|Year : 2019 | Volume
| Issue : 3 | Page : 229-233
A prospective study of gastro-oesophageal reflux disease symptoms and quality of life 1-year post-laparoscopic sleeve gastrectomy
Andrew G.N. Robertson, Andrew J Cameron, Brian Joyce, Phil Le Page, Bruce Tulloh, Andrew C de Beaux, Peter J Lamb
Department of Upper GI Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
|Date of Submission||19-Feb-2018|
|Date of Acceptance||30-Apr-2018|
|Date of Web Publication||4-Jun-2019|
Peter J Lamb
Department of Upper GI Surgery, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh Eh16 4SA
Source of Support: None, Conflict of Interest: None
Introduction: There are concerns that laparoscopic sleeve gastrectomy (LSG) can cause severe gastro-oesophageal reflux disease (GORD). The aim of this study was to assess GORD symptoms and quality of life following LSG.
Methods: A prospective study of patients undergoing LSG (2014–2016) was performed with follow-up by DeMeester Reflux/Regurgitation Score, Bariatric Quality of Life Index (BQLI) and Bariatric Analysis and Reporting Outcome System (BAROS) Score pre-operatively, 6 months and 1-year post-operatively.
Results: Twenty-two patients were studied. Mean modified DeMeester Reflux/Regurgitation Score improved from 2.25 (±0.67) pre-operatively to 0.81 (±0.25) at 12 months (P = 0.04). At 12 months, two patients had symptomatic reflux, but overall satisfaction score was unaffected. Mean BQLI Score underwent a non-significant improvement at 12 months. BAROS Score showed all patients to have excellent (n = 19) or very good (n = 3) results (12 months).
Conclusion: GORD symptoms improve for most patients' 1-year post-operatively. A small proportion of patients will develop troublesome GORD, but overall satisfaction remains high.
Keywords: Gastro-oesophageal reflux disease, laparoscopic sleeve gastrectomy, quality of life
|How to cite this article:|
Robertson AG, Cameron A, Joyce B, Le Page P, Tulloh B, de Beaux AC, Lamb PJ. A prospective study of gastro-oesophageal reflux disease symptoms and quality of life 1-year post-laparoscopic sleeve gastrectomy. J Min Access Surg 2019;15:229-33
|How to cite this URL:|
Robertson AG, Cameron A, Joyce B, Le Page P, Tulloh B, de Beaux AC, Lamb PJ. A prospective study of gastro-oesophageal reflux disease symptoms and quality of life 1-year post-laparoscopic sleeve gastrectomy. J Min Access Surg [serial online] 2019 [cited 2019 Aug 22];15:229-33. Available from: http://www.journalofmas.com/text.asp?2019/15/3/229/235404
Andrew G. N. Robertson and Andrew J Cameron contributed equally to this work
| ¤ Introduction|| |
Laparoscopic sleeve gastrectomy (LSG) is an accepted surgical treatment for morbid obesity. Since becoming a stand-alone procedure in 2008, it continues to grow in popularity across the world. LSG has been shown to have significant improvements in patient weight and improvements in co-morbidities. Concerns exist that LSG may worsen or provoke gastro-oesophageal reflux disease (GORD)., This also has been a concern for other restrictive bariatric procedures including laparoscopic-adjustable gastric banding., A systemic review and meta-analysis suggest paradoxical outcomes for GORD in patients after LSG. Although weight loss often alleviates GORD symptoms through reduced intra-abdominal pressure, the potential for decreased gastric emptying and increased intraluminal pressure may lead to GORD. This may partially explain the heterogeneous reported results between and within studies., The aim of this pilot study was to assess patient-reported outcomes of GORD symptoms and quality of life for 1-year post-LSG.
| ¤ Methods|| |
A prospective pilot study of patients undergoing LSG between 2014 and 2016 was undertaken. Patients were selected for surgery after successful completion of Tier 3 weight loss management including losing 5% of total body weight pre-operatively. In this practice, an exclusion for LSG was severe GORD. Endoscopy and pH/manometry were not carried out pre-operatively. The technique used for LSG involved mobilisation of the greater curve from the antrum to the angle of His and mobilisation of the posterior body of the stomach. Intra-operatively, the hiatus was closely inspected in all patients by clear exposure using the Nathanson retractor. Dissection of the overlying peritoneum was carried out as required. If present a hiatus hernia was repaired using anterior 0 Ethibond sutures (Johnson and Johnson Medical, New Brunswick NJ, USA), the posterior hiatus was also inspected and repaired as required. If no hiatal hernia was present, the phreno-oesophageal ligament was preserved. A stapled sleeve resection was subsequently performed over a 34F bougie. The staple line was oversewn with 2/0 polydioxanone in areas of serosal split/staple line bleeding if required.
Patients who agreed to the study were followed up clinically and completed a modified DeMeester Reflux/Regurgitation Score as part of the Adelaide Reflux Questionnaire, the Bariatric Analysis and Reporting Outcome System (BAROS) Score and the Bariatric Quality of Life Index (BQLI) Score pre-operatively, at 6 months and 1-year post-operatively. The BQLI Score was subdivided into medical questions (n = 23) and functional, social and quality of life questions (n = 14). This was to assess whether changes in the quality of life were due to changes in symptoms and medical issues or social functioning. Patients were asked about overall satisfaction with the result of surgery at 1-year post-operatively. Questionnaires were completed by patients, with trained personnel on hand to offer one-to-one assistance. Statistical analysis was performed using IBM SPSS statistics (NY, USA). Statistics analysis was performed using paired t-tests.
| ¤ Results|| |
Twenty-six patients underwent LSG during the study period. Four patients withdrew from the study: one for mental health reasons, one because of geographical relocation and two withdrew consent. Twenty-two patients with a mean age of 51 years (range 32–72) were studied. Nineteen were female. There were no mortalities and no significant post-operative complications. Two of the 22 patients had incidental hiatal herniae detected and repaired.
Percentage total weight loss was 18.0% ± 6.0 (6 months) and 20.3% ± 7.9 (1 year). 15/22 (68%) were on antihypertensives pre-operatively but only 10/22 (45%) at 12 months (P = 0.012). 18/22 (82%) were diabetic at pre-operative assessment. 13/22 (59%) were on reduced medication at 12 months. None had complete resolution of their diabetes.
Overall satisfaction with sleeve gastrectomy
All 22 patients were satisfied with the operation at 1 year and would recommend the operation. Mean satisfaction levels were 9.55 ± 0.89 (10 = extremely satisfied, 0 = extremely dissatisfied).
Quality of life
There was an overall statistically significant improvement in symptoms and an excellent or very good outcome on BAROS over the 1st year post-LSG.
Gastro-oesophageal reflux disease symptoms
No patients had symptomatic reflux pre-operatively. Two patients had incidental hiatal herniae detected and repaired and neither of these reported GORD symptoms at any point. There was a non-significant increase in the mean modified DeMeester Reflux/Regurgitation Scores pre-operatively (2.25 ± 0.67) and at 6 months post-operatively (2.38 ± 0.59). Scores subsequently decreased dramatically by 12-month post-operatively to 0.81 ± 0.25 (P = 0.04). This was because two patients reported symptomatic reflux at 12 months: one developed de novo symptoms at 6 months, the other developed de novo GORD between 6 and 12 months. All patients were routinely placed on a PPI for the first 3 months. 13/22 (59%) remained on a PPI after 1 year. PPI therapy used was lansoprazole 30 mg od (n = 6), lansoprazole 30 mg bd (n = 2), lansoprazole 30 mg prn (n = 3) and omeprazole 20 mg od (n = 2). Indications for continued PPI therapy were daily GORD partially controlled by PPI (n = 2), infrequent GORD occurring less than once per week and requiring prn PPI only (n = 3), upper abdominal pain with no GORD (n = 3), prophylactic cover for non-steroidal anti-inflammatories (n = 4) and prophylactic cover for intermittent steroid use for asthma (n = 1).
Mean Adelaide Dysphagia Score improved slightly from 7.41 ± 1.58 pre-operatively to 7.57 ± 2.25 at 6 months and further improved significantly to 8.23 ± 1.61 at 12 months (P = 0.02). 13/22 (59%) reported no swallowing difficulty at all (scoring 9) at 1 year.
Four patients reported difficulty swallowing at 1 year. Three of the four had no problems pre-operatively or at 6 months. One of the four had reported issues with swallowing pre-operatively and at 6 months. All four patients underwent barium swallows which showed no abnormality. One patient had a gastroscopy which revealed no abnormality.
Quality of life
Bariatric analysis and reporting outcome system
At 6 months, eight patients had excellent, 12 had very good and 2 good outcomes on BAROS, with a mean BAROS Score of 7.14 ± 1.8. At 12 months, these had improved to 19 excellent and 3 very good with a mean score of 8.14 ± 1.0. Subanalysis of the quality of life showed a statistically significant improvement over the post-operative first 6 months which was maintained at 12 months.
Overall mean BQLI Score underwent a non-significant improvement from 46.6 ± 7.8 pre-operatively to 48.5 ± 8.9 at 6 months and 49.62 ± 2.46 at 12-months post-operatively (P = 0.45). A subanalysis revealed a significant improvement in both the functional and self-confidence components at 12 months. The improvement in confidence occurred after the 6-month period. There was a highly significant improvement in the QOL component at both 6 and 12 months [Table 1].
Gastro-oesophageal reflux disease patients (n = 2)
Both patients with GORD at 1 year were satisfied with the operation at 1 year and would recommend the operation. Satisfaction levels, determined by a patient-reported question and score, were high for both. At the time of surgery, neither patient had an incidental hiatal hernia. A summary of characteristics is shown in [Table 2].
|Table 2: Summary of outcomes of patients with gastro-oesophageal reflux disease|
Click here to view
| ¤ Discussion|| |
The main findings of this study are that LSG leads to a statistically significant improvement in GORD symptoms at 12-month post-operatively for most patients. This occurs after an initial increase in GORD symptoms over the first 6 months. A small proportion of patients develop troublesome GORD symptoms post-operatively, but some of these will resolve spontaneously. Patients reported an improvement in the quality of life symptoms which was more marked at 12 months and less evident at 6 months post-operatively. Nevertheless, the presence of GORD symptoms does not necessarily reduce patient-reported satisfaction with surgery.
The main weaknesses of the study were the small numbers and lack of oesophageal physiology measurements. However, this was designed as a pilot study to assess changes in GORD, quality of life and satisfaction over the 1st year. Repeated oesophageal physiology studies assessments have been shown to be unpopular, add extra expense and would not alter patient management.,
The main strengths of the study are that it was a prospective study providing a detailed analysis of GORD symptoms, quality of life and satisfaction using validated questionnaires.,,
Techniques to prevent GORD post-LSG include excluding patients with severe GORD, preserving the incisura angle and the phreno-oesophageal ligaments and repairing any hiatal herniae., However, there is no general consensus. Both our patients who had a hiatal hernia repair did not develop symptomatic GORD; this is in keeping with a recently published study. In this study 10% of patients had a hiatus hernia detected intra-operatively, which were repaired. This is similar to a recent study, in which 4% had a hiatal hernia but up to 50% had laxity of the hiatus meriting repair.
The effects of LSG on GORD are heterogeneous amongst study populations with new-onset GORD varying between 0% and 35% in published studies with variable follow-up (1–60 months). We have shown that GORD may develop after 6 months and also may resolve over the 1st year. Interestingly, in keeping with the findings of a recent study, the present study showed GORD symptoms to increase slightly over the first 6 months in most patients before significantly improving by 1 year. These data are useful as patients can be made aware to expect a transient increase in symptoms over the first 6 months that is likely to settle. This may be due to the initial increased sleeve pressure that subsequently reduces with time. We have also shown that GORD symptoms do not necessarily affect overall satisfaction with surgery., A recent randomised controlled trial has shown GORD symptoms to be worse after LSG than gastric bypass, but overall quality of life to be similar, questioning the significance of GORD symptoms for some patients. Our findings are similar with regard to high satisfaction levels and reported quality of life despite the development of GORD symptoms. In our study, most patients post-LSG has a significant improvement in self-reported GORD symptoms. One of the two patients who developed GORD from our study did so after 6 months and a different patient had a resolution of GORD symptoms after that time.
Almost 60% of patients remained on PPI therapy at 1 year. Although 60% persisted on PPI only 2/13 patients were on this for daily GORD partially controlled by PPI, 3/13 patients required infrequent PPI use for occasional GORD episodes. The other 8/13 patients were on PPI therapy, continued by their general practitioner for non-GORD-related reasons – dyspeptic symptoms (n = 3) and prophylaxis against gastric ulceration from non-steroidal therapy or intermittent steroid use (n = 5). Previous studies have shown heterogeneity in the use of PPI post-sleeve but tend to show an increase in their use. The effect of PPI post-sleeve on symptoms in the current study remains unknown.
Patient-reported outcomes and quality of life assessments have been established as end-point outcomes from surgery. Our study showed that 1 year after LSG all patient have either an excellent (n = 19) or very good (n = 3) result on BAROS scoring. Subanalysis showed the improvements in patient-reported quality of life to occur in the first 6 months and this was maintained at 12 months. The overall BQLI Score showed a non-significant increase over 12 months. On further analysis, this did not reach significance due to the development of osteoarthritis in two patients and a further patient increasing analgesia requirements. Subanalysis revealed an improvement in the self-reported quality of life outcomes over the 12 months. Patient-reported quality of life improved over the first 6 months and self-confidence by the 12-month period. Our subanalysis reveals improved psychological well-being and social functioning over the 1-year post-LSG.
| ¤ Conclusion|| |
LSG improves the quality of life for most patients by 1 year following the operation. Patient-reported GORD symptoms for most patients improved over the 1st year. This occurs after a transient increase in GORD symptoms at 6 months. A small proportion of patients may develop troublesome GORD post-operatively, but this does not affect overall satisfaction with surgery.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| ¤ References|| |
Oor JE, Roks DJ, Ünlü Ç, Hazebroek EJ. Laparoscopic sleeve gastrectomy and gastroesophageal reflux disease: A systematic review and meta-analysis. Am J Surg 2016;211:250-67.
Page PL, Martin D, Taylor C, Wang J, Wadhawan H, Falk G, et al.
Does hiatal repair affect gastroesophageal reflux symptoms in patients undergoing laparoscopic sleeve gastrectomy? Surg Endosc 2018;32:2373-80.
DeMeester TR, Wang CI, Wernly JA, Pellegrini CA, Little AG, Klementschitsch P, et al.
Technique, indications, and clinical use of 24 hour esophageal pH monitoring. J Thorac Cardiovasc Surg 1980;79:656-70.
Lamb PJ, Myers JC, Jamieson GG, Thompson SK, Devitt PG, Watson DI, et al.
Long-term outcomes of revisional surgery following laparoscopic fundoplication. Br J Surg 2009;96:391-7.
Oria HE, Moorehead MK. Updated bariatric analysis and reporting outcome system (BAROS). Surg Obes Relat Dis 2009;5:60-6.
Weiner S, Sauerland S, Fein M, Blanco R, Pomhoff I, Weiner RA, et al.
The bariatric quality of life index: A measure of well-being in obesity surgery patients. Obes Surg 2005;15:538-45.
Thereaux J, Barsamian C, Bretault M, Dusaussoy H, Lamarque D, Bouillot JL, et al.
PH monitoring of gastro-oesophageal reflux before and after laparoscopic sleeve gastrectomy. Br J Surg 2016;103:399-406.
Ece I, Yilmaz H, Acar F, Colak B, Yormaz S, Sahin M, et al.
Anew algorithm to reduce the incidence of gastroesophageal reflux symptoms after laparoscopic sleeve gastrectomy. Obes Surg 2017;27:1460-5.
Mahawar KK, Jennings N, Balupuri S, Small PK. Sleeve gastrectomy and gastro-oesophageal reflux disease: A complex relationship. Obes Surg 2013;23:987-91.
Biter LU, van Buuren MM, Mannaerts GH, Apers JA, Dunkelgrün M, Vijgen GH, et al.
Quality of life 1 year after laparoscopic sleeve gastrectomy versus laparoscopic roux-en-Y gastric bypass: A Randomized controlled trial focusing on gastroesophageal reflux disease. Obes Surg 2017;27:2557-65.
[Table 1], [Table 2]