A New Algorithm to Reduce the Incidence of ...

OBES SURG DOI 10.1007/s11695-016-2518-0

ORIGINAL CONTRIBUTIONS

A New Algorithm to Reduce the Incidence of Gastroesophageal Reflux Symptoms after Laparoscopic Sleeve Gastrectomy. Ilhan Ece 1 & Huseyin Yilmaz 1 & Fahrettin Acar 1 & Bayram Colak 1 & Serdar Yormaz 1 & Mustafa Sahin 1

# Springer Science+Business Media New York 2016

Abstract Background Laparoscopic sleeve gastrectomy (LSG) is one of the most prefered treatment option for morbid obesity. However, the effects of LSG on gastroesophageal reflux disease (GERD) are controversial. Asymptomatic GERD and hiatal hernia (HH) is common in obese patients. Therefore, it is important to identify the high risk patients prior to surgery. This study aims to evaluate efficacy of cruroplasty for HH during LSG in morbidly obese patients using ambulatory pH monitoring (APM) results, and to investigate the patients’ selection criteria for this procedure. Methods This retrospective study includes outcomes of 59 patients who underwent LSG and HH repair according to our patient selection algorithm. Outcomes included preoperative GERD Health-Related Quality of Life (GERD-HRQL) questionnaire, APM results, percentage of postoperative excess weight loss, and total weight loss. Results For a total of 402 patients, APM was applied in 70 patients who had a positive score of GERD-HRQL, and 59 patients underwent LSG and concomitant HH repair who had a DeMeester score of 14.7% or above. There was no statistically significant difference in weight loss at 6 and 12-month follow-up. Two patients (3.3%) had symptoms of GERD at 12 months postoperatively, and only one (1.6%) patient required treatment of proton pump inhibitor for reflux. In the total cohort, 11 (2.7%) patients also evolved de novo GERD symptoms.

* Ilhan Ece [email protected]

1

Department of Surgery, Faculty of Medicine, Selcuk University, 42075 Konya, Turkey

Conclusions This study confirm that careful attention to patient selection and surgical technique can reduce the symptoms of GERD at short-term. Routine bilateral crus exploration could be a major risk factor of postoperative GERD. Keywords Laparoscopic sleeve gastrectomy . Gastroesophageal reflux disease . Hiatus hernia repair . Obesity . pH monitoring

Introduction Gastroesophageal reflux disease (GERD) is a common obesity related comorbidity that adversely affects the quality of life of patients. GERD is defined as the presence of reflux symptoms or erosive esophagitis [1]. Increased intragastric pressure that occurs due to external compression of surrounding adipose tissue and transient relaxation of the lower esophageal sphincter (LES) causes acid reflux [2]. Weight reduction often provides sufficient improvement of symptoms [3]. Roux-en-Y gastric bypass (RYGB) is very effective in treating symptoms related to GERD, and is also accepted as the gold standard bariatric procedure in patients with GERD [4, 5]. Laparoscopic sleeve gastrectomy (LSG) is a widely regarded form of weight loss surgery due to lower levels of morbidity and mortality. LSG is also safer than RYGB in terms of long-term nutritional deficiency results. Recently, however, the effect of LSG on GERD symptoms has become controversial. A review of 15 studies demonstrated that four of them found an increased incidence of GERD after sleeve gastrectomy, and seven studies reported reduced GERD symptoms after sleeve gastrectomy [6]. Many authors reported that technical considerations, including complete removal of the gastric fundus, avoid the creation of a narrow or BCorkscrew^ sleeve, and that routine repair of identified hiatal hernias (HH)

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can reduce the incidence of GERD after LSG [7, 8]. HH is a major risk factor for GERD in the general population and also following LSG. Symptomatic HH affects nearly 15% of patients with a body mass index (BMI) of >35 kg/m2 [9]. Nevertheless, the positive effect of hiatal hernia repair (HHR) during sleeve gastrectomy has yet to be well defined by randomized prospective trials. Ambulatory pH monitoring (APM) is one of the most effective diagnostic test for GERD [10]. The test provides the detection of esophageal acidification periods for a direct diagnosis of gastro esophageal reflux and quantification of the exposure of the distal esophagus to acid [11]. This test has high sensitivity and specificity in the diagnosis of GERD. False positive results may be due to acidic food ingestion or non-reflux-related fluctuations in pH due to electrode drift. However, these disadvantages can be easily eliminated by providing appropriate information to the patients, and controlled electrode placement via X-ray. The objective of this study is to evaluate the effect of LSG in combination of HHR on APM results concerning GERD symptoms, and to compare the effect on weight loss.

Materials and Methods The data of 402 patients who underwent LSG from February 2010 to January 2015 in the obesity surgery clinic of our University Research Hospital were included in this retrospective study. The study was approved by the local Ethics Committee and the need for patient informed consent was waived. This study has been performed in accordance with the ethical standards laid out in the Declaration of Helsinki. Bariatric surgery candidates were selected according to the International Federation for the Surgery of Obesity (IFSO) criteria for bariatric surgery. As such, patients with a body mass index (BMI) of 40 kg/m2 or more, or between 35 and 40 kg/m2 together with significant comorbidity (type 2 diabetes, hypertension, or obstructive sleep apne) considered for bariatric surgery. Patients with complicating diseases resulting in an American Society of Anesthesiologists score of IV, and a previous history of gastric surgery, and anti-reflux procedures were excluded. The patients’ characteristics, comorbidities, and preoperative APM results were recorded before surgery. Postoperative data, including pH monitoring and weight loss results, were also recorded 1 year after surgery. Preoperative Evaluation All patients underwent a standard preoperative evaluation, consisting of cardiac, pulmonary, and endocrinological evaluations, abdominal ultrasound, upper gastrointestinal endoscopy, and the application of the Gastro esophageal Reflux

Disease Health-Related Quality of Life (GERD-HRQL) questionnaire. Esophagogastroduodenoscopy was performed before surgery to assess GERD signs, esophagitis, or HH. In our clinical practice, we accepted endoscopic findings of GERD and high GERD-HRQL scores as an indication of ambulatory pH monitoring (Fig. 1). Results were considered positive when the GERD-HRQL score was >28. Concurrently, endoscopic detection of hiatal hernia at any size was accepted as an indication of crus exploration and cruroplasty. Regardless of whether it is symptomatic, small sized defects were repaired primarily, and the patients who had hiatal defects larger than 5 cm were also subjected to a posterior mesh repair. Ambulatory pH Monitoring Twenty-four hour-APM was performed before the operations and also 1 year after LSG with an Ohmega device (Ohmega; Medical Measurement System, Enschede, Netherlands). All patients presented for APM probe placement after 8 h of fasting. Patients were informed that they should discontinue proton pump inhibitors (PPI) for least 7 days, and H2blockers, or antiacids for 3 days prior to the study. The pH probe was calibrated using buffer solutions with pH 4.0 and 7.0. The calibrated pH probe was transnasally positioned 5 cm above the lower esophageal sphincter, as determined by X-ray. All subjects were instructed by an experienced nurse to keep a normal diet and to record symptoms, meal times, and the times of supine and upright postures. Data including acid exposure time, the number of reflux episodes, and time of longest episodes were recorded for a 24-h period and analyzed using the MMS Database Software v9.1 computer program. The characteristics of acid reflux and DeMeester scores were calculated automatically by the software. An abnormal DeMeester score was considered to be 14.7% and above. Surgical Technique All operations were performed under general anesthesia by using a five-trocar technique after preoperative antibiotic (Cefazoline 2 g IV) and thromboembolism (LMWH) prophylaxis. Intermittant pneumatic compression stockings were placed on both legs. The patient was placed in semilithotomy and reverse trendelenburg position. Pneumoperitoneum was established by insertion of the first supra-umbilical 10 mm-trocar after lifting the abdominal wall. The left lobe of the liver was then retracted using a 5 mm grasper. The greater curvature vessels of the stomach were divided using a vessel sealing device (Ligasure, Maryland, Covidien, USA). The posterior gastric vessels were also sealed, and the left crus was separated from the retrogastric fat tissue. The right crus was not dissected in patients without GERD symptoms. Both diaphragmatic cruses were explored

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height (meter) x height × 25. In the formula, 25 shows the ideal BMI. %EWL was calculated as follows: [(preoperative weight- follow up weight)/(preoperative weight- ideal body weight)] × 100, and %TWL was calculated as [(preoperative weight−excess weight loss)/preoperative weight] × 100. Statistical Analysis

Fig. 1 Management algorithm of high risk patients for GERD

routinely in patients with a positive DeMeester score. Posterior formal crus repair with non-absorbable sutures was performed to address all types of small (5 min was significantly lower than in the preoperative records (Table 3).

Assessment of Weight Loss Postoperative Courses The weight loss of patients were evaluated by the percentage of total body weight loss (%TWL), and percentage of excess weight loss (%EWL). Ideal body weight was calculated as

Thirty-eight (64.4%) of the patients were being treated with PPI for GERD in the preoperative period. At the 12-month-

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GERD health related quality of life questionnaire

Questions

Scores

1. How bad is your heartburn?

012345

2. Heartburn when lying down?

012345

3. Heartburn when standing up? 4. Heartburn after meals?

012345 012345

5. Does heartburn change your diet? 6. Does heartburn wake you from sleep?

012345 012345

7. Do you have difficulty in swallowing?

012345

8. Do you have pain while swallowing? 9. Do you have gloating or gassy feelings?

012345 012345

10. If you take medicine, does this affect your daily life?

012345

How satisfied are you with your present condition? Satisfied__Neutral__ Dissatisfied __ Scale: 0, no symptoms; 1, symptoms noticeable; but not bothersome; 2, symptoms noticeable and bothersome but not every day; 3, symptoms bothersome every day; 4, symptoms affect daily activities; and 5, symptoms are incapacitating, unable to do daily activities

postoperative follow-up, only two (3.3%) patients had a higher score of DeMeester than 14.7%, and only one (1.6%) patient required PPI treatment for reflux. Postoperatively, only 11 (2.7%) patients had de novo GERD symptoms across the total cohort, and all these patients were treated with antisecretory agents. However, conversion to Roux-en-Y gastric

Table 2

Preoperative features of the patients

Variable

Total cohort (n = 402)

Study cohort (n = 59)

Age* (years) Gender (f/m) BMI* (kg/m2) ASA Ia IIa IIIa Comorbidities Hypertensiona Coronary artery diseasea Type 2 diabetesa Glucose intolerancea

33.2 ± 12.7 221/181 44.6 ± 5.1

34.8 ± 14.2 42/28 43.4 ± 4.6

181 (45.0) 142 (35.3) 79 (19.7)

33 (47.1) 21 (30.0) 16 (22.8)

78 (19.4) 5 (1.2) 110 (27.3) 38 (9.4)

12 (20.3) 0 (0) 19 (32.2) 5 (8.4)

121 (30.0) 45 (11.2) 24.2 ± 9.2 21.8 ± 5.6

16 (27.1) 7 (11.8) 38.6 ± 10.7 19.2 ± 6.2

Dyslipidemiaa Sleep apne syndromea GERD-HRQL score* Follow-up (months)*

Datas are presented as *mean ± standard deviation,a n (%) F female, M male, BMI body mass index, ASA American Society of Anesthesiologists score, GERD-HRQL gastroesophageal reflux diseasehealth related quality of life questionnaire

bypass was also required in two of these patients. In the study cohort, only one patient was excluded from the study due to conversion to open surgery. We observed no other major intraoperative complications. A staple line leak with low output was detected in one (1.6%) patient, and was treated with applying a self expandable metallic stent. The healing of the leakage was confirmed by contrast swallow test and abdominal computerized tomography, and the stent was removed within 4 weeks. There were no cases of pulmonary embolism, postoperative bleeding, or death. Only one (1.6%) patient developed deep vein thrombosis, and successfully treated with oral warfarin. Also, two (3.3%) patients treated with drainage and oral antibiotics for port-site infection. Two patients (3.3%) in the study group experienced port-site hernia (PSH). One of the patients were diabetic and male. The other patient was a 55-year-old female with chronic obstructive pulmonary disease. All of the PSHs’ confirmed by ultrasound, and elective mesh hernioplasty was performed. Two patients complained of having difficulty swallowing solid food in the early postoperative period, but this problem resolved spontaneously within 3 weeks. Weight Loss Out of a total of 402 patients, 362 (90.0%) were completely followed for 12 months. When the study group was compared to all patients, %TWL was not different in the first 6-monthfollow-up period. The patients who underwent LSG plus HHR in this study group had a high %TWL 1 year after surgery, but this difference was not statistically significant (Table 4).

Discussion The main finding of this study is that the LSG and concomitant HHR can provide an effective improvement of GERD symptoms in morbidly obese patients. The preoperative incidence of GERD in this study is similar to other reports [9]. In our obesity clinic, we have created a new algorithm to diagnose GERD objectively. Because bilateral crus exploration is not routinely required during LSG, the dissection of the diaphragmatic crus and the division of the posterior ligaments of the gastroesophageal junction is a common cause of Type I HH [10]. Therefore, we do not recommend routine exploration of cruses and the destruction of the ligaments around the abdominal esophagus. In clinical practice, the GERD-HRQL questionnaire and APM test results can be used as indications of cruroplasty. Many studies have shown that the incidence of GERD symptoms can increase from 7.8 to 20% during the first year following LSG [7], and the data from the literature is currently controversial concerning the effect of LSG on GERD

OBES SURG Table 3 results

Preoperative and postoperative ambulatory pH monitoring test

Variable

Preoperative pH monitoring results (n = 70)

Postoperative pH monitoring results (n = 59)

p

De Meester score (%)

33.8 ± 11.6

9.6 ± 5.7