LSG associated with rise in GERD but not hiatal hernia

Updated: Mar 23

Approximately one-third of the patients developed gastroesophageal reflux disease (GERD) up to two years after laparoscopic sleeve gastrectomy (LSG), although the incidence of hiatal hernia after bariatric surgery was low, according to researchers from Saudi Arabia. The outcomes were featured in the paper, ‘Gastroesophageal Reflux Disease and Hiatal Hernia After Laparoscopic Sleeve Gastrectomy: A Retrospective Cohort Study’, published in Cureus.

The authors noted that the relationship between developing GERD and hiatal hernia after LSG remains unclear and therefore, they decided to assess the incidence of new-onset GERD and hiatal hernia up to two years after LSG and to identify any associated risk factors for the development of GERD.


This retrospective cohort study included data from two centres – the King Abdulaziz Medical City (KAMC) in Riyadh and King Abdulaziz Hospital (KAH) in Al-Ahsa from January 2016 to February 2019. All patients who underwent LSG in KAMC or KAH from January 2016 to February 2019 were included in the study. Patients were excluded following previous bariatric surgery, a history of GERD symptoms or diagnosed with GERD before surgery, diagnosed with hiatal hernia preoperatively or had intraoperative hiatal hernia repair.


For a diagnosis of GERD or hiatal hernia postoperatively, GERD symptoms grade were classified clinically as: none; grade 1: mild symptoms and no proton pump inhibitor (PPI) use; grade 2: moderate symptoms and periodic PPI use; grade 3: severe symptoms and frequent PPI use, upper endoscopy, oesophageal manometry and 24-hours PH mentoring, barium contrast study, and the period from surgery at which GERD had been diagnosed.


Outcomes

A total of 500 patients underwent LSG and 142 met the inclusion criteria. The mean age was 39.38±12.68 years, males accounted for 35.2% (n=50) while females were 64.8% (n=92). The percentage and frequency of comorbidities were as follows: hypertension 33.09% (n=47), diabetes mellitus 32.4% (n=46), dyslipidaemia 24.6% (n=35), obstructive sleep apnoea 16.2% (n=23); smokers accounted for 14.1% (n=20).


Preoperative BMI mean was 45.29±7.22, post-operative BMI mean at six months was 34.40±6.30 with a mean change in BMI of 11.91kg/m2. From the 142 patients who were followed up for 24 months, post-operative new-onset GERD was observed in 47 (33.1%) patients, of those 29 (61.7%) reports mild symptoms with no PPI use, 13 (27.65%) reported moderate symptoms with periodic PPI use and five (10.63%) reported severe symptoms with frequent PPI use.


In total, 15 patients were diagnosed using upper endoscopy, 32 were diagnosed by symptoms reporting and PPI use. Post-operative hiatal hernia was observed in five (3.5%) patients. It was significantly associated with GERD (p=0.007). The average time for the development of GERD was six months, and most cases presented three months after the procedure.


From the 47 patients who developed GERD, 36 were females, and 11 were males; gender was significantly associated with GERD development (p=0.038), the mean age was 42.74 ± 11.72 years and it was also significantly associated with GERD development (p=0.026). Out of the comorbidities (hypertension, diabetes mellitus, dyslipidaemia, obstructive sleep apnoea) and smoking, hypertension was the only statistically significant associated risk factor (p=0.014). Preoperative and postoperative BMI were not statistically significant (p=0.440, p=0.549) nor the EBMI% (p=0.419).


The authors noted that the higher rate of GERD incidence in their study compared to the literature is due to the lack of standard evaluation methods to diagnose GERD - a combination of objective and subjective methods.

“Due to this reason, the need for more reliable tests such as upper endoscopy, or oesophageal function tests such as oesophageal manometry and 24-hours PH mentoring (even though the latter has no utility in routine clinical settings) offer a more precise estimate of the incidence,” they caution.

They recommended offering consultation for patients with identified risk factors about the risk of having GERD and the need for alternative methods to lose weight, such as LRYGB.


They said that future randomized and multi-centre trials are needed to improve the understanding of the anatomic and pathophysiological mechanisms to put an end to this debate and to delineate the risk factor associated with GERD development after LSG.


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