麻豆传媒

For individuals with obesity, bariatric surgery is a proven intervention for inducing weight loss and mitigating adverse health effects. Of the two most common forms of bariatric surgery, laparoscopic vertical sleeve gastrectomy (LVSG) is more frequently performed than laparoscopic Roux-en-Y gastric bypass (LRYGB). An ongoing concern is the effect of laparoscopic surgery on occurrence and severity of gastroesophageal reflux disease (GERD), which is a common finding in patients with obesity.¹ A recent study has demonstrated that risk of GERD developing or worsening is higher with LVSG than with LRYGB 5 years after surgery, supporting current practice to limit or avoid LVSG in patients with pre-existing GERD.¹

To clarify the impact on GERD of the two forms of bariatric surgery, researchers performed a meta-analysis of randomized controlled trials published between January 1999 and March 2024 and compared outcomes (including GERD) with LVSG vs LRYGB in adult patients (鈮�18 years) with severe obesity. Five studies, in which a total 554 patients underwent LVSG and a total of 539 underwent LRYGB, were assessed. Included studies had to report at least 5 years of postoperative follow up on GERD.¹ Statistical analysis included assessment of publication bias, pooled odds ratios (ORs) and 95% confidence intervals (CIs) using a random effects model, tests of heterogeneity (Cochrane鈥檚 Q statistic and I2 index), and impact of the population effect size (z-statistic). Statistical significance was defined as P 鈮�0.05.¹

Results of the meta-analysis found that LVSG was associated with worse GERD outcomes across all examined endpoints. Revision surgery for GERD was required more often following LVSG (OR 11.47; 95% CI 1.83-71.69; P = 0.02; I2 = 0%) and more patients who received LVSG than LRYGB required pharmaceutical treatment for GERD (OR 3.89; 95% CI 2.31-6.55; P 鈮�0.01; I2 = 0%). Overall, more patients required either surgical or pharmaceutical intervention after LVSG for GERD and/or development of de novo GERD than after LRYGB (OR 5.98; 95% CI 3.48-10.29; P 鈮�0.01; I2 = 0%). Certainty of evidence across the 5 studies was moderate to high and there was a moderate to high level of bias in GERD outcomes. 

One possible source of bias lay in how GERD was described in the studies. Three assumed GERD was present based on patient-reported assessment instruments (eg, Gastrointestinal Quality of Life Index), one defined GERD if patients required proton-pump inhibitors (PPIs) after surgery, and one defined GERD by postoperative PPI use or evidence of endoscopic esophagitis or abnormal manometry.¹ The study authors note that these are not definitive assessments of GERD and thus 鈥渢here remains a lack of clarity around the diagnosis of GERD鈥� that may have confounded their results.¹ In the two included studies that reported preoperative and postoperative GERD outcomes, LVSG was associated with higher rates of new or worsening GERD after surgery and LRYGB was associated with dramatically higher rates of GERD remission or improvement.¹

Need for revision surgery to manage GERD following LVSG or LRYGB showed the widest range across the 5 included studies. At 5 years, none of the patients (0/539) who underwent LRYGB had revision surgery, compared with 40 of 554 patients who underwent LVSG. The OR here (11.47) strongly favored LRYGB to avert the need for additional surgery.¹

The study authors note that there are a number of modifiable factors to decrease GERD risks with LVSG. These include sleeve size, with some, but not all data, suggesting that larger sleeves may help reduce intragastric pressure and associated GERD.¹ Other factors include sleeve shape, distance of the closure from the pylorus (antral-sparing may reduce GERD vs antral dissecting), and quality of the surgical technique.¹

Patients who require bariatric surgery for obesity management can understandably expect an improvement in their quality of life after surgery. Development of new GERD or worsening GERD postoperatively undermines quality of life and carries medical risk as well. GERD has been associated with development of esophageal disease, including erosive esophagitis and Barrett鈥檚 esophagus, a known precursor to esophageal malignancy.¹ The substantial risk for new/worsening GERD after LVSG requires regular surveillance for esophageal disease, which when added to the costs of increased pharmaceutical use, adds to healthcare costs and resource use for patients and health systems.¹ In a time of increasing healthcare cost concerns, the findings of this study may provide additional information for physicians and patients to consider.

This meta-analysis offers a number of factors to consider when decisions are being made about laparoscopic surgery, but the main takeaway is that LVSG consistently is associated with worse outcomes related to GERD. The authors note that risk for GERD following LVSG warrants a 鈥減rudent鈥� approach that includes 鈥渞outine preoperative gastroscopy and esophageal function testing鈥� before offering bariatric surgery.¹ This study, according to the authors, 鈥渆ncourages the need for standardization of GERD diagnostic practices and surgical techniques in bariatric patients to minimize the development of GERD and its long-term consequences in the future in LVSG patients.鈥�¹

Published: December 27, 2024