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Mechanisms of Esophageal and Gastric Transit Following Sleeve Gastrectomy

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Abstract

Purpose

Sleeve gastrectomy (SG) patients have substantially altered anatomy. The mechanism of rapid gastric emptying and the role of esophageal contractile function in esophago-gastric transit has not been defined. We aimed to determine the mechanisms of esophago-gastric transit and role of esophageal function following sleeve gastrectomy.

Methods

Prospective study of twenty-six asymptomatic participants post SG underwent nuclear scintigraphy and high-resolution manometry. Fourteen had semi-solid stress barium to model the emptying process. Concurrent video fluoroscopy and manometry were performed on 7 participants.

Results

Demographic data are as follows: age 45.3 ± 15.0 years, 73.1% female, excess weight loss 62.2 ± 28.1% at 8 months. Scintigraphy showed rapid gastric emptying (24.4 ± 11.4 vs. 75.80 ± 45.19 min in control, p < 0.001) with 35.24 ± 17.12% of bolus transited into small bowel on initial frame. Triggered deglutitive reflux was common (54.4% vs. 18.2%, p = 0.017). Stress barium delineated separate vertical and antral gastric compartments with cyclical emptying of 8 stages, including reflux-induced repeated esophageal peristalsis. During manometry, ramping effects were noted, with sequential swallows producing sustained isobaric pressurizations in proximal stomach (33.6 ± 29.5 mmHg). Video fluoroscopy showed individual esophageal peristalsis generating pressurizations at 5.0 ± 1.4 cm below lower esophageal sphincter (LES), at amplitude of 31.6 ± 13.1 mmHg, associated with intragastric transit. Pressurizations were sustained for 17.3 ± 8.2 s, similar to the prolonged LES contraction (18.5 ± 9.0 s, p = 0.355).

Conclusions

Repeated esophageal peristaltic contractions induced isobaric pressurization of proximal stomach, thus providing the drive to pressurize and empty the vertical compartment of the gastric sleeve. Transit following SG appeared to be esophageal-mediated and followed a distinct cycle with strong associations with reflux.

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Authors and Affiliations

  1. Department of Surgery, Central Clinical School, Monash University, 99 Commercial Road, Melbourne, VIC, 3004, Australia

    Yazmin Johari, Anagi Wickremasinghe, Pradipta Kiswandono, Geraldine Ooi, Cheryl Laurie, Wendy Brown & Paul Burton

  2. Oesophago-gastric and Bariatric Unit, Department of General Surgery, The Alfred Hospital, Melbourne, Australia

    Yazmin Johari, Geraldine Ooi, Wendy Brown & Paul Burton

  3. Department of Nuclear Medicine, The Alfred Hospital, Melbourne, Australia

    Helen Yue, Paul Beech & Kenneth Yap

  4. Department of Gastroenterology, Royal Melbourne Hospital and University of Melbourne, Melbourne, Australia

    Geoffrey Hebbard

Authors
  1. Yazmin Johari
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  2. Anagi Wickremasinghe
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  3. Pradipta Kiswandono
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  4. Helen Yue
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  5. Geraldine Ooi
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  6. Cheryl Laurie
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  7. Geoffrey Hebbard
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  8. Paul Beech
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  9. Kenneth Yap
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  10. Wendy Brown
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  11. Paul Burton
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Contributions

Yazmin Johari was extensively involved in design, data collection, data analysis, presentation, and write up.

Anagi Wickremasinghe, Pradipta Kiswadono, Helen Yue, Geraldine Ooi, and Cheryl Laurie were involved in the initial design, patient recruitment, data collection, and data representation.

Geoffrey Hebbard, Paul Beech, Kenneth SK Yap, Wendy Brown, and Paul Burton were extensively involved in initial concept, design, supervision, data analysis, presentation, write up, and final approval of the paper.

Corresponding author

Correspondence to Yazmin Johari.

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Conflict of Interest

Wendy Brown received grants from Johnson and Johnson, grants from Medtronic, grants from GORE, personal fees from GORE, grants from Applied Medical, grants from Apollo Endosurgery, grants and personal fees from Novo Nordisc, and personal fees from Merck Sharpe and Dohme, outside the submitted work. The other authors declare that they have no conflict of interest.

Ethical Approval

Ethics approval was obtained from the Alfred Hospital Human Research and Ethics Committee (HREC) no. 380/16 and The Avenue Hospital HREC no. 236.

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An information statement was provided prior to commencement. Written informed consent was obtained in an opt-in manner.

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Johari, Y., Wickremasinghe, A., Kiswandono, P. et al. Mechanisms of Esophageal and Gastric Transit Following Sleeve Gastrectomy. OBES SURG 31, 725–737 (2021). https://doi.org/10.1007/s11695-020-04988-1

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  • DOI: https://doi.org/10.1007/s11695-020-04988-1

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