key: cord-0029852-tst6yv84
authors: Pavone, Giovanna; Tartaglia, Nicola; Porfido, Alessandro; Panzera, Piercarmine; Pacilli, Mario; Ambrosi, Antonio
title: The new onset of GERD after sleeve gastrectomy: A systematic review
date: 2022-04-05
journal: Ann Med Surg (Lond)
DOI: 10.1016/j.amsu.2022.103584
sha: 0cf7a388598cd6ad52cdc94ab5789fcd2f910a2a
doc_id: 29852
cord_uid: tst6yv84

BACKGROUND: The main adverse effect is gastroesophageal reflux disease (GERD), with concern on the development of Barrett's esophagus and esophageal adenocarcinoma in the long term. However, the relationship between SG and GERD is complex. The aim of this study is to systematically evaluate all published data existing in the literature to evaluate the effect of sleeve gastrectomy on GERD, esophagitis, BE in order to clarify the long-term clinical sequelae of this procedure. MATERIALS AND METHODS: This systematic review was conducted in accordance with the guidelines for Preferred Reporting Items for Systematic Review. The work has been reported in line with the PRISMA criteria [19]. We evaluated the quality and risk of bias of this Systematic Review using AMSTAR 2 checklist [20]. Published studies that contained outcome data for primary sleeve gastrectomy associated with the primary and secondary outcomes listed below were included. The UIN for ClinicalTrial.gov Protocol Registration and Results System is: NCT05178446 for the Organization UFoggia. RESULTS: 49 articles were eligible for inclusion that met the following criteria: publications dealing with patients undergoing laparoscopic SG, publications describing pre- and postoperative GERD symptoms and/or esophageal function tests, articles in English, human studies and text complete available. CONCLUSIONS: We have controversial data on LSG and GERD in the literature as there is a multifactorial relationship between LSG and GERD. The most recent studies have shown satisfactory control of postoperative reflux in most patients and low rates of de novo GERD. These data are leading to wider acceptance of LSG as a bariatric procedure even in obese patients with GERD.

Obesity is classified as one of the most severe global public health problems. Over 2.1 billion adults worldwide are considered overweight or obese; 640 million of these are classified as obese. Sleeve gastrectomy (SG) has become the most common procedure performed in the world since 2014 [1] because it is well defined, it is easier to perform than other types of bariatric surgery, the learning curve is shorter, the morbidity and mortality rates are low, and it leads to effective weight loss [2] . Obese patients develop obesity-related comorbidities including type 2 diabetes mellitus (T2DM), hypertension, dyslipidemia, coronary artery disease, certain types of cancer, and gastroesophageal reflux disease (GERD) [3] [4] [5] [6] [7] . The main adverse effect is gastroesophageal reflux disease (GERD), with concern on the development of Barrett's esophagus and esophageal adenocarcinoma in the long term. However, the relationship between SG and GERD is complex [8] [9] [10] [11] [12] . Different mechanisms involved: disruption of the angle of His, partial sectioning of sling fibers of the lower esophageal sphincter (LES), reduced gastric compliance due to gastric fundus removal, occurrence of hiatal hernia (HH), or reduced antral function. In contrast, other studies have reported a decreased prevalence of GERD after SG [13] [14] [15] explained by several mechanisms including weight loss, decreased acid production and accelerated gastric emptying. The measured increase in GERD prevalence ranged from 2.1% to 34.9% in the analyzed literature. There was marked heterogeneity between the studies in regard to a number of factors including preoperative BMI, method of evaluating GERD, exclusion criteria, length of follow-up, and operative technique [16] [17] [18] [-] [18] .(see fig 1) The aim of this study is to systematically evaluate all published data existing in the literature to evaluate the effect of sleeve gastrectomy on GERD, esophagitis, BE in order to clarify the long-term clinical sequelae of this procedure.

This systematic review was conducted in accordance with the guidelines for Preferred Reporting Items for Systematic Review. The work has been reported in line with the PRISMA 2020 criteria [19] .

We evaluated the quality and risk of bias of this Systematic Review using AMSTAR 2 checklist [20] .

A systematic search was performed using electronic searches in EMBASE, Medline, Cochrane Library, and Psychinfo. Free text search in all fields was performed for "Sleeve Gastrectomy", "Bariatric Surgery", "Obesity", "Gastrectomy", "Gastric Sleeve", "Stomach Staple", "Gastroesophageal Reflux", "Gastro -Esophageal reflux "," Reflux "," Metaplasia "," Barrett's esophagus "and" Barrett's esophagus". The search included all study designs, with additional non-research captured studies identified through bibliographic cross-references.

Published studies that contained outcome data for primary sleeve gastrectomy associated with the primary and secondary outcomes listed below were included.

The UIN for ClinicalTrial.gov Protocol Registration and Results System is: NCT05178446for the Organization UFoggia (https://clinic altrials.gov/ct2/show/NCT05178446).

Figure (PRISMA Flow Chart) shows the study selection flowchart. Through the literature search, we identified 707 citations. We removed any duplicates and were left with 120 references. After excluding irrelevant reports by reviewing titles and abstracts, we then retrieved 73 full-text articles that were eligible. There were 8 articles with unrelated topics, 2 without full text, 9 conference abstracts, and 5 non-English/ Chinese literatures excluded. Ultimately, 49 original articles were included, as shown in the study flowchart (Table 1) . .

Obesity is one of the risk factors for GERD, which has resulted in a significant increase in the incidence of GERD worldwide [70] .

Obesity has been reported to increase the incidence of GERD with an OR of 1.73 and Barrett's esophagus with an OR of 1.24; esophageal adenocarcinoma is the most serious complication of GERD (OR, 2.45) [71, 72] .

Numerous studies have been performed in the literature with controversial results on the onset of GERD after LSG.

Albanopoulos et al., Alexandrou et al. and Althuwaini et al. [22, 23] showed that LSG seemed to precipitate GERD symptoms, dissection near the angle of His, and drastic reduction in gastric capacity increased the chance that patients would maintain or develop new GERD symptoms.

The studies by Arman et al., Borbely et al. and Braghetto et al. [26, 30, 32] found that LSG is associated with a significantly higher likelihood that acid-lowering medications are needed to control GERD symptoms 12 months after LSG compared with gastric bypass. LSG leads to a considerable rate of postoperative GERD. De novo GERD consist of approximately half of preoperative silent GERD and completely de novo GERD. Most patients with preoperative silent GERD have become symptomatic after LSG. Barrett's esophagus could be a late complication after SG and bariatric surgeons should be aware of the important association between GERD and obesity. Burgerhart et al. [34] confirm that it seems likely that the increase in acid exposure after LSG is due to the modified anatomy, which leads to a decrease in the resting pressure of Les. The study results support the idea that in patients with significant preoperative symptoms of GERD, gastric bypass surgery may be more appropriate than LSG.

Del Genio et al. and DuPree et al. [42, 43] claim that LSG is an effective restrictive procedure that creates delayed esophageal emptying without compromising the function of the LES. Retrograde movements and increased acid exposure are likely due to postprandial stasis and regurgitation. LSG did not reliably relieve or improve GERD symptoms and induced GERD in some previously asymptomatic patients.

Indeed, Flolo et al. [46] confirmed that the incidence of GERD more than doubled from baseline at 2 years and further increased at a rate of 35% at 5 years.

De novo gastroesophageal reflux symptoms appear between the third and sixth postoperative year. This unfavorable evolution may have been prevented in some patients by continuous follow-up outpatient visits beyond the third year.

The new onset of postoperative GERD is an unfortunate side effect of LSG, and more studies reflecting the aggressive closure of healing defects are needed to determine if this provides a long-term solution to this problem.

LSG can increase the prevalence of GERD despite satisfactory weight loss.

In the study by Menenakos et al. [60] about 25% of patients developed or worsened their GERD symptoms, all responsive to PPi treatment (65 out of 261 patients). Heartburn was significantly relieved after the postoperative first trimester. Symptoms of GERD are especially common in the first few months. Gastroesophageal reflux is the main complication. Proton pump inhibitor treatment is mostly effective in controlling patients' symptoms. Endoscopic surveillance is desirable in the long term for these patients. Rebecchi et al. and Sharma et al. [65, 66] concluded that in obese patients with GERD, LSG improves symptoms and controls reflux in most cases, whereas in patients with no preoperative evidence of GERD, de novo reflux is rare. Therefore, LSG should be considered an effective option for the surgical treatment of obese patients with GERD. The presence of GERD cannot be considered a contraindication to sleeve gastrectomy. There is improvement in Gerd as assessed by the symptom questionnaires. The new onset of GERD detected on scintigraphy may not be pathological as there is a decrease in total acid production after surgery; however, it still remains an important issue and needs long-term follow-up [74] [75] [76] .

The limitations of this study are high heterogeneity and no data from randomized controlled trials. Several studies had varying selection criteria when offering surgery to people with and without GERD. There was a lack of data on the standardization of surgical technique. The follow-up time interval was variable, and long-term subgroup analysis was performed in an attempt to compensate for this. Some studies aimed to study reflux specifically, while others reported it as secondary outcomes. Studies using physiological and invasive techniques to investigate GERD have found higher rates than those using symptomatology alone.

We have controversial data on LSG and GERD in the literature as there is a multifactorial relationship between LSG and GERD. The most recent studies have shown satisfactory control of postoperative reflux in most patients and low rates of de novo GERD. Compared to LSG, obese patients receiving LRYGB had a lower risk of new onset or worsening of GERD. Some patients have been converted to LRYGB treatment due to severe reflux after LSG. Therefore, we recommend LRYGB as the preferred treatment for obese patients with GERD. These data are leading to wider acceptance of LSG as a bariatric procedure even in obese patients with GERD, provided a tubular cuff is created, as recently stated in the 5th International Consensus Conference on sleeve gastrectomy [73] .

In conclusion, bariatric surgery has become safer as surgeons gain experience in evaluating and treating obese patients, but careful medical evaluation is mandatory before choosing the type of bariatric surgery, especially for those patients who already have GERD.

GIOVANNA PAVONE, NICOLA TARTAGLIA, ALESSANDRO POR-FIDO, PIERCARMINE PANZERA, MARIO PACILLI, ANTONIO AMBROSI declare haven't been funded.

The ethics committee of our institution approved the study.

Informed consent was obtained from all individual participants included in the study.

NICOLA TARTAGLIA and GIOVANNA PAVONE performed the study conception and design.

ALESSANDRO PORFIDO analyzed and interpreted the data. MARIO PACILLI and PIERCARMINE PANZERA contributed to acquisition of the data.

ANTONIO AMBROSI revised the manuscript.

1. Name of the registry: ClinicalTrials.gov 2. Unique Identifying number or registration ID: NCT05178446 3. Hyperlink to your specific registration (must be publicly accessible and will be checked): https://register.clinicaltrials.gov/prs/app/act ion/SelectProtocol?sid=S000BJ15&selectaction=Edit &uid=U0005YQF&ts=2&cx=-xs6cux

The Guarantors are Professor Nicola Tartaglia and Professor Antonio Ambrosi.

Not commissioned, externally peer-reviewed.

GIOVANNA PAVONE, NICOLA TARTAGLIA, ALESSANDRO POR-FIDO, PIERCARMINE PANZERA, MARIO PACILLI, ANTONIO AMBROSI declare no conflict of interests.

Supplementary data to this article can be found online at https://doi. org/10.1016/j.amsu.2022.103584.

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