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ESOPHAGEAL MOTILITY ABNORMALITIES AFTER BARIATRIC SURGERY: PATIENT SYMPTOMS NOT AN INDICATOR
Caroline E. Sheppard*1,2, Daniel C. Sadowski3, Christopher J. de Gara1, Daniel W. Birch1,2
1Surgery, University of Alberta, Edmonton, AB, Canada; 2Centre for the Advancement of Minimally Invasive Surgery, Edmonton, AB, Canada; 3Medicine, University of Alberta, Edmonton, AB, Canada
Introduction
Several previous investigations have identified that esophageal motor disorders have a higher prevalence in patients with obesity. It is unclear if the increased prevalence of esophageal motor disorders persists in patients with esophageal symptoms subsequent to weight loss after bariatric surgery.
Aim
The objective of this study was to determine the frequency and types of esophageal motility abnormalities in postoperative bariatric patients referred for troublesome gastroesophageal symptoms.
Methods
Patient data was prospectively collected over an 18-month period from 1602 patients undergoing ambulatory 24h pH/impedance and high resolution esophageal manometry. Patients who underwent bariatric surgery, as well as obese patients with no previous gastric surgery, were included. Intragastric pressure (IGP) was measured at basal conditions, 5cm below the lower esophageal sphincter (LES) margin using the manometry analysis software package. Esophageal motility disorders were identified using the Chicago 3.0 classification scheme.
Results
553 patients in the study group met the definition for obesity (BMI greater than 30kg/m2) and no previous gastric surgery. A total of 47 patients had undergone previous bariatric surgery, including 16 sleeve gastrectomies (SG), 11 Roux-en-Y gastric bypasses (RYGB), 9 adjustable gastric bands (AGB), and 11 vertical banded gastroplasties (VBG). The presenting symptoms for the bariatric surgery group were most often heartburn, dysphagia, regurgitation, and epigastric pain. Overall, abnormal manometric results were found in 40% of bariatric patients compared to 47% in the obese group. AGB most frequently had esophageal abnormalities (63%). Types of esophageal abnormalities are described in Table 1. No referred symptoms after bariatric surgery were significantly predictive of abnormal esophageal motility. A proportion of patients also underwent 24h pH and impedance off anti-secretory therapy. 50% AGB (n=2), 33% RYGB (n=3), 80% SG (n=5), and 0% VBG (n=2) had a positive DeMeester score for gastroesophageal reflux. 20% of bariatric patients and 35% of obese patients had both reflux and an esophageal motility disorder. Only 40% of SG and 100% of VBG had a positive symptom association probability with their referred symptoms.
Conclusions
There were no significant differences in esophageal motility abnormalities between symptomatic obese and bariatric patients. The mechanism for these abnormalities does not appear to be associated with BMI or IGP, as previously hypothesized after SG. Symptoms after bariatric surgery also do not appear to be associated with esophageal motility disorders or reflux. These results emphasize the importance of a bariatric clinic follow-up with extensive experience to manage these complicated symptoms and disorders to limit unnecessary clinical interventions.
Table 1. Patient demographics and esophageal manometry results.
| | Obese (n=533) | SG (n=16) | RYGB (n=11) | AGB (n=9) | VBG (n=11) | | Average age (years) | 53.7±13.7 | 50.3±12.8 | 47.6±11.8 | 49.4±10.7 | 56.5±9.0 | | Gender (%Y) | 71 | 100 | 91 | 100 | 100 | | Average BMI (kg/m2) | 35.4±5.2 | 33.8±6.0 | 33.7±9.2 | 39.9±8.2 | 39.7±6.8 | | Hiatal hernia (%) | 28 | 31 | 18 | 25 | 18 | | Average LES pressure (mmHg) | 29.3±15.9 | 21.9±10.8 | 30.4±19.4 | 31.0±7.9 | 32.7±22.4 | | Intragastric pressure (mmHg) | 14.6±5.7 | 15.5±4.3 | 16.0±6.8 | 13.8±3.7 | 22.0±17.3 | | Ineffective esophageal motility (%) | 23 | 24 | 36 | 38 | 18 | | Esophagogastric junction outflow obstruction (%) | 12 | 0 | 0 | 25 | 9 | | Spasm (%) | 4 | 0 | 0 | 0 | 18 | | Achalasia (%) | 5 | 0 | 0 | 0 | 0 | | Scleroderma (%) | <1 | 0 | 0 | 0 | 0 | | Hypertensive peristalsis (%) | 2 | 0 | 0 | 0 | 0 |
BMI: body mass index. SG: sleeve gastrectomy. RYGB: Roux-en-Y gastric bypass. AGB: Adjustable gastric band. VBG: Vertical banded gastroplasty.
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