SSAT - THE ROLE OF PRE-OPERATIVE ESOPHAGEAL MANOMETRY AND PH MONITORING IN BARIATRIC SURGICAL PROCEDURE SELECTION.

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THE ROLE OF PRE-OPERATIVE ESOPHAGEAL MANOMETRY AND PH MONITORING IN BARIATRIC SURGICAL PROCEDURE SELECTION.
Ciro Andolfi^*, Mustafa Hussain, Alejandro Plana, Vivek N. Prachand
Department of Surgery, University of Chicago, Chicago, IL

Background: Although bariatric surgery results in significant weight loss and comorbidity improvement, two surgical options [sleeve gastrectomy(SG),adjustable gastric banding(AGB)] can exacerbate pre-existing gastroesophageal reflux disease(GERD). Accordingly, individuals with GERD and/or metabolic comorbidity may obtain benefit with Roux-en-Y gastric bypass(RYGB), while less obese patients without metabolic comorbidities or GERD may avoid the nutritional and internal hernia risk associated with RYGB by undergoing SG. The severity of gastroesophageal reflux(GER) symptoms does not always correlate with the esophageal testing [high resolution manometry (HRM), pHmonitoring]. We obtain these tests in patients with significant GER symptoms who express preference for SG over RYGB and low BMI patients without metabolic comorbidities who express a strong preference for RYGB over SG to objectively assess GER and guide surgical recommendation. We hypothesize that the information gained significantly impacts both the surgical recommendation and the patient’s willingness to consider a surgical option that differs from their initial preference.
Patients and methods: Forty-nine bariatric surgery candidates with GER symptoms underwent esophageal testing (24-hour pH monitoring and HRM). Pre-testing surgeon recommendation and patient procedure preferences were compared to the final recommendation and procedure eventually performed.
Results: Of 42 patients with typical and 7 with atypical GER symptoms, only 20/49(41%) were found to have GERD. 33/49(67%) expressed initial preference for SG, of whom 13/33(39%) were found to have GERD and RYGB recommended. Only 7/13(54%) underwent RYGB, with the other six opting not to have surgery. 9/49(18.4%) expressed initial preference for RYGB, 6/9(67%) of whom were found to have GERD. The three patients without GERD underwent SG. In the two patients seeking AGB, HRM showed esophageal dysmotility and RYGB was recommended and performed. Of the five patients seeking duodenal switch(DS), one was found to have GERD, and duodenal switch without sleeve gastrectomy was performed as a staged DS procedure. Of the 33 patients for whom RYGB was recommended by the surgeon on the basis of GER symptoms, testing excluded the presence of GERD in 17/33(51%), and SG was offered to 13 of these patients. Of the four patients for whom RYGB remained the recommendation, two had esophageal dysmotility and two had high BMI and metabolic comorbidities. In the11 patients with mild GER symptoms for whom SG was felt to be reasonable by the surgeon and preferred by the patient, 3/11(27%) were found to have GERD, and RYGB was recommended.
Conclusions: Severity of GER symptoms does not correlate with GERD presence in bariatric surgery candidates. Esophageal testing substantively impacts patient preference, surgeon recommendation, and bariatric procedure performed.

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