severe psychiatric disorder, binge- been shown to be superior to dieting and behavior eating of sweets, and previous stomach or bowel surgery.
modification for long-term weight loss and improvement The patients were divided into two groups—33 (51%) of associated co-morbidities [1] (Fig. 1).
underwent SRSG and 32 (49%) patients underwent SRGB.
The most performed bariatric surgery procedure is the All patients underwent an esophago-gastro-duodenoscopy Roux-en-Y gastric bypass (RYGB) [2], whereas sleeve during the preoperative period and at 12–14 months after gastrectomy (SG) is an emerging restrictive procedure [3] that has shown good results with regard to weight loss and Results Preoperatively, 15 patients (23.8%) were found to has some potential advantages, such as a lower probability have EE, six (19.4%) in the SRSG group and nine patients of vitamin and mineral deficiencies, access to the entire (28.1%) in the SRGB group (p=0.7795). Postoperatively, intestinal tract, no need for subcutaneous ports or adjust- there was an increase in the number of patients with EE in ments, the absence of dumping syndrome and a lowerprobability of intestinal obstruction. In addition, SG can beperformed in patients who have inflammatory bowel G. P. S. Miguel (*) : P. H. O. de Souza : J. de Siqueira Neto : disease and those who have undergone bowel surgery and F. Mustafa : É. S. Zambrana : P. S. de Carvalho can be converted into a RYGB [3, 4]. Both SG and RYGB Federal University of Espírito Santo–UFES, can be performed with or without the placement of a Obesity has been associated with acid reflux in the lower esophagus and gastroesophageal reflux disease (GERD), Federal University of São Paulo–Unifesp, and several mechanisms have been proposed for this were divided into two groups, 33 (51%) underwent SRSG (SRSG group) and 32 (49%) underwent SRGB (SRGB group). All patients underwent an esophago-gastro- duodenoscopy (EGD) both during the preoperative period Resolution
Two patients, both from the SRSG group, were excluded Unaltered
due to the development of a fistula. One of them underwent a total gastrectomy, leading to resolution of the fistula, and Fig. 1 Evolution of EE, as a complication, by group. Chi-square test: The surgical procedures were performed at the Hospital Universitário Cassiano Antônio de Moraes of the Universi-dade Federal do Espírito Santo (HUCAM/UFES–Cassiano association such as increased intra-abdominal pressure, Antônio de Moraes University Hospital, Federal University reduced esophageal clearance, increased transient relaxation of Espírito Santo). All of the procedures were performed by of the lower esophageal sphincter, distorted anatomy of the the same surgeon in an open fashion and using a similar gastroesophageal junction, and a high-fat containing diet [7].
anesthetic technique (i.e., peridural anesthesia with com- Bariatric surgery has an impact on the frequency of GERD in obese patients, although the prevalence of GERD The patients in the SRSG group underwent the following varies following different types of bariatric surgery [8]. The procedures: ligation of the vessels of the greater curvature influence of these procedures on GERD is controversial, of the body and fundus of the stomach, resection of the and there are few studies that compare two techniques, fundus and part of the body of the stomach using a linear stapler (80 mm, Tyco®) and a 32-French (Fr) tube to The aim of this study was to compare weight loss and calibrate the remaining stomach and placement of a 6.2-cm assess the evolution of erosive esophagitis (EE) in patients Silastic ring around the stomach at 5.0 cm below the who underwent either a Silastic® ring sleeve gastrectomy (SRSG) or a Silastic® ring Roux-en-Y gastric bypass The patients in the SRGB group underwent the follow- ing procedures: creation of a small, proximal gastric pouchand exclusion of a large part of the stomach using a linearstapler (80 mm, Tyco®) and a 32-Fr tube to calibrate the gastric pouch; creation of an intestinal loop of 150 cm and abiliopancreatic loop of 40 cm; and placement of a 6.2 cm Silastic ring around the stomach 5.0 cm below theesophagogastric junction.
We carried out a non-randomized, prospective, controlled In both groups, the stapled lines were reinforced, and a clinical study. This study was approved by the Research methylene blue test was performed to verify whether the Ethics Committee of the University Hospital of the Federal staple line was secure. The patients were given a liquid diet University of Espírito Santo, Brazil (protocol number 049/06) on the first postoperative day and were discharged on the and registered at clinicaltrials.gov (NCT00873405). To third postoperative day. They received dietary guidance and normalize the study population, we adopted the following instructions regarding physical activity. In addition, patients inclusion criteria: female gender, age 20–60 years old, BMI from both groups were prescribed similar vitamin and 40–45 (inclusive), and written informed consent. The exclu- mineral supplementation. Also, they were given proton sion criteria were secondary obesity, alcohol or drug use, pump inhibitor (IBP; Omeprazole, 20 mg daily) up to severe psychiatric disorders, binge-eating of sweets, and 90 days postoperatively. The patients, who were on IBP use by the time of the protocol EGD, had its use discontinued2 weeks before the exam.
Sixty-five female patients were enrolled in the present studyand had a mean age of 36.03 years old, mean BMI of 42.47, Weight loss, BMI reduction, and waist circumference were and waist circumference of 119.62 cm. The 65 patients assessed. The percentage of excess BMI loss was calculated as follows: (preoperative BMI−current BMI) ÷ (preopera- 14 (45.2%) in the SRSG group and a decrease to two tive BMI–25)×100. The presence of endoscopic esophagi- (6.3%) in the SRGB group, giving a total of 16 patients tis, defined by the finding of erosion at the esophageal mucosa, was recorded in both the pre- and postoperative Statistical analysis of each group separately, with regard to EE, showed a significant difference between thepreoperative and postoperative periods only for the SRGB Three patients from the SRSG group (9.7%) showed Descriptive analyses were conducted, and the results were improved EE; 17 (54.8%) showed maintained EE; and 11 expressed as means, standard deviations, medians, frequencies (35.5%) showed worsened EE. A different scenario was (%), and minimum and maximum values. The Mann–Whitney observed in the SRGB group, in which only one patient U test was used to assess sample variation and homogeneity (3.1%) showed worsened EE, whereas 23 (71.9%) showed between the groups. The Fisher exact and chi-squared tests unaltered EE, and eight (25%) showed resolved EE. There were used to compare results between the two groups. In was a significant difference between the two groups, with assessments between time and groups of categorical varia- better EE evolution observed in the SRGB group (p= bles, generalized estimating equations were used. A p value <0.05 was considered to be statistically significant.
Although it was not the main focus of the present study, it was noteworthy that a fistula developed at the staple linein two patients (6%) in the SRSG group (p=0.4936). Both patients required reoperation: one of them died, and theother underwent a total gastrectomy that led to resolution of In the preoperative period, no significant difference in age, BMI, or waist circumference was found between patients inthe SRSG group vs. the SRGB group. Among the entirepatient sample, BMI decreased from 42.45±1.63 to 27.49± 2.65 kg/m2 (p<0.05). The percentage of excess BMI losswas 86.98±14.86%. In addition, we observed a reduction in The SG procedure is increasingly being used in bariatric waist circumference from 119.83±7.64 to 90.31±7.51 cm surgery [3, 4, 9–12]. There are few prospective clinical (p<0.05). The results obtained with both surgical proce- studies in the literature, however, that compare this dures were similar with regard to weight loss, BMI emerging procedure with RYGB [3, 12].
reduction, percentage of excess BMI reduction, and waist In the present study, SG was performed, and a Silastic® ring was placed around the stomach. This procedure Preoperatively, 15 patients (23.8%) from the total sample resulted in a small, functional stomach, similar to that were found to have EE, six (19.4%) in the SRSG group and obtained with traditional vertical gastroplasty, and removal nine (28.1%) in the SRGB group (p=0.7795).
of the principal site of ghrelin production, giving SRSG In the postoperative period (12–14 months after surgery), characteristics of both bariatric and endocrine surgery [6].
there was an increase in the number of patients with EE to Removal of the principal site of ghrelin production leads to Table 1 Weight loss (WL), percentage of excess BMI loss (%eBMI), and preoperative and postoperative body mass index (BMI), waistcircumference (WC), by group (mean ± standard deviation) a t Student p=0.6914b t Student p=0.9004c ANOVA: group p=0.5731, period p=0.0000, group x period p=0.6205d ANOVA: group p=0.2476, period p=0.0000, group x period p=0.5649 a decrease in ghrelin levels, adding a hormonal element to SRSG was demonstrated to be a risk factor for EE at 1 year SRSG, that other restrictive procedures, such as adjustable after surgery (p=0.0451). There was an increase in the gastric banding lack [13]. Some authors have reported the prevalence of EE in the SRSG group and a decrease in the use of added restriction in SG to increase the intensity and SRGB group, despite a significant decrease in body weight duration of weight loss [6, 14, 15]. In addition, by placing a and waist circumference in both groups. There are only a Silastic® ring around the stomach in all the patients in this few studies analyzing EE in bariatric patients, and studies study, both procedures were identical in terms of the that include SG patients are even rarer.
portion of the stomach located above the ring.
Alexander et al. compared a group of 27 patients who Gastric bypass is the most used procedure in bariatric underwent a banded sleeve gastrectomy (BSG) using a surgery and is considered the gold standard by many. Some biological band with a sex-, age-, and initial BMI-matched researchers have reported that SG is less risky than RYGB control group of 54 patients who underwent RYGB. In [3, 9, 10]. In this study, however, the most serious addition to other results, a higher prevalence of GERD was complications occurred in the SRSG group, which was observed in the BSG group after 1 year of follow-up [17].
noteworthy, although not statistically significant.
In a retrospective observational study, Lakdawala et al.
Weight loss, BMI reduction, waist circumference reduc- compared 50 laparoscopic SG patients to 50 laparoscopic tion, and percentage of excess BMI loss were significant RYGB patients at 1 year after surgery. Resolution of GERD and similar in both groups. These findings are in accor- was observed in all 13% of the patients who presented with dance with some studies [3, 4, 12], but in disagreement GERD preoperatively in the RYGB group, whereas the with others [9, 10] that have regarded SG as the first stage prevalence of GERD increased from 5% to 9% in the SG of a definitive surgery. The positive results of the present study were probably due to judicious selection of the The evolution of EE over a longer-term follow-up is patient sample, which excluded those with a BMI greater controversial. Himpens et al. compared GERD in 40 than 45 and those with prior stomach or bowel surgery.
patients with laparoscopic gastric banding and 40 patients Other factors that might have contributed to the results of with SG. A higher incidence of GERD was observed in the the present study include the calibration of the remaining SG group (21.8%) at 1 year after surgery, but at 3 years, stomach using a 32-Fr tube and the placement of a Silastic® only one out of 40 patients (3.1%) in the SG group was still ring. In other studies in which weight loss was less taking a proton pump inhibitor medication [19]. On the pronounced, tubes with a greater caliber were used [16], other hand, Bohdjalian et al. observed a 31% rate of chronic and a Silastic® ring was not placed [9, 10].
use of anti-acid medication at 5 years after surgery among Suter et al. evaluated GERD in 345 morbidly obese patients and found a 31.8% rate of EE [7], similar to our As our results, the improvement in GERD has been observations in this study in the preoperative period shown by some studies with RYGB patients. Mejia-Rivas et (23.8%). With regard to the evolution of EE in our study, al. observed an improvement of GERD symptoms, areduction in esophageal acid exposure time and betteresophageal motility after 6 months of RYGB [8]. Frezza et al. also studied the symptomatic effects of laparoscopic RYGB in GERD and found improvements in some of thetypical and atypical symptoms of GERD. Furthermore, the authors suggested that obese patients might be better servedby RYGB than by fundoplication given the weight loss effect [21]. One hundred fifty RYGB patients were compared with a control group in a Chinese study that found a high prevalence of GERD among patients with morbid obesity and a reduction in the number of patients with EE, from 42.3% to 3.8% during the postoperative period [22]. Csendes at al. reported a reduction in EE from translated into the superiority of this study over previous 97% preoperatively to 7.2% at 21 months after RYGB. The work in which the groups investigated were not similar [3], authors suggested that acid suppression resulting from a samples were not homogeneous [4], and included patients reduction in parietal cell mass combined with the Roux-en- often presented with a BMI <40 [3, 4, 12] and/or >50 [3, 4, Y gastrojejunostomy, which protects the esophagus from duodenal contents, led to the positive outcome [23].
To reduce interpretation bias by the endoscopist, we only There have been some studies comparing RYGB with recorded the presence or absence of EE without grading or other surgical techniques. Fifteen RYGB patients were studied classification. This study also could have been improved by by Merrouche et al. with regard to esophageal function over assessing GERD symptoms. We analyzed the endoscopic an average follow-up period of 31 months. Improvements findings, but it is critical to understand that, whereas an were observed in GERD symptoms, 24-h pH-metry data, endoscopy showing clear evidence of Barrett’s esophagus total time with pH >4 and the DeMeester score. The or esophagitis confirms the diagnosis of GERD, a normal authors compared these results with those of an adjust- endoscopy in no way excludes GERD [31]. Thus, if we had able gastric band group, which showed worse values for considered symptomatic GERD patients with normal some parameters such as pH-metry and occasional severe endoscopies, our results may have been different. Even though the role of preoperative endoscopy in bariatric Our results show a 35.5% increase in the prevalence of surgery is controversial [32], a more thorough preoperative EE among SRSG patients at 1 year after surgery. This evaluation was necessary in this study, as we were finding was recently encountered in other SG studies [25, assessing a relatively new procedure and were working 26] and probably occurred because of the creation of a high with a lack of understanding of its complications and pressure gastric chamber due to the pyloric function associated with the destruction of anti-reflux cardia phys-iologic mechanisms. Other contributing factors include themaintenance of larger parietal cells contiguous with the esophagus and the removal of a gastric pacemaker andgastric fundus, leading to dysmotility and no distention In summary, GERD is a frequent co-morbidity associated with obesity and has implications regarding which bariatric Similar mechanisms were proposed by Bernstine and procedure should be performed. The two techniques colleagues, who performed a gastric emptying scintigraphy compared in this study led to different outcomes with in 21 patients before and 3 months after a laparoscopic regard to the evolution of EE: SRSG worsened the sleeve gastrectomy with preservation of the antrum using a evolution of EE, whereas there was a decrease in the 48-Fr tube for calibration and no band. Their results, prevalence of EE in the SRGB group. Thus, the use of however, showed no difference between the preoperative SRGB should be preferred in patients who present with and postoperative periods, demonstrating the possible signs and symptoms of GERD or with a hiatal hernia.
importance of antral integrity [27]. Other authors have also Given that both of the techniques studied here promoted analyzed gastric emptying after SG and found different similar weight loss and that their anatomical aspects were results [28–30]. Despite gastric emptying has been affected identical above the Silastic® ring, the pathophysiological by band placement, it has not contributed to a different mechanism behind the worsening of EE in SGSG should be evolution observed between groups because both are derived from the anatomy below the ring. In addition, anatomically identical in the portion above the ring, further studies with longer follow-up periods are needed.
meaning that the band itself does not lead to the differentoutcomes observed between SRSG and SRGB.
Acknowledgments The authors would like to thank Drs. Marcos The greatest limitation of this prospective, controlled Machado Reuter Motta and José Manoel Binda, endoscopists from study was the lack of randomization. This occurred because HUCAM-UFES, for performing the EGDs.
the Research Ethics Committee and the authors of this Conflict of Interest Disclosure The authors declare that they have study believed the often irreversible surgical procedures performed could not have been decided upon withoutpatient consent. A similar ethical issue was reported by theauthors of the Swedish Obese Subjects study [1]. To overcome this limitation, we selected patients with verysimilar characteristics. Both groups were comprised of 1. Sjöström L, Narbro K, Sjöström D, et al. Swedish obese subjects patients with a similar age, BMI, waist circumference, and study. Effects of bariatric surgery mortality Swedish obese fasting glucose level in the preoperative period. This point subjects. N Engl J Med. 2007;357(8):741–52.
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