Sleeve or gastric bypass

 

 

This blog provides free general information for anyone who is seeking to understand more about the difference between the sleeve gastrectomy and gastric bypass surgery, that is currently available for weight loss (in 2020), not intended as a medical consult. Please seek proper medical advice for individual assessment and management.

 

The crucial learning points are:

Patient often self-select the type of bariatric procedure they wish to have based on:

  • The safety and efficacy of the procedure
  • The advantage, disadvantage, side effects, acute and long term complications of each procedure
  • Post op care (GP follow up and availability of allied health care) needs to be available for patients in remote area
    • This may include digital follow up in the post Covid-19 era
  • Understand that there will be weight regain and other post op issues with any bariatric procedures and some patients may require further operative interventions in the future

 

Choosing to have a sleeve gastrectomy or gastric bypass is based on so many other clinical aspects as well, which include:

  • Not just the long term weight loss result and weight regain
  • Issues with Type 2 diabetes mellitus and post op reflux
  • Issues with subfertility and future pregnancy
  • Issues with gallstones and ERCP

 

This blog essentially discuss:

  • Why it is preferable and much safer to choose a sleeve gastrectomy, especially for young females in their reproductive age group (who wish to get pregnant in the future) or are concern about the long term follow up issues with the gastric bypass.
  • The issues with acid or alkaline/bile reflux and why some patients may decide to choose the Roux Y gastric bypass instead

 

This blog won’t cover every aspects in the decision making process. Patients need to do their research thoroughly, to discuss all this with their general practitioners (GP), allied health team and family members before making the correct choice.

 

 

 

 

Introduction

Bariatric Surgery in Australia

Currently (in 2020) in Australia most patients have a choice between various primary procedures, which include laparoscopic gastric band, sleeve gastrectomy, single anastomosis or omega loop gastric bypass, the Roux Y gastric bypass or the SADI-S.

 

Revision procedures may include the above or the more complex bypass procedures, which is mainly the bilio-pancreatic duodenal switch (BPD-DS) or single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S), also known as the stomach intestinal pylorus preserving surgery (SIPS).

 

Nowadays the tech savvy patients are often well informed by social media, in our information rich environment and often are well inter connected, asking questions and reflecting on the experiences of other patients who had the surgery previously.

 

Patients may self select the procedure they wish to have and often also select the surgeon they wish to see.

 

It is understandable that some surgeons would perform one the above bariatric procedures in preference over the others because of how their practices have evolved over time.

  • For example some practices may specialise in primary sleeve gastrectomy and some others in the complex revisional bypass procedures.

 

The role of the bariatric surgeon sometimes is about patient education, providing support, performing the bariatric procedure to tailor for the need of the individual patients or refer on to other surgical colleagues if they don’t provide the service (eg, the SADI-S).

 

Surgeons and bariatric physicians/GP need to have good knowledge of the various surgical procedures that are available and give appropriate advice. The patients then take part in the final decision making process.

 

However with the ever increasing data published and more results being available from so many research conducted around the world, it is easy to get lost amongst the vast information that is presented to the patients.

  • The treating medical team can also be easily influenced by other institution’s experiences.

 

Hence in summary, the decision making process is becoming harder with so many pro and cons of each procedure to be considered.

 

Before we begin discussing the reasons to choose between the sleeve gastrectomy or gastric bypass, It is important to re-iterate that bariatric surgery is not just about achieving the maximum weight loss possible.

 

The aim of bariatric surgery is to:

  • Achieve durable and maintained excess weight loss (>50% EWL) in the long term
  • For the treatment (or resolution) of obesity associated co-morbidities (mainly Type 2 diabetes mellitus, hypertension, dyslipidaemia, obstructive sleep apnoea)
  • To improve the quality of life (in a physical, psycho-social sense, better employment, family life and emotional well-being)
  • To reduce premature cardio-vascular morbidity/mortality (fatal or non-fatal heart attacks and strokes) and increase survival (life span)

 

 

 

 

Proven scientific research

 

The published data confirmed that:

  • Bariatric surgery is the most effective long term sustainable weight loss treatment for the morbidly obesity (BMI>40) patients.
  • Bariatric surgery is effective for treatment of medical co-morbidities associated with obesity, with remission rates up to 92% (for type 2 diabetes mellitus), 75% (for hypertension) and 96% (for obstructive sleep apnoea).
  • Bariatric surgery reduces premature cardio-vascular mortality associated with obesity.
  • Weight loss surgery can help improve non alcoholic steatohepatitis (NASH), reduce albumin loss in the urine, improve kidney function and reduce chronic inflammation.
  • Peri-operative mortality rates from bariatric surgery is very low, reported to be <1%.

 

 

Bariatric surgery and cancer prevention in female patients

? Only a relative indication for bariatric surgery

 

More recently there are evidence that bariatric surgery are associated with reduced obesity related cancer incidence (especially post-menopausal breast and endometrial cancers) and perhaps decreased cancer mortality.

 

Breast and endometrial cancer are highly sensitive to oestrogen levels. Visceral fat has aromatase which increases the circulating levels of oestradiol.

 

Central obesity often is a chronic inflammatory state, with increased pro-inflammatory markers (CRP, TNF-a, IL-6), which leads to a state of insulin resistance and reduced sex hormone binding globulin, which increase the bioavailability of ostrogen.

  • Oestrogen is believed to be associated with tumour formation and spread (tumourogenesis and metastasis respectively).
  • Rapid, significant and sustained weight loss after bariatric surgery has been shown to significantly reduce the levels of oestrogen.

 

Bariatric surgery also have other cancer reduction benefits, which may include decrease in the chronic inflammatory state, reduce inflammatory markers, alter the fat and bile salt metabolism, decrease in gut hormones, changes in metabolism, changes in gut microflora, changes in intestinal gluconeogenesis and maybe many more factors that is yet to be discovered.

 

For now we do not understand much about the role of gastric bypass and the increase or decrease rate of inflammatory colitis or colorectal cancer.

 

However it is important to stress to the referring doctors and the members of the public that cancer prevention are usually not the primary aim for patient seeking weight loss surgery.

Patients are more troubled by the increased risk of premature cardio-vascular mortality (by the age of 50 years) than mortality from breast, endometrial or other gastro-intestinal (GIT) cancers at the age of 70 years or older.

 

 

 

 

Laparoscopic sleeve gastrectomy or gastric bypass

 

After the long introduction and background information above, we should look at the 3 common bariatric operations currently available in Australia, which include laparoscopic sleeve gastrectomy (LSG), one anastomosis gastric bypass (OAGB) and Roux Y gastric bypass (RYGBP).

 

All these should be considered as permanent or not entirely reversible.

  • These patients will never return to a normal full sized stomach or have the entire small intestinal length restored again.

 

There are other surgical alternatives such as the laparoscopic adjustable gastric band and the single anastomosis duodenal-ileal bypass (SADI-S).

 

There are also non-surgical or endoscopic techniques such as the gastric balloon, endoscopic sleeve gastrectomy and other innovative techniques. All these are not discussed in this section.

 

 

 

Sleeve gastrectomy versus gastric bypass

The key features for patient to understand

 

  LSG OAGB RYGBP

Description

About 2/3 to 3/4 of the stomach is removed, creating a long narrow tube.

 

The small intestine anatomy or length is not altered.

The upper stomach is narrowed into a long tube and the stomach is joint to the mid part of the small intestine (150-200cm from the duodenal jejunal flexure).

 

There is only one anastomosis.

The upper stomach is narrowed into a long tube and the stomach is joint to the upper part of the small intestine (>25-50cm from the duodenal jejunal flexure). The alimentary limb is > 100-150cm before it is joined to the rest of the small intestine.

There are 2 anastomoses.

Average total body weight loss 30% 30-35% or more 30-35%
Estimated excess weight loss 50-60% 50-70% 50-70%
Weight regain Weight regain does recur after 2 to 3 years.

 

LSG can be converted to OAGB, RYGBP or SADI.

Weight regain does recur after 3 to 5 years.

 

 

Further surgery for weight regain may or may not be possible.

Weight regain does recur after 3 to 5 years.

 

Further surgery for weight regain may or may not be possible.

Advantage There is more restriction with the sleeve. Patients are less able to eat without experiencing early satiation, discomfort or nausea.

 

This surgery is the easiest to perform with the least complications.

 

Nutrients, vitamins and drugs are still able to be absorbed in the proximal small intestine.

 

The lowest risk for nutritional side effects.

Weight loss is from both restriction and hormonal changes in the brain gut axis.

 

There may be less absorption of dietary fats in the gut.

 

OAGB is easier to perform than the RYGBP.

Weight loss is from both restriction and hormonal changes in the brain gut axis.

 

There may be less absorption of dietary fats in the gut.

Disadvantage Have more acid reflux, nausea and vomiting.

 

In the early stages most patients struggle to eat and take longer to recover/progress to eating solid foods.

 

There is a potential for long term complications of reflux, include erosive oesophagitis, peptic stricture and Barrett’s oesophagus.

 

Some patients may need a hiatus hernia repair and convert the LSG to RYGBP.

 

 

There is a risk for developing dumping syndrome and neuro glycopenic symptoms.

 

Lifelong multivitamin and mineral supplements are necessary.

 

Lifelong follow up with the GP and dietician with blood tests (2 to 3 times a year) is necessary.

 

There is a risk for marginal/stomal ulcer and anastomotic stricture, which may need gastroscopy and dilatation. Bleeding or chronic non healing gastric ulcers may need revision surgery.

 

There is a risk of bile/alkaline reflux. Some patients need to have the OAGB converted to RYGBP.

There is a risk for developing dumping syndrome and neuro glycopenic symptoms.

 

Lifelong multivitamin and mineral supplements are necessary.

 

Lifelong follow up with the GP and dietician with blood tests (2 to 3 times a year) is necessary.

 

There is a risk for marginal/stomal ulcer and anastomotic stricture, which may need gastroscopy and dilatation. Bleeding or chronic non healing gastric ulcers may need revision surgery.

 

There is a risk for internal hernia and small bowel obstruction. This require an emergency operation.

 

Endoscopy procedures Gastroscopy and ERCP can be performed with ease. The remnant stomach can’t be screened with a gastroscopy.

 

ERCP is extremely difficult to perform and needs specialized double balloon enteroscoopy.

 

ERCP may not be possible in some patients.

The remnant stomach can’t be screened with a gastroscopy.

 

ERCP is extremely difficult to perform and needs specialized double balloon enteroscoopy.

 

ERCP may not be possible in some patients.

Pregnancy concerns Pregnancy is generally safe and have minimal nutritional risk. With morning sickness or inadequate dietary intake, there is a risk for vitamin deficiencies (especially folate) and risk for congenital malformation.

 

If bowel obstruction develops, it is not safe to order x-rays or perform surgery without adding risk to the pregnancy.

 

With morning sickness or inadequate dietary intake, there is a risk for vitamin deficiencies (especially folate) and risk for congenital malformation.

 

If bowel obstruction develops, it is not safe to order x-rays or perform surgery without adding risk to the pregnancy.

 

Specific surgical

complication

Staple line leak and bleeding. Anastomotic leak, marginal ulcer/stricture, bile reflux, adhesive small bowel obstruction. Anastomotic leaks, marginal ulcer/stricture, internal hernia, small bowel obstruction.
Absolute or relative contraindications Large hiatus hernia, acid reflux and Barrett’s oesophagus. Inflammatory bowel disease, patients on NSAIDS, anti coagulation or immunosuppressants.

 

Previous major abdominal/pelvic surgery and adhesions.

 

Patients living in remote/rural areas with lack of medical services to treat surgical complications.

Inflammatory bowel disease, patients on NSAIDS, anti coagulation or immunosuppressants.

 

Previous major abdominal/pelvic surgery and adhesions.

 

Patients living in remote/rural areas with lack of medical services to treat surgical complications.

 

 

 

 

Physiology differences between the sleeve and bypass

We have to stress to the readers that the mechanisms of bariatric surgery are still not entirely clear.

 

In the past there have been a lot of studies on the hunger and satiety hormones, such as ghrelin and other incretins. Sometimes these studies create more confusion than clarity. In the future no doubt more scientific research and more information will be available to improve our understanding of obesity and metabolic problems.

 

Patients may choose gastric bypass surgery over the sleeve because of the superior weight loss results and the clinical improvements in T2DM but we do not understand the entire long term physiological consequences of this procedure.

 

The main anatomical difference between the sleeve and gastric bypass is the exclusion/bypass of the duodenum and proximal jejunum.

  • This may have a weight independent anti diabetes effect which leads to remission of insulin resistance and T2DM (proximal or hindgut hypothesis). We do not understand this area very well.

 

 

  • Nutrient exposure in the distal small intestine and changes in the immunological signaling pathways probably plays a significant role in metabolic syndrome as well. Whether this is due to weight loss (independent of the choice of weight loss surgery) or due to anatomical changes (dependent on choosing a gastric bypass procedure) we do not know for sure at this stage.

 

 

 

Definition of weight loss success after any bariatric surgery

The ideal weight for everyone following the Caucasian standard is to have a BMI 20-25. The world’s population in the last century rarely have morbid obesity issues.

This is obviously not the case any more in the 21st century.

 

With the introduction of bariatric surgery, there is also a need to define what constitutes successful weight loss surgery outcomes.

  • Around 1982, surgeons began describing weight loss surgery as achieving >50% excess weight loss (EWL) and this has been the standard to which we measure the success of bariatric surgery ever since.
  • More recently the definition of weight loss success after surgery include >20% (total body weight loss) TWL. This is easier to calculate and TWL getting used more often in modern day scientific research.

 

In contrast the definition for success using medical pharmacology treatments (without bariatric surgery) is >5% TWL.

  • Fortunately reduction in medical co-morbidities can be seen after 5-10% TWL.

 

Some researchers have noted that:

  • Weight loss surgery provides 4 times the weight loss in the long term
  • Overall the successful long term weight loss (>20% TWL) is expected in 70% of patients

 

 

The definition of weight regain after bariatric surgery however is not clear at this stage.

There has been several suggestion, which include:

  • BMI >35 after initial success of BMI <35 after the initial surgery
  • EWL <50% after initial success of >50% EWL after the initial surgery
  • Weight regain >25% EWL from the lowest weight (nadir)
  • Weight regain >10% from the lowest weight (nadir)
  • Not able to maintain >20% TWL at all

 

 

Less successful outcome (<20% TWL) is observed in:

  • Gastric band surgery
  • Lower pre-op BMI
  • Patients with pre-op T2DM and HPT
  • Age over 40 years
  • Male gender
  • Substance abuse (alcohol)
  • Medical causes of weight regain

 

 

 

 

Weight loss pre-operatively

From a technical point of view, bariatric surgery will not be safe or possible without adequate reduction in body weight, visceral adiposity and most importantly the size of the fatty liver.

 

Ideally patients are advised to lose >10% of their body weight or >3kg of body fat before elective bariatric surgery. This can be achieved using the very low calorie or energy diet (VLCD or VLED) and recently also the introduction of a very low calorie ketogenic diet (VLCKD).

  • The low carbohydrate diet will reduce the glycogen storage in the liver.
  • These diets also induce ketosis, which helps to suppress hunger.

 

 

Low calorie diet (LCD) is usually 800 – 1 200kcal per day, with >100g carbohydrate, 1g/kg protein a day and fat <30%.

 

Very low calorie diet (500 – 800 kcal/day, with >50g carbohydrate, 1.5g/kg protein (usually 65-70g protein/day) and <30% fat.

 

The Formulite, a brand of VLED has a higher content of protein, lower amount of carbohydrate and sugar. It also has added fiber, digestive enzyme and probiotics.

  • This was introduced to improve patient tolerance due to the unwanted side effects of VLCD, which mainly include bloating, flatulence, constipation or diarrhea.
  • There is probably no superior weight loss result between this and other brands of VLCD in the short pre-op period

 

 

Some dietician may also recommend omega 3 poly unsaturated fatty acid supplements together with VLCD in the pre-op period.

  • This may be beneficial for patients with known non-alcoholic fatty liver disease (NAFLD).

 

 

 

 

 

 

Weight loss results after laparoscopic sleeve gastrectomy

 

The LSG produces weight loss results and improvements in T2DM comparable to the RYGBP in the medium term.

  • The greatest benefit in having the LSG is the safety profile and the versatility of the procedure (option for revision in the future), especially for the young female patients in their reproductive age group, who does not have T2DM or cardiac disease.

 

Weight loss and resolution rate is better with the gastric bypass but there is probably no statistical difference between these two procedures in the 2 to 3 years follow up after the initial procedure.

 

In the long term, weight regain is higher with the sleeve than the gastric bypass, 3 to 5 years or more after the initial procedure.

 

 

It is estimated that nearly 15 – 30% of patients require revision surgery after an initial LSG for inadequate weight loss or weight regain.

  • One study published that weight regain is estimated to occur in 5.7 % (after 2 years) to 75% (after 6 years).
  • Obviously the figures depends on which definition of weight regain is used (as described above)

 

Weight regain after a LSG may be associated with:

  • A larger sleeve remnant or large/undissected posterior fundic pouch
  • Patients in the older age group
  • Patients who achieve a lower maximum weight loss in the first year
  • Poor eating habits or lack of positive lifestyle change after surgery
  • Early or multiple pregnancies after the initial surgery

 

We need to emphasize that readers need to be cautious when reading any surgical literature and not apply everything they read to their individual case.

 

Weight loss success, failure or regain is really the interaction of a combination of factors:

  • Technical factors (large sleeve remnant, sleeve dilatation)
  • Physiological factors (regulation of gut hormones)
  • Medical factors (poor metabolism , medical conditions, medication use, etc)
  • Psychological factors (nutritional behaviour, maladaptive/binge eating, loss of control eating habits)

 

 

Weight regain after bariatric surgery

 

Weight regain will occur after any bariatric surgery with time.

Weight regain may be associated with the return of medical co-morbidities (hypertension, T2DM) and reduced health related quality of life.

 

It is estimated that patient will regain 5-10% of their total weight loss (TWL) within the first decade after bariatric surgery.

 

The percentage of patients who develop weight regain after a sleeve gastrectomy and RYGBP may occur up to 76-87% or more.

 

Specifically with regards to the RYGBP:

  • The Swedish Obese Subject Study (SOSS) showed that after RYGBP, there is a regain of 10% of the TWL
  • The Longitudinal Assessment of Bariatric Surgery (LABS) showed a regain of 7% TWL (7 years after RYGBP)
  • Another study showed a regain of 12% TWL 12 years after RYGBP

 

 

 

Issues with polycystic ovarian syndrome (PCOS)

 

PCOS describes a combination of symptoms, which include:

  • Obesity (>2/3 young women with PCOS also have obesity)
  • Insulin resistance
  • Hyperandrogenism (biochemical and clinical, such as hirsutism)
  • Poly cystic ovaries
  • Ovulatory dysfunction and subfertility
  • There is an increased LH:FSH ratio (high LH leads to increase androgen production and low FSH impair ovarian follicular development)
  • Increased oestrogen levels (may or may not be related to increased risk for developing breast and endometrial cancers)

 

With successful weight loss, there is a chance for restoration of menstrual patterns and ovulatory cycles.

 

Young female patients who are concerned about falling pregnant soon after weight loss surgery will need to consult their general practitioners or gynaecologist.

  • Some patients are recommended to commence contraception prior to bariatric surgery.
  • Patients are advised against falling pregnant in the 12 to 18 months after bariatric surgery.

 

 

Issues regarding pregnancy

 

Majority of patients considered for bariatric surgery in Australia are females in the younger reproductive age group.

  • They face the choice of having weight loss surgery before pregnancy (for subfertility issues).
  • Or after they have finished their family (to prevent weight regain issues).

 

One of the indication for weight loss surgery is PCOS and subfertility. After many failed attempts, such as IVF treatments, some patients may be referred by their gynaecologist for bariatric surgery.

 

Specifically weight loss:

  • Helps to reduce the risk for developing gestational diabetes, hypertension in pregnancy, fetal macrosomia (or the opposite small for gestational age), pre term delivery (or admission to the neonatal intensive care unit).
  • Reduce the elective/emergency Caesarean delivery rate and post-partum haemorrhage.

 

These two factors are the common reason for younger women seeking bariatric surgery. However, most surgeons recommend that patients post pone getting pregnant for 12 to 24 months after bariatric surgery:

  • To allow adequate time to lose weight and time for resolution of medical co-morbidities associated with obesity.
  • Also to reduce the risk of developing micronutrient deficiencies during pregnancy.

 

Patients need to discuss with their GP or gynaecologist regarding contraception after weight loss surgery.

  • With the enlarging uterus, the intra-abdominal pressure is increased and the intestine and other abdominal organs are displaced upwards. The risk of small bowel obstruction may increase, especially after previous intestinal surgery or gastric bypass.
  • It is much safer for patients intending to get pregnant in the future to have a sleeve than a bypass. The RYGBP, OAGB, SADI or BPD may be associated nutritional deficiency during pregnancy. This may lead to small for gestation age fetus and premature births.

 

Patients who are pregnant must have supplements regardless of whether they had a sleeve gastrectomy or a bypass. These include:

  • Folic acid 0.4 to 1mg daily up to 12 weeks of gestation (to prevent neural tube defects) (5mg daily if there has been a history of NTD in the past)
  • Iron supplements 50-80mg per day
  • Vitamin B12 1mg per week
  • Zinc 10mg per day
  • Copper 1mg per day
  • Vitamin A less than 5 000 IU per day
  • Protein intake should be more than 60g a day

 

Obviously these patients needs to be screened for gestational diabetes.

 

 

Weigh gain may occur after pregnancy or breast feeding.

  • If there are no medical risk factors, some patients may elect to have weight loss surgery after they have finished their family in order to reduce the risk of weight regain.

 

 

 

Issues with medications and absorption

 

Patients will need close monitoring for some of their medical conditions and have their medications adjusted by the GP before and after weight loss surgery. Especially pertaining to hypertensive, diabetic, thyroid medications, antidepressants and various other tablets.

 

Patients are advised to avoid cigarette and non-steroidal anti-inflammatory drugs to reduce the risk of gastric ulcers, bleeding and perforation.

 

 

Issues with gallstones (GS)

 

Studies reported asymptomatic or symptomatic gall stones developed in 26 to 30% of patients after a sleeve gastrectomy in the first year.

Symptomatic gallstones occur at a higher rate after gastric bypass, some studies reported GS in up to 29% of these patients. The risk increases because of rapid weight loss in a shorter period of time.

 

There is no consensus for the role of medications (ursodeoxycholic acid) to prevent gallstone formation or the role for prophylactic cholecystectomy.

  • Ursodeoxycholic acid is a secondary bile acid that inhibits cholesterol secretion in the bile, which helps to reduce cholesterol stone formation.
  • Some patients will need to take this medication 500mg daily for more than 6 months in order to see benefits in the reduction rate for cholecystectomy (in the first 1 to 3 years after bariatric surgery).

 

 

 

Issues with gastro-oesophageal acid reflux (GERD)

 

It is estimated that de novo gastro-oesophageal reflux may be present in over half the patients before bariatric surgery.

 

After a sleeve gastrectomy the reflux symptoms may be resolved with successful weight loss in maybe up to 60% of patients, (it may remain unchanged or becomes worse).

 

In contrast another study reported:

  • That 70% of patients who had GERD pre-operatively will continue to have GERD after surgery.
  • Incidence of new onset of GERD is estimated to occur in up to 35% of patients

 

Intra thoracic migration of the remnant tubularized stomach up into the chest is now being recognized to occur after a sleeve gastrectomy. The shortened oesophagus may also increase the risk of the upward gastric migration.

  • This may cause refractory reflux as well as difficulty swallowing (dysphagia) and chest pain (odynophagia) during meals.
  • Often this will require a surgical correction to repair the hiatus hernia.

 

Most surgeons do recommend RYGBP for patients with severe reflux. But note symptomatic reflux may persist even after the RYGBP, there is no guarantee that the RYGBP will eliminate all the heartburn symptoms.

  • Before patients decide to have a RYGBP, it is encouraged that they do more research into the long term side effects and complications of surgery. Please read the blog on Roux Y gastric bypass.

 

 

Assessments for reflux

 

Reflux is diagnosed by patient’s self reporting or via a patient based questionnaire.

 

The Montreal definition (2006) (this is patient symptom based not endoscopic diagnosis) states that GERD is a disease associated with troublesome symptoms and complications due to reflux of stomach contents up the oesophagus. There are classified as oesopahgeal or extra-oesophageal symptoms, which may include laryngitis, cough, asthma and dental problems related to acid reflux.

 

GERD is often an empirical diagnosis based on the doctor’s assessment and the patient’s response to a trial of PPI medications.

  • Few patients are referred to have a screening gastroscopy (to diagnose the severity of reflux, such as the LA classification for erosive oesophagitis) or to check for complications (such as Barrett’s oeosphagus).
  • Even less frequenty patients are referred for physiological testing, such as a high resolution oesophageal manometry study (HRM) (using the Chicago criteria, a classification system for oesophageal dysmotility)
  • Or ambulatory 24 hour multi-channel intraluminal impedance pH study (MII-pH).

 

The Los Angeles (2005) classification (A to D) is an endoscopic diagnosis and grading system for the severity of erosive oesophagitis, based on the length of the mucosal breaks, the extend or the confluence of the erosions.

 

The Rome 4 criteria were more strict to define the heartburn phenotypes. The consensus group also recommended an oesophageal biopsy at the same time to rule out oesinophillic oesohagitis.

  • This is to help distinguish between non erosive reflux disease (NERD) from functional heartburn and reflux hypersensitivity.

 

The Lyon consensus group evaluated GERD diagnostic tests and categorize these diagnostic tests as being adequate (to diagnose/refute GERD) or being inadequate (where more investigations are needed, as mentioned above).

 

Reasons to consider a RYGBP

  • The rate of new onset of reflux is much higher after a sleeve gastrectomy compare to a gastric bypass. The possible explanation for this may include the destruction of the angle of His, deceased gastric compliance and increased intraluminal gastric pressure causing secondary regurgitation and reflux.

 

  • Similarly GERD symptoms has been reported to improve by 90% after RYGBP. Reflux oesophagitis may decrease from 45 to 20%. However there are patients with persistent reflux symptoms after RYGBP, the reason for this is uncertain.

 

 

 

Gastroscopy checks after a sleeve gastrectomy

Investigations for Barrett’s oesophagus

 

It is well published that the sleeve gastrectomy is highly efficient in achieving good medium/long term significant weight loss and resolution of medical co-morbidities.

 

LSG reduces gastric compliance and increased intra gastric pressure, which may be good for restriction and satiation but it may also cause food regurgitation or acid reflux up the oesophagus.

 

Consequently a significant number of sleeved patients do suffer from acid or alkaline/bile reflux.

  • Majority of these symptoms may be mild but a few develop oesophagitis and Barrett’s oesophagus (maybe in up to 6% of patients after a sleeve).
  • Fortunately there had been no reports that sleeve gastrectomy result in increased risk of oeosphageal cancers at this stage.
    • One study reported that the annual oesopahgeal adenocarcinoma or cancer risk for a short segment (<3cm) Barrett’s eosophagus was 0.03% and for a long segment (>3cm or 4 -10cm) Barrett’s oesophagus was 0.22%.

 

 

With regards to heartburn or dysphagia (difficulty swallowing)

  • A post op Barium swallow test or gastroscopy is recommended.
  • A gastroscopy is necessary to search for erosive/reflux oesophagitis, which is described using the Los Angeles classification.
    • The gastroscopy is also important to diagnose or exclude a hiatus hernia, peptic stricture, Barrett’s oesophgus, peptic ulcer disease and duodeno-gastric bile reflux or chemical gastritis.

 

Barrett’s oesophagus needs to be confirmed on endoscopy and biopsy.

  • The Seattle protocol described 4 quadrant biopsies every 1-2cm along the columnar lined oesophagus starting from the gastro-oesophageal junction (at the top of the gastric rugae folds).
  • Histology confirmation with both specialized intestinal metaplasia and Goblet’s cells. Obviously it is important to rule out dysplastic or malignant changes on histology.

 

Some gastroscopes have magnifying views and narrow band imaging, a special optical image enhancing technology to inspect the vascular and mucosal pattern to help target the biopsies to the area of concern (areas of neovascularization) to improve the detection rate for Barrett’s metaplasia and dysplasia..

 

Gastroscopy can describe the extend and subsequent regression of the Barrett’s oesophagus using the Prague classification.

  • Obviously patients will need life long surveillance once Barrett’s oesophagus is diagnosed, the clinical guidelines has been published by the Gastroenterological Society of Australia (GESA).
  • Patients are usually referred to a gastroenterologist who specializes in this area for long term screening and surveillance.

 

Other investigations are available to diagnose acid reflux if the Barium swallow test or gastroscopy is inconclusive, such as a high resolution manometry or 24 hour pH study. However this is uncommonly done at the present time.

 

  • There are various endoscopic treatment options for Barrett’s oesopahgus with dysplasia. The more common procedures include radio-frequency ablation using the Halo technology (HALO RFA) with a reported 98% success rate and 92% of patients remains disease free after 5 years of follow up.
  • Other endoscopic treatments include argon plasma treatment (APC) or endoscopic mucosal or submucosal resection (EMR or ESD).

Once again it is stressed that all these procedures should be done by a gastroenterologist with specialized interest in screening and treating Barrett’s oesophagus.

 

 

 

 

RYGBP is only one option for treating reflux or Barrett’s oesophagus after a sleeve gastrectomy

 

Please read the section on sleeve or gastric bypass regarding issues with reflux after a sleeve gastrectomy.

 

RYGBP is very effective in controlling heartburn symptoms in a majority of patients. However it is emphasized that the reflux symptoms may persist (partial resolution) or recur many years later.

  • Medications such as antacids (Gaviscon, Mylanta, etc) and PPI medications may need to be continued in the long term.

 

 

RYGBP is an effective surgical treatment for sleeved patients with severe heartburn symptoms or those who had developed complications, such as erosive oesophagitis or Barrett’s oesophagus.

  • Barrett’s remission rates of 50 to 80% has been reported.
  • Some patients has been reported to be free of dysplasia after RYGBP.

 

In other words RYGBP does not always achieve complete resolution of the reflux symptoms or guarantee resolution of Barrett’s oesophagus.