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Five-year outcomes show a low incidence of Barrett Esophagus after bariatric surgery

The five-year outcomes from a non-randomised clinical cohort trial has found that a low incidence of Barrett Esophagus (BE) in 169 patients after laparoscopic sleeve gastrectomy (LSG) and Roux-Y-gastric bypass (LRYGB). However, the prevalence of reflux symptoms and esophagitis was higher in LSG compared to LRYGB patients.

Figure 1: Grade of reflux-esophagitis (LA Classification) pre- and post- bariatric surgery. Following LSG there is an increase in the frequency and severity of mucosal inflammation, whereas the opposite is the case after LRYGB.

The evidence seems to indicate that gastroesophageal reflux disease (GERD) seems more frequent after LSG than LRYGB and retrospective case series have raised concerns about a high incidence of BE after LSG, the study authors from Clara Hospital Basel, Basel and University Hospital Zürich, Zürich, Switzerland, noted. Therefore, they undertook the study to compare the incidence of reflux symptoms and mucosal disease after LSG and LRYGB, with particular attention to the de novo development of BE after LSG.


The primary endpoint was cumulative incidence of Barrett’s esophagus (BE) ≥5 years after primary LSG or LRYGB. Secondary endpoints included prevalence and severity of reflux esophagitis (endoscopy), reflux symptoms (questionnaires), use of proton pump inhibitors (PPI), severity of acid reflux (pH-measurement), weight loss and remission of comorbidities. The researchers contacted patients that had undergone surgery at least five-years previously and they completed questionnaires and repeat gastroscopy with biopsies were performed.


In total, 86 patients were recruited to the LRYGB cohort and 83 patients to the LSG cohort. Preoperatively, there were no differences between the two intervention groups concerning sex, age, weight and prevalence of comorbidities. As expected from the clinical policy of the participating bariatric centres, reflux symptoms and reflux esophagitis were less prevalent in the group that subsequently underwent LSG.


Outcomes

The investigators reported that at five-years the use of proton pump inhibitors was more common in the LSG- than the LRYGB-group (42/83 (50.6%) vs. 17/86 (19.8%)) and LSG-patients - who had not taken PPI before surgery - were more likely than LRYGB-patients to use PPI after surgery (38/76 (50.0%) vs. LRYGB (13/75; 17.3%)).


Reflux esophagitis was present in pre-operative endoscopy in 19/83 (23.0%) of LSG and 24/86 (27.9%) of LRYGB patients. At five-years, the presence of esophagitis was more common in the LSG- than LRYGB-patients (48/83 (57.8%) vs. 23/86 (26.7%)). LSG-patients with esophagitis before surgery experienced remission in 1/17 (5.9%) and LRYGB-patients in 14/24 (58.3%). De novo development of esophagitis was more common in LSG-patients: 27/50 (54.0%) vs. 13/62 (21.0%) and there was a shift in the distribution towards more severe disease (Figure 1).

Clinically relevant GERD-Q scores (>8 points) were more frequent in LSG- than LRYGB-patients (41/79 (51.9%) vs. 9/86 (10.5%)) and “moderate-severe” dyspeptic symptoms were also more frequent in the LSG- than in the LRYGB-group (24/79 (30.4%) vs. 8/86 (9.3%)). Swallowing problems were not common and psychometric assessments were similar in both groups.


The proportion of symptoms associated with reflux (symptom index) was median 33% [0.00, 66.00] in LSG with very few symptoms in the LYRGB group triggered by reflux events. In the LSG group, there was an association between symptom severity (GERD-Q), acid exposure (r2=0.38) and reflux esophagitis (r2=0.32).


Multivariate analysis with cross-validation revealed that the predictors of GERD after surgery were the operation-group, pre-operative GERD diagnosis, demographic variables and BMI. The LSG-operation was the most relevant predictor for a postoperative diagnosis of GERD, with an area-under-curve (AUC) of 0.62 (95%CI 0.52 to 0.71). Adding preoperative reflux as a second predictor increased the AUC to 0.64 (95% CI 0.55 to 0.74). Adding sex, age and BMI did not alter the results.

Reduction in body weight expressed as percentage excessive BMI loss (%EBMIL) at five years was 53.6% in the LSG-group and 71.8% in the LRYGB-group (p=0.002). At follow-up (median of 7.0 ± 1.5 years), %EBMIL was 57.6% in the LSG-group and 67.4% in the LRYGB-group (p=0.001).


Preoperatively, 20/83 (24.1%) of LSG and 27/86 (31.4%) of LRYGB patients had type 2 diabetes. At follow-up, the remission rate in LSG-patients was 11/20 (55.0%) and 14/27 in LRYGB (51.9%). De novo diabetes was seen in 3/63 (4.8%) LSG-patients and none in the LYRGB patients.


Hiatal hernia was described in pre-operative endoscopy in 17/83 (20.5%) of LSG and 23/86 (26.7%) of LRYGB-patients. At five -years, hiatal hernia was found in more LSG- than LRYGB-patients (33/83 (40.2%) vs. 16/86 (18.6%)). LSG-patients with hiatal hernia before surgery had no hernia at follow-up in 6/17 (35.3%) and LRYGB-patients in 16/23 (69.6%). De novo development of hiatal hernia was more common in LSG- than LRYGB-patients (19/53 (35.8%) vs. 9/63 (14.3%)).


“This finding provides some reassurance for obese patients that have had LSG and also for doctors and surgeons caring for this cohort” the authors concluded. “Notwithstanding this finding, the high incidence of moderate to severe reflux esophagitis in LSG patients at follow-up, supports the recommendation that (i) pre-operative endoscopy should be performed to inform patient selection for bariatric procedures and (ii) post-operative surveillance should be performed after LSG, even in the absence of GERD symptoms.”


The findings were reported in the paper, 'Prospective clinical cohort study: Low incidence of Barrett esophagus but high rate of reflux disease at 5-year follow-up after Sleeve Gastrectomy vs. Roux-Y-Gastric Bypass', published in SOARD. To access this paper, please click here

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