Laparoscopic sleeve gastrectomy does not reliably improve GERD symptoms

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1. Patients receiving laparoscopic sleeve gastrectomy (LSG) had lower rates of resolution of GERD as compared to patients receiving gastric bypass (GB). 

2. Preoperative GERD symptoms were associated with increased surgical complications, postoperative adverse events, and required provisional surgery after LSG. 

Evidence Rating Level: 3 (Average) 

Study Rundown: Gastroesophageal reflux disease (GERD) is an obesity-related that has been associated with an increased risk of esophageal adenocarcinoma. The Roux-en-Y gastric bypass (GB) procedure results in significant loss of excess body weight and improved control of GERD.  A newer surgical option that has been gaining popularity due to its relative ease and low complication rate is the Laparoscopic Sleeve Gastrectomy (LSG), though the procedure’s effect on GERD remained an open question. This study evaluated GERD in the context of LSG and compared the results with a control population of patients receiving the standard GB operation. Among patients who underwent LSG, only 15.9% experienced resolution of their GERD symptoms, as compared to 62.8% of gastric bypass patients.

Though limited by the retrospective design and lack of an objective confirmation of GERD diagnoses, the results of this study suggest that despite the advantages of LSG over traditional GB, the procedure does not provide reliable attenuation of GERD symptoms. The study also found that patients with pre or postoperative GERD experienced more complications and may have suboptimal weight loss after LSG. The authors suggest that preexisting severe GERD be considered a relative contraindication for the procedure.

Click to read the study, published today in JAMA Surgery

Relevant reading: Bariatric surgery: a review of procedures and outcomes

In-Depth [retrospective cohort study]: This multicenter retrospective cohort study characterized the relationship between GERD and LSG surgery and compared the outcomes with standard GB surgery. Utilizing the Bariatric Outcomes Longitudinal Database (BOLD), the records of 4,832 patients who underwent LSG were compared with 33,867 patients who underwent GB between 2007 and 2010. Patients undergoing LSG were on average older and more likely to be male than those undergoing GB (P = 0.01 and 0.007 respectively). Additionally, patients undergoing LSG had lower rates of preoperative GERD, hypertension, diabetes mellitus, hypercholesterolemia, and obstructive sleep apnea than those undergoing GB (all P < 0.001). Analysis of the surgical outcomes with relation to GERD were analyzed only in patients with complete postoperative data over 6 months of follow up but did not adjust for the preoperative differences between the cohorts.

The severity of GERD in preoperatively and postoperatively was assessed on a scale from 0 (no GERD) to 5 (severe symptoms, not controlled with proton-pump inhibitors) based on medical diagnosis and the need for medications or other interventions. In patients undergoing LSG, 15.9% of patients with preoperative GERD experienced resolution of their symptoms, and 9.0% experienced worsening of their symptoms. In patients with preoperative GERD who underwent GB, 62.8% experienced resolution of their symptoms while only 2.2% experienced worsening symptoms (p < 0.05).

Patients with preexisting GERD who underwent LSG were found to experience worse outcomes than those patients without preexisting GERD who underwent LSG. The overall complication rate increased from 10.6% in patients without GERD, to 15.1% with GERD, and 16.3% with severe GERD (p = 0.007). Adverse gastrointestinal events also increased from 3.6% in patients without GERD, to 6.9% with GERD, and 7.5% with severe GERD (p = 0.012). Additionally, the need for revisional surgery after LSG increased from 0.3% in patients without GERD to 0.06% with GERD (p = 0.03). Finally, the incidence of weight loss failure, defined as losing less than 50% of excess body weight, was greater in patients with preoperative severe GERD, 34.0%, than in those without preexisting GERD, 28.0% (p = 0.017).

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