Roux-en-Y gastric bypass (RYGB) is the procedure of choice for patients presenting for bariatric surgery in the presence of gastroesophageal reflux disorder (GERD), erosive esophagitis (EE) and Barrett's esophagus (BE), providing there are no competing contraindications (active smoking, dependence on regular non-steroidal anti-inflammatory drugs, complex abdominal wall hernia(s), active inflammatory bowel disease etc), according to researchers from McGill University, Montreal, QC, Canada.
The study authors have published a review of the current literature regarding GERD prior to and after bariatric surgery and establishes a framework for evaluating and managing GERD in both the pre- and post-operative setting for common bariatric procedures such as the sleeve gastrectomy (SG), RYGB, adjustable gastric band (AGB) as well as one-anastomosis gastric bypass (OAGB). In addition, they highlight the latest recommendations from major international bariatric societies for screening prior to surgery, the incidence of GERD after each respective procedure and a summary of current trends in the management of post-operative GERD after bariatric surgery.
They also noted that access to routine objective testing like upper endoscopy remains “a significant hurdle.” Subsequently, GERD is a challenging medical condition prior to surgery and actual pre-operative incidence of reflux in patients who undergo bariatric surgery is difficult to determine, with guidelines and recommendation recommendations regarding screening pre-operatively, continually evolving.
Current pre-surgical recommendations include:
The ASMBS guidelines state that patients with clinically significant gastrointestinal symptoms should be evaluated before bariatric procedures with imaging studies including upper gastrointestinal series (UGI) or upper endoscopy.
IFSO recommends upper endoscopy to be considered for all patients with upper GI symptoms prior to bariatric surgery and those without upper GI symptoms due to the high rate (25.3%) of unexpected findings that may alter management or contraindicate surgery. IFSO also recommends routine upper endoscopy to be considered in populations where the community incidence of significant gastric and esophageal pathology is high, particularly when the procedure will lead to part of the stomach being inaccessible (ie. RYGB), one-anastomosis gastric bypass (OAGB).
European Association for Endoscopic Surgery (EAES) guidelines (endorsed by IFSO-EC, EASO and ESPCOP) have a conditional recommendation for routine upper endoscopy prior to bariatric surgery, given that the literature on the topic is prone to bias and stating that “selective endoscopy in patients with upper abdominal symptoms might be more appropriate.”
Surgery and reflux
According to the authors, standardising the SG technique has improved outcomes and minimised the risk of post-op GERD, and they note that the presence of GERD before surgery is not considered an absolute contraindication for SG. However, the patient requires appropriate pre-operative counselling regarding the possible outcomes of SG with respect to their GERD symptoms and the risk of long-term complications such as EE and BE, highlighting the need for pre-operative upper endoscopy.
For post-operative endoscopic surveillance for GERD, both IFSO and ASMBS recommend routine upper endoscopy 2-3 years after SG irrespective of GERD symptoms to detect any de novo BE and if normal again every five years. As for the management of GERD after SG, the 2019 ASMBS guidelines clearly suggest that patients with de novo GERD or worsened symptoms after SG should be first treated with acid suppression using proton pump inhibitors (PPIs), and only those with symptoms refractory to medical therapy should be considered for a conversion to an RYGB.
The researchers caution that GERD has consistently been described as a late complication of AGB with worsening or de novo reflux in up to a third of patients, with studies identifying GERD as the reason for reoperation or AGB removal in 3%-44%.
RYGB is the preferred primary bariatric surgery especially for patients with severe GERD symptoms (i.e., endoscopic finding of esophagitis Los Angeles Classification grades C and D and/or a 24 h or 48 h pH test or pH-impedance testing with total acid exposure time greater than 6%) and despite acid suppression.
The authors note that the amelioration of the histologic changes caused by GERD has also been shown in a recent systematic review of studies involving patients with documented BE who underwent RYGB with at least one year of follow-up, which found endoscopic evidence of regression in BE in 36%-62% of patients; moreover, no patients had progression of their BE after surgery.
Both IFSO and ASMBS recommend that only symptomatic patients should undergo endoscopic surveillance after RYGB and in cases with persistent symptoms should likely be repeated every five years, and acid suppression using PPIs and lifestyle modifications are the first lines of therapy for GERD after RYGB
One major post-operative concern after OAGB has always been bile reflux and due to the lack of data IFSO recommends against OAGB as primary bariatric surgery in patients with long-segment or dysplastic BE. The Federation also recommends upper endoscopy following OAGB (same as for SG).
“Surgeons should be aware that there are silent histologic changes that may occur after these procedures requiring close endoscopic surveillance particularly after SG and OABG,” the authors concluded. “Reflux following RYGB, while rare, is challenging to manage and investigations into complications of RYGB should be initiated prior to determining the appropriate surgical management. Further studies need to be completed utilizing objective measurements of GERD as upper GI symptoms following bariatric surgery can be difficult to differentiate from true GERD.”
To access the paper, ‘Reflux and bariatric surgery: a review of pre-operative assessment and post-operative approach’, published in the journal, Mini Invasive Surgery, please click here