MANAGING REFLUX AFTER BARIATRIC SURGERY: CONVERSION OF SLEEVE GASTRECTOMY TO GASTRIC BYPASS
Laura Mazer*, Scott A. Cunneen, Daniel Shouhed, Edward H. Phillips, Miguel Burch
Surgery, Cedars Sinai Medical Center, West Hollywood, CA
Introduction: Laparoscopic sleeve gastrectomy (SG) is now the most commonly performed weight loss operation in the United States. While most patients have improvement or even resolution of gastroesophageal reflux (GERD) after SG, between 2-18% experience new onset disease. Options for these patients include medication, endoscopic treatment, or conversion to roux en Y gastric bypass (RNYGB). There are very few reports describing outcomes after conversion to bypass for GERD, and the largest series to date includes 11 patients. We present our data on 21 patients undergoing conversion from SG to RNYGB for GERD.
Methods: A retrospective review of the prospectively maintained clinical database at one bariatric center of excellence was performed between Jan 2013-Nov 2018. Included patients had a SG for morbid obesity and underwent conversion to RNYGB. Outcomes studied included quality of life scores, proton pump inhibitor (PPI) usage, and body mass index(BMI). Descriptive statistics were calculated with chi square test and students ttest.
Outcomes: During the study period, a total of 226 revisional bariatric procedures were performed by four surgeons. 32(14%) were conversions of SG to gastric bypass; 5(16%) for stricture, 3(9%) for inadequate weight loss, 2(6%) for persistent fistula, and 21(66%) for GERD. Of these 21, 85% were women, with mean age of 42.6. Mean interval between SG and conversion was 35 months (range 9-121). 7 patients (33%) had a prior gastric band; 52% had a hiatal hernia repair (HHR) performed during initial SG, and 67% had a HHR at the time of the bypass. At time of sleeve, 24% of patients were taking daily PPI, and average scores on the validated GERD health-related quality of life instrument (GERD-HRQL) was 8. At time of conversion, 90% of patients were taking daily PPI, and average GERD-HRQL was 33.5 (p <0.01). GERD-HRQL scores went down significantly after conversion, from a mean of 33.5 preoperatively to 7.2 at 6-month follow-up. These changes were durable over an average of 24 months of follow-up. Similarly, daily PPI usage dropped to pre-sleeve levels, from 90% of patients at time of conversion to 28% at 6 months. 75% of patients were off medication at time of last follow-up. The change in PPI usage and the change in GERD-HRQL from pre- and post-bypass at 6 and 24 months were both significant (p <0.01). There was no significant change in BMI between pre- and post-bypass at any time point (p 0.26).
Conclusions: GERD after sleeve gastrectomy can be severe and not amenable to medical management. We present 21 patients who underwent conversion from SG to RNYGB for severe GERD. Conversion to RNYGB was effective for controlling GERD symptoms, with a significant percentage having improved quality of life and reduction of medication usage, even though conversion to bypass did not result in significant additional weight loss.
Weight and heartburn related outcomes in long term follow up after conversion of SG to RNYGB
| Before SG | At conversion to RNYGB | 6 months after RNYGB | 12 months after | 24 months after | |
| BMI (mean) | 41.2 | 33.3 | 30.4 | 29.9 | 28.2 |
| GERD-HRQL* (mean) | 8 | 33.5 | 7.2 | 21.5 | 17 |
| Daily PPI (%) | 24% | 90% | 28% | 24% | 24% |
*GERD health related quality of life scale
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