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Abdulrahman Mosaid Alolyyan et al, 2020;4(2):518–521.

International Journal of Medicine in Developing Countries

Gastro-esophageal reflux disease post gastric sleeve surgery: a review article

Abdulrahman Mosaid Alolyyan1, Ahmad Yousef Aljuraifani1, Hamad Mohammad Aloraini1, Abdullah Ahmad Alhatlani1, Abdulmajeed Abdulrazaq Alzahrani1, Abdullah Abdulaziz Almuhaymidi1, Yassin Hassan Alzubaidi2

Correspondence to: Abdulrahman Mosaid Alolyyan

*Medical Intern, Qassim University, Unaizah, Qassim province, Saudi Arabia.

Email: ab.alolyyan [at] gmail.com

Full list of author information is available at the end of the article.

Received: 22 December 2019 | Accepted: 03 January 2020


ABSTRACT

Although the gastric sleeve is a commonly performed procedure to treat morbid obesity, long-term complications represent a challenge for this procedure. Gastroesophageal reflux is an example of these complications, which is under-evaluated in medical literature. This review article aimed at evaluating the literature on the occurrence of gastroesophageal reflux disease after gastric sleeve surgery. Medical databases were examined thoroughly to explore the eligible articles for inclusion. Twenty-two articles appeared in the search result. The produced reports were evaluated against the pre-decided inclusion criteria. After reviewing the literature, four articles were eligible to be included in this review. The included articles were published between 2012 and 2019. The study concludes that there are some data about the increasing trend of gastroesophageal reflux disease after gastric sleeve procedure. However, data from high-quality studies with better study design are crucial to confirm this finding.


Keywords:

GERD, gastric sleeve, postoperative, complications.


Introduction

Obesity is the leading comorbidity that can increase the risk of morbidity and mortality [1]. Obesity is also showed to be a significant risk factor for cancer, diabetes, and atherosclerotic diseases [2,3]. Moreover, the prevalence of obesity is increasing globally, while the safety of medications to control obesity is still questionable [4].

Based on the current limitations of medications available for the treatment of obesity [5], surgical treatment became a commonly used option to manage morbid obesity, especially with failure or intolerance of medical treatment [6,7]. In addition, bariatric surgery, in some instances, is more preferable by patients due to offering weight control over the long term [8].

Gastric sleeve is a relatively novel type of bariatric procedure that is widely acceptable by surgeons and patients [9]. Gastric sleeve is proved to be a more safe procedure with minimal risk of complications compared to other types of bariatric surgery [10,11].

However, currently, there are some concerns about an increased incidence of gastroesophageal reflux disease (GERD) after gastric sleeve [12]. GERD after gastric sleeve was observed in patients who did not suffer from GERD before the operation, as well as worsened symptoms of GERD for patients who had a positive history before the procedure [13,14]. Yet, the data in the medical literature regarding the incidence and risk factors of GERD post-gastric sleeve are inconclusive [15].

Therefore, this review aims at examining the literature for the incidence and causes of GERD following gastric sleeve procedures.


Materials and Methods

An online examination for different databases was carried to find the articles that are included in this piece of work. A wide range of databases was used, including PubMed, Google Scholar, and CINAHL. Different keywords were used, including GERD, gastric sleeve, and complications, to find all the potential articles to be included in this review.

Twenty-two articles resulted from this search that contained any of the pre-mentioned keywords. Fourteen items were excluded because they did not mention the association between GERD and gastric sleeve operation; however, they were discussing either GERD or gastric sleeve separately. Also, four articles were excluded because of being editorials or short communications. Only four articles were included that were published in the duration between 2012 and 2019.


Discussion

GERD is considered as a gastrointestinal disease, where the patient suffers from reflux of gastric content resulting in a burning sensation and sometimes regurgitation [2,6,8]. The diagnosis of GERD can be carried out through different tools including, the patient’s description for the burning sensation, use of acid-reducing agents, and also some questionnaires that are pre-designed to diagnose GERD [9,14].

Gastric sleeve is a procedure that provides long-term control for patients who are identified as obese or morbidly obese [16]. The level of obesity is determined based on the body mass index (BMI). Obese patients have a BMI greater than 30, while morbidly obese patients have a BMI greater than 35 [16,17].

Gastric sleeve procedure is a surgical intervention that divides the stomach in a vertical section to reduce the stomach size by about quarter its size prior to the procedure [10,18,19].

Obesity is considered an aggravating factor for GERD symptoms [3,8]. This could be explained by the increased intra-abdominal pressure resulting from abdominal obesity, which in turn increases the pressure on the esophagus from the stomach [14,18]. The correlation between obesity and GERD has been evaluated in the medical literature [20].

Some reports revealed a significant direct and positive relationship between BMI and GERD, either new-onset GERD or worsening of symptoms of present disease [17,20]. This correlation is independent of the pressure in the stomach while respiration, which can influence the pressure in the esophagus in inspiration [16,21].

Moreover, intra-gastric pressure, patient’s BMI and esophageal pressure were all significant risk factors for hiatus hernia, which consequently is a risk factor for GERD and worsening of pre-existing GERD symptoms [16,21].

Other important factors that can influence the intra-gastric pressure are the fats in the visceral area, and the rigidity of ligaments and muscles in the gastro-esophageal area [17,19]. However, no linear association was found between GERD and hiatus hernia, as well as the incidence of hiatus hernia and the severity of GERD symptoms [17,18,19]. In addition, inter-subject variability affects the response of the esophagus to the exposure to gastric acidity, which can affect the degree of severity for GERD symptoms [13,16].

In the case of gastric sleeve, the shape of the stomach is changed to a smaller size, which increases the pressure inside the gastric cavity due to the reduced diameter of the stomach [12,15]. Hence, the pressure is more elevated with the closure of the pyloric sphincter, leading to the symptoms of GERD [10,13,19].

It is also important to note that there are other important factors that can influence the severity of symptoms after the gastric sleeve procedure [14,19]. These factors include the dissection performed in the fibers located on the lower gastric sphincter, as well as the alteration in the Hiss angle [17,20]. These factors can reduce the gastro-esophageal pressure; however, the gastric sleeve results in a pear-like shape, which increases the severity of GERD symptoms as well as promoting the development of GERD if it was not present prior to the procedure [11,17].

Sometimes, GERD appears as a complication after gastric sleeve, which may arise from narrowing of the space lying between the horizontal and vertical portions of the gastric sleeve, stenosis, and the presence of hiatus hernia that is not properly diagnosed before the gastric sleeve procedure [11,13,20]. In addition, over dissecting the antrum can lead to impaired emptying of the stomach, which can promote the development of GERD [13,21].

GERD can be improved following gastric sleeve through different mechanisms. Primarily, weight reduction will subsequently lower the pressure in the abdominal cavity [5,8]. Moreover, dissection of the stomach fundus, which produces acid, will decrease the production of acid, in addition to the improved emptying rate and extent of the stomach [3,6,10]. All these factors will play a significant role in improving the symptoms of GERD, thus reducing its burden [6, 8].

Some reports demonstrated that GERD incidence could increase up to 35% following gastric sleeve procedure [9,12]. However, this number is highly dependent on BMI, the surgical technique, the method of GERD diagnosis [1113,21]. In addition, the change in gastric anatomy following gastric sleeve surgery can promote Gastroesophageal reflux disease (GERD) symptoms [7,9,13]. This is mainly featured by the alteration in the angle of His.

Also, the obliteration occurring in gastric sleeve surgery can increase the incidence of early-onset GERD; yet, some reports revealed that repair of the angle of His could result in improvement of GERD symptoms [18,21].

Furthermore, Roux-en-Y gastric bypass procedure has been proposed as a solution for patients who have GERD following gastric sleeve and did not improve on PPI treatment [2,9]. Moreover, the changes in gastric pressure following gastric sleeve can increase the severity of GERD symptoms due to reduced gastric compliance [9,11]. This mechanism is proposed to affect about 2% of patients undergoing gastric sleeve, leading to the development of new-onset GERD following the procedure [12,15], while this percent can go up to 30% in patients who were previously diagnosed with GERD pre-gastric sleeve, and suffer from worsened symptoms after the procedure [14,16,20].

In addition, it has been shown that GERD can occur at any stage after the operation, either very early or later. However, the incidence of early-onset GERD within the first year after the gastric sleeve was reported to be higher than the late-onset GERD [2,8,11].


Conclusion

There are some data about the increasing trend of GERD after gastric sleeve procedure. However, data from high-quality studies with better study design are crucial to confirm this finding. In addition, surgeons should inform patients who will undergo a gastric sleeve operation about the risk of GERD following the procedure. Also, patients’ awareness about the risk factors of new-onset GERD following the operation should be considered by policymakers.

Patients who suffer from GERD post gastric sleeve, and are not responding to PPI, could be better candidates for Roux-en-Y gastric bypass procedures. Future randomized and multi-center trials should also focus on the hiatal hernia repair in patients who will undergo a gastric sleeve procedure, in order to reduce the risk of GERD post-gastric sleeve.


Conflict of interest

The authors declare that there is no conflict of interest regarding the publication of this article.


Funding

None.


Consent for publication

Not applicable.


Ethical approval

Not applicable.


Author details

Abdulrahman Mosaid Alolyyan1, Ahmad Yousef Aljuraifani1, Hamad Mohammad Aloraini1, Abdullah Ahmad Alhatlani1, Abdulmajeed Abdulrazaq Alzahrani1, Abdullah Abdulaziz Almuhaymidi1, Yassin Hassan Alzubaidi2

  1. Medical Intern, Qassim University, Unaizah, Qassim province, Saudi Arabia
  2. Resident doctor, Ibn Sina National College for Medical Studies, Jeddah, Saudi Arabia

References

  1. Oor JE, Roks DJ, Ünlü Ç, Hazebroek EJ. Laparoscopic sleeve gastrectomy and gastro-esophageal reflux disease: a systematic review and meta-analysis. Am J Surg. 2016;211(1):250–67. https://doi.org/10.1016/j.amjsurg.2015.05.031
  2. Juodeikis Ž, Brimas G. Long-term results after sleeve gastrectomy: a systematic review. Surg Obes Rela Dis. 2017;13(4):693–9. https://doi.org/10.1016/j.soard.2016.10.006
  3. Li J, Lai D, Wu D. Laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy to treat morbid obesity-related comorbidities: a systematic review and meta-analysis. Obes Surg. 2016;26(2):429–42. https://doi.org/10.1007/s11695-015-1996-9
  4. Brethauer SA, Kim J, El Chaar M, Papasavas P, Eisenberg D, Rogers A, et al. Standardized outcomes reporting in metabolic and bariatric surgery. Obes Surg. 2015;25(4):587–606. https://doi.org/10.1007/s11695-015-1645-3
  5. Mahawar KK, Carr WR, Jennings N, Balupuri S, Small PK. Simultaneous sleeve gastrectomy and hiatus hernia repair: a systematic review. Obes Surg. 2015;25(1):159–66. https://doi.org/10.1007/s11695-014-1470-0
  6. Silecchia G, De Angelis F, Rizzello M, Albanese A, Longo F, Foletto M. Residual fundus or neofundus after laparoscopic sleeve gastrectomy: is fundectomy safe and effective as revision surgery?. Surg Endosc. 2015;29(10):2899–903. https://doi.org/10.1007/s00464-014-4017-5
  7. Stenard F, Iannelli A. Laparoscopic sleeve gastrectomy and gastro-esophageal reflux. World J Gastroenterol. 2015;21(36):10348. https://doi.org/10.3748/wjg.v21.i36.10348
  8. Homan J, Betzel B, Aarts EO, van Laarhoven KJ, Janssen IM, Berends FJ. Secondary surgery after sleeve gastrectomy: Roux-en-Y gastric bypass or biliopancreatic diversion with duodenal switch. Surg Obes Relat Dis. 2015;11(4):771–7. https://doi.org/10.1016/j.soard.2014.09.029
  9. Hendricks L, Alvarenga E, Dhanabalsamy N, Menzo EL, Szomstein S, Rosenthal R. Impact of sleeve gastrectomy on gastro-esophageal reflux disease in a morbidly obese population undergoing bariatric surgery. Surg Obes Relat Dis. 2016;12(3):511–7. https://doi.org/10.1016/j.soard.2015.08.507
  10. Melissas J, Braghetto I, Molina JC, Silecchia G, Iossa A, Iannelli A, Foletto M. Gastroesophageal reflux disease and sleeve gastrectomy. Obes Surg. 2015;25(12):2430–5. https://doi.org/10.1007/s11695-015-1906-1
  11. Versteegden DP, Nienhuijs SW. Improvement in quality of life after bariatric surgery: sleeve versus bypass. Surg Obes Relat Dis. 2018;14(2):170–4. https://doi.org/10.1016/j.soard.2017.10.008
  12. Gibson SC, Le Page PA, Taylor CJ. Laparoscopic sleeve gastrectomy: review of 500 cases in single surgeon A ustralian practice. ANZ J Surg. 2015;85(9):673–7. https://doi.org/10.1111/ans.12483
  13. Andersen JR, Aasprang A, Karlsen TI, Natvig GK, Våge V, Kolotkin RL. Health-related quality of life after bariatric surgery: a systematic review of prospective long-term studies. Surg Obes Relat Dis. 2015;11(2):466–73. https://doi.org/10.1016/j.soard.2014.10.027
  14. Kehagias I, Zygomalas A, Karavias D, Karamanakos S. Sleeve gastrectomy: have we finally found the holy grail of bariatric surgery? A review of the literature. Eur Rev Med Pharmacol Sci. 2016;20(23):4930–2.
  15. Abdemur A, Han SM, Menzo EL, Szomstein S, Rosenthal R. Reasons and outcomes of conversion of laparoscopic sleeve gastrectomy to Roux-en-Y gastric bypass for nonresponders. Surg Obes Relat Dis. 2016;12(1):113–8. https://doi.org/10.1016/j.soard.2015.04.005
  16. Sucandy I, Chrestiana D, Bonanni F, Antanavicius G. Gastroesophageal reflux symptoms after laparoscopic sleeve gastrectomy for morbid obesity. The importance of preoperative evaluation and selection. North Am J Med Sci. 2015;7(5):189. https://doi.org/10.4103/1947-2714.157624
  17. Flølo TN, Andersen JR, Kolotkin RL, Aasprang A, Natvig GK, Hufthammer KO, et al. Five-year outcomes after vertical sleeve gastrectomy for severe obesity: a prospective cohort study. Obes Surg. 2017;27(8):1944–51. https://doi.org/10.1007/s11695-017-2605-x
  18. Lo Menzo E, Szomstein S, Rosenthal RJ. Changing trends in bariatric surgery. Scand J Surg. 2015;104(1):18–23. https://doi.org/10.1177/1457496914552344
  19. Khan A, Kim A, Sanossian C, Francois F. Impact of obesity treatment on gastro-esophageal reflux disease. World J Gastroenterol. 2016;22(4):1627. https://doi.org/10.3748/wjg.v22.i4.1627
  20. Ellatif ME, Alfalah H, Asker WA, El Nakeeb AE, Magdy A, Thabet W, et al. Place of upper endoscopy before and after bariatric surgery: a multi-center experience with 3219 patients. World J Gastrointest Endosc. 2016;8(10):409. https://doi.org/10.4253/wjge.v8.i10.409
  21. Naik RD, Choksi YA, Vaezi MF. Consequences of bariatric surgery on oesophageal function in health and disease. Nat Rev Gastroenterol Hepatol. 2016;13(2):111–9.


How to Cite this Article
Pubmed Style

Alolyyan AM, Aljuraifani AY, Aloraini HM, Alhatlani AA, Alzahrani AA, Almuhaymidi AA, Alzubaidi YH. Gastro-esophageal reflux disease post gastric sleeve surgery: a review article. IJMDC. 2020; 4(2): 518-521. doi:10.24911/IJMDC.51-1577044424


Web Style

Alolyyan AM, Aljuraifani AY, Aloraini HM, Alhatlani AA, Alzahrani AA, Almuhaymidi AA, Alzubaidi YH. Gastro-esophageal reflux disease post gastric sleeve surgery: a review article. https://www.ijmdc.com/?mno=78999 [Access: October 15, 2021]. doi:10.24911/IJMDC.51-1577044424


AMA (American Medical Association) Style

Alolyyan AM, Aljuraifani AY, Aloraini HM, Alhatlani AA, Alzahrani AA, Almuhaymidi AA, Alzubaidi YH. Gastro-esophageal reflux disease post gastric sleeve surgery: a review article. IJMDC. 2020; 4(2): 518-521. doi:10.24911/IJMDC.51-1577044424



Vancouver/ICMJE Style

Alolyyan AM, Aljuraifani AY, Aloraini HM, Alhatlani AA, Alzahrani AA, Almuhaymidi AA, Alzubaidi YH. Gastro-esophageal reflux disease post gastric sleeve surgery: a review article. IJMDC. (2020), [cited October 15, 2021]; 4(2): 518-521. doi:10.24911/IJMDC.51-1577044424



Harvard Style

Alolyyan, A. M., Aljuraifani, . A. Y., Aloraini, . H. M., Alhatlani, . A. A., Alzahrani, . A. A., Almuhaymidi, . A. A. & Alzubaidi, . Y. H. (2020) Gastro-esophageal reflux disease post gastric sleeve surgery: a review article. IJMDC, 4 (2), 518-521. doi:10.24911/IJMDC.51-1577044424



Turabian Style

Alolyyan, Abdulrahman Mosaid, Ahmad Yousef Aljuraifani, Hamad Mohammad Aloraini, Abdullah Ahmad Alhatlani, Abdulmajeed Abdulrazaq Alzahrani, Abdullah Abdulaziz Almuhaymidi, and Yassin Hassan Alzubaidi. 2020. Gastro-esophageal reflux disease post gastric sleeve surgery: a review article. International Journal of Medicine in Developing Countries, 4 (2), 518-521. doi:10.24911/IJMDC.51-1577044424



Chicago Style

Alolyyan, Abdulrahman Mosaid, Ahmad Yousef Aljuraifani, Hamad Mohammad Aloraini, Abdullah Ahmad Alhatlani, Abdulmajeed Abdulrazaq Alzahrani, Abdullah Abdulaziz Almuhaymidi, and Yassin Hassan Alzubaidi. "Gastro-esophageal reflux disease post gastric sleeve surgery: a review article." International Journal of Medicine in Developing Countries 4 (2020), 518-521. doi:10.24911/IJMDC.51-1577044424



MLA (The Modern Language Association) Style

Alolyyan, Abdulrahman Mosaid, Ahmad Yousef Aljuraifani, Hamad Mohammad Aloraini, Abdullah Ahmad Alhatlani, Abdulmajeed Abdulrazaq Alzahrani, Abdullah Abdulaziz Almuhaymidi, and Yassin Hassan Alzubaidi. "Gastro-esophageal reflux disease post gastric sleeve surgery: a review article." International Journal of Medicine in Developing Countries 4.2 (2020), 518-521. Print. doi:10.24911/IJMDC.51-1577044424



APA (American Psychological Association) Style

Alolyyan, A. M., Aljuraifani, . A. Y., Aloraini, . H. M., Alhatlani, . A. A., Alzahrani, . A. A., Almuhaymidi, . A. A. & Alzubaidi, . Y. H. (2020) Gastro-esophageal reflux disease post gastric sleeve surgery: a review article. International Journal of Medicine in Developing Countries, 4 (2), 518-521. doi:10.24911/IJMDC.51-1577044424