Figure - available from: Obesity Surgery
This content is subject to copyright. Terms and conditions apply.
Source publication
Introduction
Patients with one-anastomosis gastric bypass (OAGB) can develop gastroesophageal reflux disease (GERD). The nature of this GERD (acid or biliary) remains unclear.
Objective
To assess the nature of GERD via impedance pH testing in patients presenting with reflux post OAGB.
Methods
Retrospective analysis of a prospectively collected da...
Similar publications
This systematic review evaluates the indications and results of revisional bariatric surgery (RBS) in gastroesophageal reflux disease (GERD). A systematic literature search and meta-analysis was performed for articles published by April 1, 2021. After examining 722 papers involving 17,437 patients, 48 studies were included (n = 915 patients). RBS f...
Citations
... It is difficult to distinguish acid reflux from biliary reflux based on the symptoms, and often these two overlap. Nehmeh et al. evaluated the GERD etiology using 24-h impedance-pH monitoring in patients with GERD symptoms after OAGB and found that acid, bile, and mixed types of GERD in 30.2%, 27.9%, and 11.6% of patients respectively [35]. Saarinen et al. showed de novo EGD findings suggestive of bile reflux in 39.5% of patients after OAGB and only 2.6% of them had evidence of bile reflux in the esophagus using bile reflux scintigraphy, six months after OAGB; hence, 20% of patients experienced de novo GERD symptoms [31]. ...
Purpose
Gastroesophageal reflux disease (GERD) is an issue after one anastomosis gastric bypass (OAGB) and modification of OAGB with adding an anti-reflux system may decrease the incidence of postoperative GERD. This study aimed to compare the efficacy of the anti-reflux mechanism to treat preoperative GERD and prevent de novo GERD.
Methods
A prospective randomized clinical trial study was conducted on patients with a body mass index of 40 and more from August 2020 to February 2022. Patients undergoing one anastomosis gastric bypass with and without anti-reflux sutures (groups A and B, respectively). These patients had follow-ups for one year after the surgery. GERD symptoms were assessed in all the patients using the GERD symptom questionnaire.
Results
The mean age was 39.5 ± 9.8 years and 40.7 ± 10.2 years in groups A and B respectively. GERD symptoms remission occurred in 76.5% and 68.4% of patients in groups A and B, respectively. The incidence of de novo GERD symptoms was lower in group A, compared to group B (6.2% and 16.1% in groups A and B respectively), without any statistically significant difference (p-value: 0.239).
Conclusion
GERD symptoms and de novo GERD after OAGB seems to be under-reported after OAGB. This study suggests that applying an anti-reflux suture can decrease de novo GERD symptoms.
Graphical abstract
... Among them, GERD has great importance as it strongly affects quality of life (12,36) and incurs costs related to long-term use of medications, with potential sideeffects (37) and the need for additional revisional surgeries (38). Recent reports have demonstrated that among gastric bypasses, OAGB may be associated not only with biliary reflux but also with acid reflux (39), and RYGB, even if it is the gold standard procedure to treat associated obesity and GERD, is associated with a non-negligible rate of long-term reflux (12,16,(40)(41)(42). ...
Background/aim:
Long-term gastroesophageal reflux (GERD) after gastric bypass for obesity is underestimated. The present study aimed to evaluate the rate of treated GERD and the factors influencing it in a cohort of patients who underwent gastric bypass.
Patients and methods:
Patients who underwent one-anastomosis gastric bypass (OAGB) or Roux-en-Y gastric bypass (RYGB) as a primary bariatric procedure between 2010 and 2011 at a French private referral center were included in the study. The primary endpoint was the 10-year prevalence of GERD.
Results:
In total, 422 patients underwent RYGB and 334 underwent OAGB with a biliopancreatic limb of 150 cm. The mean age was 38.9±11.3 years, and 81.6% of patients were female; the mean preoperative body mass index was 42.8±5 kg/m2 Preoperative GERD was diagnosed in 40.8% of patients in the total cohort, 31.7% in the RYGB group versus 49.1% in the OAGB group (p<0.0001). At 10-year follow-up, the rate of GERD was 21.1%, with no difference between the two groups. Remission of preoperative GERD and de novo GERD were comparable between the two types of bypass. Surgery for GERD resistant to medical treatment was more frequent in the OAGB group. At multivariate analysis, factors significantly correlated with long-term GERD were: Preoperative GERD, total weight loss at 120 months <25%, glycemic imbalances and anastomotic ulcers.
Conclusion:
Identification and correction of modifiable factors may help reduce the incidence of long-term GERD.
... Actually, cases of gastric and esophageal cancer after OAGB are anecdotal, while bile reflux remains a reality that varies from 0.6% to 10% in different studies [3][4][5]. In addition to bile reflux (BR), patients operated on for OAGB can also suffer from acid reflux, just like patients operated on with other bariatric surgery techniques [6]. In fact, the creation of a long and narrow gastric pouch still allows the production of a sufficient quantity of acid liquid, and on the other hand, the separation from the gastric fundus could determine an alteration of the esophagus-gastric junction anti-reflux system, facilitating incontinence of the cardia. ...
... All patients in the present study underwent revision of the OAGB to conventional RYGB with the creation of a new small gastric pouch and a new GJA 2-2.5 cm wide. Some authors have also proposed only the section of the bilio-pancreatic limb with preservation of the GJA, therefore without the section of the gastric pouch (diverted-OAGB) [6,13,24]. In this second case, the bypass looks like an RYGB but does not have all the features. ...
Background
Although gastroesophageal reflux disease (GERD) affects 0.6% to 10% of patients operated on for one-anastomosis gastric bypass (OAGB), only about 1% require surgery to convert to Roux-en-Y gastric bypass (RYGB) [3–5]. The aim of the present study was to analyze the characteristics of OAGB patients converted to RYGB for GERD not responding to medical treatment.
Methods
This retrospective multicenter study included patients who underwent conversion from OAGB to RYGB for severe GERD. The conversion was performed with resection of the previous gastro-jejunal anastomosis and the use of the afferent loop as a new biliary loop.
Results
A total of 126 patients were included in the study. Of these patients, 66 (52.6%) had a past medical history of bariatric restrictive surgery (gastric banding, sleeve gastrectomy). A hiatal hernia (HH) was present in 56 patients (44.7%). The association between previous restrictive surgery and HH was recorded in 33 (26.2%) patients. Three-dimensional gastric computed tomography showed an average gastric pouch volume of 242.4 ± 55.1 cm³. Conversion to RYGB was performed on average 60 ± 35.6 months after OAGB. Seven patients (5.5%) experienced an early postoperative complication (4 patients grade IIIb and 3 grade IIb), and 3 (2.4%) a late complication. Patients showed further weight loss after RYGB conversion and an average of 24.8 ± 21.7 months after surgery, with a mean % of total weight loss (%TWL) of 6.9 ± 13.6 kg. From a clinical point of view, the problem of GERD was definitively solved in more than 90% of patients.
Conclusions
Situations that weaken the esogastric junction appear to be highly frequent in patients operated on for OAGB and converted to RYGB for severe reflux. Similarly, the correct creation of the gastric pouch could play an important role in reducing the risk of conversion to RYGB for GERD.
... Further, there are OAGB-specific concerns that restriction of the GJA and/or pouch may be detrimental to pouch clearance and thus promote debilitating symptoms of gastroesophageal reflux from either biliary or gastric acid origin. 2,12,[25][26][27][28] To address these knowledge gaps, we present a case series of 17 adult patients who underwent ER-OAGB at two centers with expertise in bariatric endoscopy to highlight the clinical efficacy and safety of this novel approach in the outpatient setting. ...
... 27,48 While transient biliary reflux has been demonstrated after OAGB, 26 further study has demonstrated nearly equal frequency of acid reflux. 25 To manage GERD, there is consensus among experts that the gastric pouch should be as long as permitted by the patient's anatomy, while also avoiding practices that may contribute to impaired pouch clearance of food contents, bile, or acid -such as creating an overly narrowed pouch or GJA. 2 Accordingly, many experts construct the GJA with a diameter between 40 and 50 mm, 2 and in series of patients with more narrowed GJA, there were increased reports of GERD. 49,50 In the present series of ER-OAGB, both the pouch and GJA were intentionally narrowed, anatomical modifications that are hypothesized to impede pouch clearance. ...
... There are OAGB surgical techniques that ostensibly help prevent reflux of both acid and bile that are unrelated to the modification from ER-OAGB -such as resection of gastric tissue (diminishing acid), as well as dependent-placement and latero-lateral construction of the GJA (attenuating bile reflux). 25 An alternative explanation is that these ER-OAGB modifications are, in some ways, protective against reflux. First, the gastric pouch is exposed to transient, physiologic biliary flow due to lack of a sphincter, and narrowing of the GJA may generate an anatomical barrier. ...
Weight recurrence after one-anastomosis gastric bypass (OAGB), the third most common metabolic and bariatric surgery performed worldwide, is observed in a subset of patients due to the chronic, progressive nature of obesity. Endoscopic revision of the OAGB (ER-OAGB) through full-thickness suturing to reduce the gastrojejunal anastomosis and gastric pouch is a potential alternative to surgical revision. Here, we present a case series of ER-OAGB and long-term nutritional support at two international centers with expertise in bariatric endoscopy. Data were retrospectively evaluated from a prospectively maintained database. The primary outcome was total body weight loss (TBWL) at 12 months. Secondary outcomes included TBWL at 3, 6, and 15 months; excess weight loss (EWL) at 3, 6, 12, and 15 months; frequency of new/worsening symptoms of gastroesophageal reflux disease (GERD); and the frequency of serious adverse events. In this series, 17 adults (70.6% female, mean age 46.8 years, mean BMI 39.1 kg/m ² ) successfully underwent ER-OAGB an average of 8 years (range 2–21 years) after OAGB for a mean weight recurrence of 43.2% (range 10.9–86.9%). TBWL from ER-OAGB was 9.7 ± 1.8% at 3 months, 13.4 ± 3.5% at 6 months, 18.5 ± 2.1% at 12 months, and 18.1 ± 2.2% at 15 months. EWL from ER-OAGB was 30.5 ± 14.7% at 3 months, 42.6 ± 16.2% at 6 months, 54.2 ± 11.3% at 12 months, and 54.2 ± 11.7% at 15 months. There were no instances of new/worsening GERD symptoms or serious adverse events. In this small series of adults who experienced weight recurrence after OAGB, ER-OAGB facilitated safe and clinically meaningful weight loss, without new or worsening GERD symptoms, when performed by experienced bariatric endoscopists in concert with longitudinal nutritional support.
... Various bariatric surgeries have been reported including laparoscopic sleeve gastrectomy (LSG), single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) and one anastomosis gastric bypass (OAGB). All of these procedures have an excellent efficacy of weight loss; however, postoperative occurrence (de novo) or exacerbation of GERD is seen in subset of patients who underwent bariatric surgery [4][5][6]. This indicates that increased weight is not a single reason for inducing gastroesophageal reflux. ...
... A randomized controlled trial (RCT) comparison of Rouxen-Y gastric bypass (RYGB) and one-anastomosis gastric bypass (OAGB), the YOMEGA Trial, demonstrated the non-inferiority of OAGB weight loss and metabolic outcome improvement at 2-year follow-up [1]. While OAGB has shown overall efficacy and safety, the procedure has been associated with a higher incidence of biliary reflux [2,3]. Medical treatment-resistant biliary reflux has an incidence of 0.6-10.0% ...
... In the instance of postoperative acid reflux, some MBS surgeons recommend revising OAGB to RYGB, and in the case of postoperative biliary reflux, advise revision to diverted OAGB [3]. A systematic review and position statement by De Luca et al. reported that almost 20.0% of reoperations after OAGB were conversions to RYGB due to bile reflux [19]. ...
Background
The advantages and disadvantages of one-anastomosis gastric bypass (OAGB) with primary modified fundoplication using the excluded stomach (“FundoRing”) is unclear. We aimed to assess the impact of this operation in a randomized controlled trial (RCT) and answer the next questions: (1) What the impact of wrapping the fundus of the excluded part of the stomach in OAGB on protection in the experimental group against developing de novo reflux esophagitis? (2) If preoperative RE could be improved in the experimental group? (3) Can preoperative acid reflux as measured by PH impedance, be treated by the addition of the “FundoRing”?
Methods
The study design was a single-center prospective, interventional, open-label (no masking) RCT (FundoRing Trial) with 1-year follow-up. Endpoints were body mass index (BMI, kg/m²) and acid and bile RE assessed endoscopically by Los Angeles (LA) classification and 24-h pH impedance monitoring. Complications were graded by Clavien-Dindo classification (CDC).
Results
One hundred patients (n = 50 FundoRingOAGB (f-OAGB) vs n = 50 standard OAGB (s-OAGB)) with complete follow-up data were included in the study. During OAGB procedures, patients with hiatal hernia underwent cruroplasty (29/50 f-OAGB; 24/50 s-OAGB). There were no leaks, bleeding, or deaths in either group. At 1 year, BMI in the f-OAGB group was 25.3 ± 2.77 (19–30) vs 26.48 ± 2.8 (21–34) s-OAGB group (p = 0.03). In f-OAGB vs s-OAGB groups, respectively, acid RE was seen in 1 vs 12 patients (p = 0.001) and bile RE in 0 vs 4 patients (p < 0.05).
Conclusion
Routine use of a modified fundoplication of the OAGB-excluded stomach to treat patients with obesity decreased acid and prevented bile reflux esophagitis significantly more effectively than standard OAGB at 1 year in a randomized controlled trial.
Trial Registration
ClinicalTrials.gov Identifier: NCT04834635.
Graphical Abstract
... Recent clinical data support that bile reflux reaching the gastric mucosa is not uncommon [52][53][54][55], with up to 36% of patients estimated of having evidence of bile in the excluded stomach and 31.6% having bile in their gastric pouch [56][57][58]. ...
Bariatric bypass surgery has been an effective treatment for morbid obesity. However, there is an increasing number of reported cases of gastric cancer after bypass surgery. Our systematic review showed an increasing trend of gastric cancer cases after bariatric bypass surgery in the last decade, mostly located in the excluded stomach (77%) and diagnosed in an advanced stage. In addition to known risk factors such as tobacco smoking (17%), H. pylori infection (6%), and family history of gastric cancer (3%), bile reflux, a recently proposed cancer-promoting factor, was also estimated in 18% of the cases. Our data suggest that gastric cancer risk assessment should be considered before gastric bypass surgery, and further investigations are needed to determine the value of post-operative gastric cancer surveillance.
... In the case of postoperative acid reflux, revision to Rouxen-Y gastric bypass (RYGB) seems suitable. In the case of postoperative biliary reflux, revision to diverted OAGB could be performed [4]. ...
Purpose
The aim of this work is to demonstrate a new concept of the surgical technique “FundoRing” for the prevention of acid and bile reflux esophagitis after gastric bypass.
Materials and Methods
A laparoscopic surgical technique of gastric bypass simultaneous with combined upper total and lower left partial fundoplication. This described case is a participant in an ongoing randomized clinical trial.
Results
The patient was without complications and was discharged on the third postoperative day. Delta BMI was 14 kg/m² (38–24) at the 1-year follow-up. The patient did not have heartburn or bile reflux esophagitis after surgery. Evaluation of the mucosa of the esophagus by upper endoscopy after each of the 3 follow-up visits demonstrated that reflux esophagitis had resolved. Intraoperative fluorescence imaging technologies (NIR/ICG) (IMAGE1 S™ Rubina®) were to determine the quality of blood supply—no violation of the blood supply to the fundoplication wrap of the gastric pouch was detected. A CT scan clearly shows a fundoplication ring around the esophagus (two-thirds) and the upper part of the gastric pouch (one-third).
Conclusion
The surgical technique of primary modified fundoplication using the excluded stomach with simultaneous gastric bypass is feasible.
... First, this may have been caused by the fact that the authors also included 34.8% revisional OAGB patients (most of whom were converted from adjustable gastric banding), and, second, by the fact that all included patients were suffering from GERD symptoms. Preoperative data on esophageal functional testing were not provided in this study [23]. ...
Background
One-Anastomosis Gastric Bypass (OAGB) is the third most common bariatric operation for patients with obesity worldwide. One concern about OAGB is the presence of acid and non-acid reflux in a mid- and long-term follow-up. The aim of this study was to objectively evaluate reflux and esophagus motility by comparing preoperative and postoperative mid-term outcomes.
Setting
Cross-sectional study; University-hospital based.
Methods
This study includes primary OAGB patients (preoperative gastroscopy, high-resolution manometry (HRM), and impedance-24 h-pH-metry) operated at Medical University of Vienna before 31st December 2017. After a mean follow-up of 5.1 ± 2.3 years, these examinations were repeated. In addition, history of weight, remission of associated medical problems (AMP), and quality of life (QOL) were evaluated.
Results
A total of 21 patients were included in this study and went through all examinations. Preoperative weight was 124.4 ± 17.3 kg with a BMI of 44.7 ± 5.6 kg/m², total weight loss after 5.1 ± 2.3 years was 34.4 ± 8.3%. In addition, remission of AMP and QOL outcomes were very satisfactory in this study. In gastroscopy, anastomositis, esophagitis, Barrett´s esophagus, and bile in the pouch were found in: 38.1%, 28.3%, 9.5%, and 42.9%. Results of HRM of the lower esophageal sphincter pressure were 28.0 ± 15.6 mmHg, which are unchanged compared to preoperative values. Nevertheless, in the impedance-24 h-pH-metry, acid exposure time and DeMeester score decreased significantly to 1.2 ± 1.2% (p = 0.004) and 7.5 ± 8.9 (p = 0.017). Further, the total number of refluxes were equal to preoperative; however, the decreased acid refluxes were replaced by non-acid refluxes.
Conclusion
This study has shown decreased rates of acid reflux and increased non-acid reflux after a mid-term outcome of primary OAGB patients. Gastroscopy showed signs of chronic irritation of the gastrojejunostomy, pouch, and distal esophagus, even in asymptomatic patients. Follow-up gastroscopies in OAGB patients after 5 years may be considered.
Graphical Abstract
... These findings are in accordance with a study by Nehmeh et al. [15] reporting that 13 of 43 patients (30.2%) had acid reflux in the 24-hour pH-metry after a follow-up of 64 months. Additionally, the authors described 12 patients (29.9%) with nonacid reflux and 5 patients (11.6%) with mixed reflux, equaling a total reflux rate of 69.8% after OAGB [15]. ...
... These findings are in accordance with a study by Nehmeh et al. [15] reporting that 13 of 43 patients (30.2%) had acid reflux in the 24-hour pH-metry after a follow-up of 64 months. Additionally, the authors described 12 patients (29.9%) with nonacid reflux and 5 patients (11.6%) with mixed reflux, equaling a total reflux rate of 69.8% after OAGB [15]. Felsenreich et al. [16] showed that patients converted from another bariatric procedure (e.g., SG) to OAGB in particular have a certain risk of GERD in a long-term follow-up after the conversion. ...
Background
Currently, 4.8% of bariatric operations worldwide are One-Anastomosis Gastric Bypass (OAGB) procedures. If a hiatal hernia is detected in a preoperative gastroscopy, OAGB can be combined with hiatoplasty. Intrathoracic pouch migration (ITM) is common after bypass procedures because the fundus, a natural abutment, is separated from the pouch.The aim of this study is to find out whether OAGB or OAGB combined with hiatoplasty carries a higher risk of ITM and therefore also gastro-esophageal reflux disease (GERD).
Setting
University hospital
Methods
Fifty patients (group 1: 25x primary OAGB; group 2: 25x primary OAGB with hiatoplasty) were included in this study. History of weight, GERD, and quality of life were recorded in patient interviews and pouch volume and ITM were evaluated using 3D-CT volumetry
Results
There were no differences in terms of patient characteristics, history of weight, pouch volume or quality of life between both groups. ITM was found in group 1 in 60% (n=15) and group 2 in 76% (n=19) of all patients (p=0.152). The ITM mean length was significantly lower in group 1 with 0.9 ±1.1cm than in group 2 with 1.8 ±1.2cm (p=0.007). Regarding GERD, there was no difference between both groups, nevertheless, significantly more patients with ITM (38.2%; n=13) were suffering from GERD compared to patients without ITM (6.3%; n=1).
Conclusion
In primary OAGB, an additional hiatoplasty was not associated with higher rates of ITM or GERD, nevertheless the length of ITM was higher after hiatoplasty. If ITM occurs, patients have a risk developing GERD.
