Long-term Outcomes Post-Sleeve Gastrectomy

• This study evaluates the long-term outcomes (at least 15 years) post-sleeve gastrectomy (SG) in non-converted patients.
• The study uses gastroscopy, esophageal manometry, 24-h pH-metry, and the Gastrointestinal Quality of Life Index (GIQLI) for evaluation.

Key Findings

• 55% of participants experienced symptomatic gastroesophageal reflux disease (GERD).
• 45% had no GERD.
• Esophagitis was found in 44% of patients via gastroscopy.
• Hiatal hernias were present in 50% of patients.
• Barrett's esophagus was detected in 13% of patients.
• Enlarged sleeves were observed in 69% of patients.
• The mean lower esophageal sphincter pressure was normal at 20.2 ± 14.1 mm Hg.
• 24-h pH-metry showed increased reflux activity: 12.9 ± 9.7%.
• The number of refluxes was increased: 98.0 ± 80.8.
• The DeMeester score was elevated: 55.3 ± 36.3.
• Patients with GERD had significantly lower GIQLI scores (107.6 ± 18.4) compared to those without GERD (127.6 ± 14.4), with p = 0.04.
• GERD, esophagitis, and Barrett's esophagus are major issues 15 years after primary SG

Recommendations

• Surveillance endoscopies are recommended at 5-year intervals for all SG patients.
• They are recommended at 3-year intervals for patients with Barrett's esophagus.

Introduction to Sleeve Gastrectomy (SG)

• Obesity is a growing global concern linked to metabolic syndrome comorbidities.
• Bariatric/metabolic operations are increasing, with SG being the most frequent since 2014.
• In 2018, 386,096 patients underwent SG, representing 55.4% of all bariatric procedures.

How SG Works

• SG involves resecting a large part of the stomach, creating a narrow gastric sleeve.
• It induces early satiety and alters gut hormone levels (ghrelin, glucagon-like-peptide 1), promoting weight loss.
• The gastric sleeve, combined with the pylorus muscle, forms a high-pressure system, potentially leading to GERD as acid escapes into the esophagus.
• Initial weight loss post-SG can reduce intra-abdominal pressure, but GERD can become a major long-term side effect.

Study Aim

• The study aims to perform objective testing (gastroscopy, manometry, 24-h pH-metry, GIQLI questionnaire) in a multicenter setting, providing the longest follow-up (>15 years) data after SG.
• It seeks to demonstrate long-term trends by assessing the same patient group evaluated after 10 years.

Patients and Methods - Patient Cohort

• The study initially included all patients who underwent SG before December 31, 2005, at three Austrian bariatric centers.
• These centers were the Medical University of Vienna, Klinik Landstraße, and Landesklinikum Hollabrunn.
• A total of 53 patients met the criteria for 15-year follow-up after SG.
• The study focused on non-converted patients, excluding those converted to other procedures within 15 years.
• 26 of the original 53 patients (49.1%) were converted during the follow-up.
• Three additional patients died within the follow-up period.
• Patients with prior bariatric operations before SG were excluded to avoid influence on GERD and esophageal functional testing outcomes.

Patient Characteristics

• Sex (female): 79% (n = 42).
• Bariatric procedures before SG: 22.6% (n = 12).
  • Gastric banding: 18.8% (n = 10).
  • Gastric stimulation: 1.9% (n = 1).
  • Gastric balloon: 1.9% (n = 1).
• Converted patients: 49.1% (n = 26).
  • RYGB: 47.2% (n = 25).
  • Duodenal switch: 1.9% (n = 1).
• Dead patients: 7.5% (n = 4).
  • Non-converted: 5.6% (n = 3).
  • Converted: 1.9% (n = 1).
• The remaining 20 patients were invited for examinations at the Medical University of Vienna.

Examinations

• Gastroscopy was performed on 16/20 patients (80%).
• 24-h pH-metry and manometry were performed on 11/20 patients (55%).
• The GIQLI questionnaire was completed by 17/20 patients (85%).
• All patients were assessed for GERD-related symptoms.
• The 15-year outcomes were compared to 10-year outcomes from a previous study on the same patient group.

Surgical Technique Details

• The surgical technique involved creating a capnoperitoneum at 15 mm Hg.
• The lesser sac was entered and opened from the pylorus to the angle of His, preserving the gastro-epiploic arcade.
• The left crus of the hiatus was visualized to detect any undiagnosed hiatal hernias.
• A 14–16-mm (42–48 French) Bougie was used to resect a major part of the stomach.
• Stapling began about 6 cm proximal to the pylorus and ended at the angle of His to resect the entire fundus.
• Belsey's fat pad was removed to improve the vision of the angle of His.
• The gastrocolic ligament was then reattached to the staple line with single-knot sutures.
• Current practice involves using a slightly smaller Bougie size of 12 mm (36 French) and starting the resection 2–3 cm from the pylorus.

Gastrointestinal Quality of Life Index (GIQLI)

• The GIQLI, developed by Eypasch et al., was used to assess the quality of life in patients with GERD.
• The questionnaire contains 36 questions about gastrointestinal symptoms, with five response categories resulting in a maximum score of 180 points.

Gastroscopy Procedure

• Gastroscopy was conducted to identify gastritis, ulcers, columnar-lined esophagus, and esophagitis.
• Biopsies were taken from the antrum, corpus, and gastroesophageal junction to diagnose Barrett's esophagus (BE).
• The Seattle protocol was followed, taking a minimum of four quadrant biopsies every centimeter.
• The size of the sleeve was evaluated, checking for hiatal hernias and remnant fundus.

24-h pH-Metry and Manometry Details

• Manometry measured the lower esophageal sphincter pressure (LESP).
• 24-h pH-metry measured the total number of refluxes and acid exposure time in the distal esophagus.
• The DeMeester score was calculated for each patient.

Statistical Analysis

• Descriptive statistics were used due to the small patient cohort.
• Data were presented as mean and standard deviation, median and range, or percentages.
• Comparison of data groups was performed by χ2 tests or Mann-Whitney U tests.
• SPSS® v24 for Windows® (IBM Corporation, Armonk, NY, USA) was used for statistical calculations.

GERD and GIQLI Questionnaire Results

• 55% (11/20) of participants experienced symptomatic GERD requiring daily proton pump inhibitors.
• 45% (9/20) were without GERD symptoms.
• Patients with symptomatic GERD scored significantly lower on the GIQLI (107.6 ± 18.4) compared to those without GERD (127.6 ± 14.4; p = 0.04).

Gastroscopy Results

• Gastroscopy was performed on 9 patients with GERD symptoms and 7 without GERD 15 years after SG.
• Remnant fundus was found in 19% (n = 3/16) of patients.
• Hiatal hernias were more common in symptomatic patients (67%, n = 6/9) compared to asymptomatic patients (29%, n = 2/7; p = 0.08).
• Bile in the sleeve was only found in 43% (n = 3/7) of patients without GERD.
• Enlarged sleeves were observed in 69% (n = 11/16) of patients, with a higher prevalence in the GERD group (89%, n = 8/9) vs. the no-GERD group (43%, n = 3/7; p = 0.15).
• Columnar-lined esophagus was found in 44% (n = 7/16) of patients, with no significant difference between GERD groups.

Gastroscopy and Histology Results

• Active gastritis was present in 78% (n = 7/9) of GERD patients and 71% (n = 5/7) of no-GERD patients.
• Esophagitis was found in 56% (n = 5/9) and 29% (n = 2/7) of the GERD and no-GERD groups, respectively (p = 0.14).
• Barrett's esophagus (BE) was identified in 13% (2/16) of patients, with one case in each group.
• Helicobacter pylori (HP) was not detected in any patient.

Manometry and 24-h pH-metry Results

• LESP was not significantly different between patients with and without GERD (22.1 ± 18.6 and 19.1 ± 9.1; p = 0.71).
• Only 2 patients were outside the normal LESP range.