The Effect of Laparoscopic Sleeve Gastrectomy on Symptoms of Gastroesophageal Reflux Disease

Background Laparoscopic sleeve gastrectomy (LSG) is a common bariatric procedure for weight loss. LSG is becoming prevalent worldwide because it is a relatively simple procedure with high efficacy. Reduced intraabdominal pressure may improve gastroesophageal reflux disease (GERD) symptoms and reduce the GERD medication needed following LSG. However, the main long-term drawback of LSG is the development of de novo GERD. Therefore, we conducted this study to determine the relationship between GERD symptoms and LSG. Methods We conducted a retrospective chart review involving 390 patients who underwent LSG. Study participants were evaluated for GERD symptoms six months before and three, six, and nine months after the procedure, and proton-pump inhibitors (PPIs) were used to control the symptoms. Participants were distributed into two groups: one group for patients with GERD symptoms (36.1%) and one group for asymptomatic patients (62.8%). We collected demographic data and assessed PPI use in both groups after three, six, and nine months postoperatively. Data were collected using Microsoft Excel (Microsoft Corporation, Redmond, WA) and analyzed using IBM SPSS Statistics for Windows, Version 20.0 (Armonk, NY: IBM Corp.). We compared data using the student's t-test for independent groups. The quantitative data were summarized using mean and standard deviation (SD), and p < 0.05 was considered statistically significant. Results Of the 390 participants who underwent LSG, 83.8% were women (n=327) and 16.2% were men (n=63), with a median age of 42 ± 11.9 years. PPI use was statistically significantly greater after LSG (34.1%) than before LSG (24.6%, p=0.019). The difference in PPI use between symptomatic and asymptomatic groups was not statistically significant three months after LSG. Conclusions Our study focuses on using PPI after LSG due to GERD symptoms. We found GERD symptoms improved three months following LSG, but de novo GERD symptoms occurred nine months after the surgery. Health providers need to discuss with their patients the potential outcomes of the surgery and manage patient expectations. Physicians should work with their patients to assess whether the benefits of bariatric surgery in controlling overweight-associated conditions, such as blood pressure, diabetes, sleep apnea, and weight loss, outweigh the risk of GERD symptoms and PPI use.


Introduction
Obesity and its related metabolic disorders are increasing in the US and worldwide [1]. Obesity increases the risk of associated diseases and worsening pre-existing diseases and increases the burden on the health care system and budgets. Obesity is a major risk factor for coronary artery disease, hypertension, diabetes, sleep apnea, hypopnea syndrome, gastroesophageal reflux disease (GERD), joint and bone disease, and arthritis [2]. Up to 50% of morbidly obese patients may suffer GERD [3].
Bariatric surgery has been proven to produce sustainable effects in morbidly obese patients with weight reduction and remission of comorbidities [4,5]. Laparoscopic sleeve gastrectomy (LSG) is one of the most common bariatric surgical procedures. Although it is a relatively recent introduction and lacks long-term results, it is a relatively simple technique with high efficacy. LSG reduces intraabdominal pressure due to weight loss, reduces acid production secondary to the acid-producing gastric fundus resection, accelerates gastric emptying, and reduces gastric volume. All these effects contribute to the reduction in gastric refluxate that putatively causes GERD symptoms [6,7]. However, a long-term adverse effect of LSG is the 1 1 1 1 1 development of de novo GERD in some patients [8]. Therefore, this study aims to assess the relationship between de novo GERD and bariatric surgery by evaluating proton-pump inhibitor (PPI) use for GERD symptoms before LSG, GERD incidence after LSG, PPI use for GERD after LSG, the incidence of postoperative esophageal gastroscopy (EGD), and de novo GERD symptoms after LSG. EGD is a screening option for severe, intractable GERD symptoms to rule out an alternative diagnosis. We noted whether our study participants received EGD due to GERD symptoms post-surgery as an indicator of symptom severity.

Materials And Methods
We conducted a retrospective review of the medical records of 390 patients who underwent LSG at the Center for Bariatric Surgery at St. Vincent Charity Medical Center (SVCMC) in 2017. The study included patients referred for morbid obesity (body mass index (BMI) ≥ 40 kg/m 2 or BMI ≥ 35 kg/m 2 with obesity-related complications such as diabetes, hypertension, sleep apnea, or musculoskeletal problems) and scheduled for weight loss surgery. This research was approved by the Institutional Review Board for research and ethics at SVCMC (Approval No. 537).
The study excluded patients younger than age 18 and pregnant patients. Participants were distributed into two groups prior to LSG: one group for patients with GERD symptoms (36.1%) and one group for asymptomatic patients (62.8%). The study was conducted at a 95% confidence interval, and a t-test was used to determine if there was a significant between the two groups.

Results
After applying the exclusion criteria, the study included 327 women (83.8%) and 63 men (16.2%). The median age was 42 ± 11.9 years. Before the LSG procedure, 118 patients had GERD symptoms (36.1%), and 209 were asymptomatic (62.8%) ( Table 1).   Also, there were no significant differences in preoperative PPI use and three-month PPI, regardless of GERD status ( Table 3).

No PPI Three Months After Surgery, n (%) PPI Three Months After Surgery, n (%) P-Value
No PPI Before Surgery 6 (0.01%) 271 (69.4%) 0.57 PPI Before Surgery 3 (0.76%) 92 (23.5%)  We noted a statistically significant decline in PPI use nine months postoperatively compared to preoperative PPI use in GERD patients (p=0.012). However, in patients without preoperative GERD, there was no significant difference in PPI use postoperatively ( Table 5).
One hundred ten patients (33.7%) had a BMI of > 50 kg/m 2 (i.e., super morbidly obese) and GERD symptoms, and were on PPI therapy before the surgery. Two hundred sixteen patients (66.3%) had BMI < 50 kg/m 2 .
Seven patients (77.8%) with a BMI < 50 kg/m 2 and preoperative GERD had postoperative GERD at the three-month follow-up. Only two patients (22.2%) with BMI > 50 kg/m 2 and preoperative GERD had postoperative GERD at the three-month follow-up.
One hundred fifty-five patients (90.6%) with a BMI < 50 kg/m 2 and preoperative GERD had postoperative GERD at six months. Sixteen patients (9.4%) with a BMI > 50 kg/m 2 and preoperative GERD had postoperative GERD at six months. By the nine-month follow-up, 180 patients (97.3%) with a BMI < 50 kg/m 2 and preoperative GERD had postoperative GERD. Only five patients (2.7%) with a BMI > 50 kg/m 2 and preoperative GERD had postoperative GERD. However, only seven of 117 patients with a BMI > 50 kg/m 2 presented for the nine-month evaluation. No significant differences were found for patients with a BMI > 50 kg/m 2 and at the nine-month follow-up for GERD symptoms compared to those with prior surgery, although we noted marginal significance (p=0.067) at six months (

Discussion
In our retrospective chart review, we assessed the effects of LSG on GERD symptoms in obese patients. GERD symptoms improved in the first three months after surgery if the patient had symptoms before surgery. However, after six to nine months, most patients developed new-onset GERD, regardless of their symptoms before the study, and some had severe symptoms that required the daily use of PPI.
Obesity increases the risk of GERD due to elevated intrabdominal pressure, loosening of the lower esophageal sphincter (LES), and histological changes of the gastroesophageal junction due to fat deposition. A vicious cycle of acid reflux to the esophagus and weak sphincters, plus weak abdominal muscle due to fat deposition, results in worsening GERD symptoms [9,10].
After reviewing the literature, the theories behind the pathophysiology of new-onset GERD after LGS are multifactorial. Due to the procedure, the stomach anatomy, the smaller size of the stomach, and the funnel shape favor acid reflux and GERD symptoms. Because the shape was manipulated, the decrease in LES pressure increases the risk of acid reflux and GERD symptoms [11].

Year Study Design Results Recommendations
Studies that showed a significant increase in risk  However, a few studies showed no significant increase in the incidence of GERD after LSG or a minimal increase with no significant symptoms but showed significant esophageal complications related to acid reflux or delayed gastric emptying after LSG [19,20]. Surprisingly, one study showed that symptoms of GERD may improve one year after LSG [21]. We found an increased risk of GERD and de novo GERD after LSG, and three-, six-, and nine-month follow-up interpretations of symptoms regarding BMI before and after surgery suggest that reduction of BMI was not the only factor associated with GERD symptoms.
Our study had some important limitations. This was a retrospective chart review with a small sample size, and many patients were lost to follow-up. Our study was also subject to confounding factors for GERD symptoms, over-the-counter PPIs or antacids, and recall bias. Also, given that several surgeons operated on