Sleeve gastrectomy and gastroesophageal reflux: a comprehensive endoscopic and pH-manometric prospective study

Background: The impact of sleeve gastrectomy (SG) on gastroesophageal reflux disease (GERD) is still greatly debated. Most of the current evidence available is solely based on symptom evaluation or medication use, while a minority have implemented objective functional measurements. Objective: To better comprehend the pathophysiological mechanisms involved in the genesis of GERD after SG. Setting: University Hospital, Italy. Methods: A total of 21 patients affected by morbid obesity and eligible for SG were prospectively enrolled in the present study. Patients were evaluated by means of endoscopy, high-resolution manometry (HRM), 24-hour pH monitoring, and the Gastroesophageal Reflux Disease Health- Related Quality of Life questionnaire. Results: Follow-up was completed at least 1 year post operation (mean follow-up, 14.3 6 2.1 mo) by 19 patients. Body mass index decreased from 41.2 6 .9 to 26.8 6 .8 kg/m2 (P , .001). Distal con- tractile integral significantly decreased from 2772.8 6 399.9 mm Hg/s/cm to 2060.4 6 338.9 mm Hg/ s/cm (P 5 .01). The 24-hour pH monitoring showed an overall reduction tendency of acid reflux, although this was not statistically significant. All analyzed endoscopic findings withstood substantial pejorative modifications after SG (P , .01). Distal contractile integral values at baseline predicted postoperative Z-line upward migration; HRM, distal latency, and DeMeester score at baseline pre- dicted the development of erosive esophagitis at follow-up, by bootstrap estimates of a logistic regression. Conclusions: Postoperative GERD-related esophageal sequelae should be carefully considered after SG. Our results demonstrate how acid reflux does not seem to play a relevant role in the pathophys- iology of post-SG GERD. Baseline HRM can help stratify the risk of developing erosive esophagitis and Z-line upward migration after SG, while postoperative endoscopic surveillance should be encouraged regardless of the presence or absence of symptoms.