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Salvatore Tolone*1, Edoardo V. Savarino2, Nicola De Bortoli3, Marzio Frazzoni4, Leonardo Frazzoni5, Giorgia Bodini6, Vincenzo Savarino6, Ludovico Docimo1
1University of Campania "Luigi Vanvitelli", Naples, Italy; 2University of Padua, Padua, Italy; 3University of Pisa, Pisa, Italy; 4Baggiovara Hospital, Modena, Italy; 5University of Bologna, Bologna, Italy; 6University of Genoa, Genoa, Italy

Introduction Obesity is a global epidemic and consequently bariatric surgery is increasingly performed. More recently, omega-loop gastric bypass (OGB), consisting primarily of a long linear lesser-curvature gastric tube with a termino-lateral gastro-enterostomy 180-200 cm distal to the ligament of Treitz, was introduced. Despite positive effect in terms of weight loss and improvement of obesity-related co-morbidities, there are concerns about a similarity with old Billroth II (BII) procedure, symptomatic biliary reflux gastritis and esophagitis requiring revision. However, scarce data are available on the physiopathological effect of these two procedures on gastro-esophageal function. We aimed at assessing the esophagogastric junction (EGJ) function, esophageal peristalsis and reflux exposure using high-resolution manometry (HRM) and impedance-pH monitoring (MII-pH) after OGB and BII.
Methods Obese (body mass index, BMI>35) patients underwent symptomatic questionnaires (GerdQ), endoscopy, HRM and MII-pH before and one year after OGB. We enrolled only obese without dysmotility or any evidence of GERD. HRM traces were classified according to Chicago Classification V. 3. EGJ contractile integral (EGJ-CI), intragastric pressures (IGP) and gastroesophageal pressure gradient (GEPG) were calculated. Total acid exposure time (AET %), total number of refluxes and symptom association probability (SAP) were assessed. A group of patients who underwent BII, referred for follow-up, was studied with the same protocol for comparison.
Results We enrolled 15 OGB patients and 12 BII subjects. After surgery, none of the patients reported de novo heartburn or regurgitation. One year after surgery, esophagitis, biliary gastritis or presence of bile was recorded in any patients Manometric features and patterns didn't vary significantly after surgery, whereas IGP and GEPG statistically diminished (from a median of 15 to 9.5, P<0.01, and from 10.3 to 6.4, P<0.01, respectively) after OGB. BII subjects had significant lower values in IGP (a median of 4.2, P<0.001), and similar GEPG 4.3, P=n.s. LES pressure as well as EGJ-CI were significantly lower in BII subjects than OGB ones (13 vs 22 mmHg, p<0.05, and 11 vs 21.5 mmHg*cm, p<0.05, respectively). A dramatic decrease in number of reflux events (from a median of 41 to 7; P<.01) was observed after OGB, whereas BII patients had a statistically significant higher values in esophageal acid exposure and number of reflux episodes (57 vs 7; P<0.001), in particular in weakly alkaline reflux (38 vs 0; p<0.001).
Conclusions In contrast to BII, OGB did not expose to gastroesophageal reflux and in particular to weakly alkaline reflux. Also the difference in IGP and in GEPG as assessed by HRM suggests that gastric bile reflux can occur more easily in BII than in OGB and that these two techniques share more differences than analogies.

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