Valutazione pH-manometrica nei pazienti obesi candidati a Sleeve Gastrectomy o bypass gastrico per via laparoscopica

Background: Aim is to evaluate the impact of laparoscopic sleeve gastrectomy (LSG) and gastric bypass (LGB) on gastroesophageal reflux disease (GERD) before and after surgery. Methods: Before surgery, GERD was evaluated by Modified Italian Gastroesophageal reflux disease-Health-Related Quality of Life (MI-GERD-HRQL) questionnaire, manometry, pH-metry, endoscopy and Rx-esophagogram. Based on these exams, patients without GERD underwent LSG and patients with GERD underwent LGB. These exams were repeated 12 months after surgery. Results: Thirteen and 6 patients underwent LSG and LGB, respectively. After LSG, all pH-manometry parameters worsened, with statistically significant difference in median DeMeester score (5.7 vs. 22.7, p=0.0026). De novo GERD occurred in 9 patients (69.2%), with erosive esophagitis in one. No statistically significant differences were observed at endoscopy and Rx esophagogram findings. The median MI-GERD-HRQL score improved from a median of 3 to 0. Overall, nine patients underwent LGB, but three were lost at follow-up. Preoperative pH-manometry changed the surgical indication from LSG to LGB in 7 out of 9 patients (77.8%). Six patients who underwent LGB completed the study, and at pH-manometry, statistically significant differences were observed in percentage of total acid exposure time, number of reflux episodes lasting >5 minutes and DeMeester score (93.8 vs. 3.6, p=0.009). No statistically significant differences were observed at endoscopy and Rx-esophagogram findings. The median MI-GERD-HRQL score improved from a median of 6.5 to 0. Conclusions: LSG has a negative impact on GERD, even in patients without preoperative GERD. LGB was proved to be the intervention of choice in patients with GERD. Preoperative pH-manometry may identify patients with silent GERD, to candidate them to LGB rather than LSG. Preoperative endoscopy, Rx esophagogram and GERD symptoms are not sufficient to decide the most appropriate intervention in obese patients. pH-manometry should be used more liberally to establish the correct surgical indication on objective grounds.