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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

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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

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Acknowledgments

The authors would like to thank associate Professor Dr. Andreas Steingötter for his technical advice and support with acquisition and analysis of Magnetic Resonance Imaging.

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Authors and Affiliations

  1. IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France

    Giuseppe Quero, Claudio Fiorillo, Pietro Mascagni & Silvana Perretta

  2. Digestive Surgery, Fondazione Policlinico Universitario “A. Gemelli” IRCSS, Rome, Italy

    Giuseppe Quero, Claudio Fiorillo & Pietro Mascagni

  3. IRCAD, Research Institute against Digestive Cancer, Strasbourg, France

    Bernard Dallemagne & Silvana Perretta

  4. Department of Gastroenterology and Hepatology, University Hospital Zürich, CH-8091, Zürich, Switzerland

    Jelena Curcic & Mark Fox

  5. Digestive Function: Basel, Laboratory and Clinic for Motility Disorders and Functional Digestive Diseases, Center for Integrative Gastroenterology, Klinik Arlesheim, CH-4144, Arlesheim, Switzerland

    Mark Fox

  6. Department of Digestive and Endocrine Surgery, NHC, Strasbourg, France

    Silvana Perretta

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  1. Giuseppe Quero
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Correspondence to Claudio Fiorillo.

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Quero, G., Fiorillo, C., Dallemagne, B. et al. 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. OBES SURG 30, 2108–2117 (2020). https://doi.org/10.1007/s11695-020-04438-y

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