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GAS-BLOAT SYMPTOMS AFTER ANTIREFLUX SURGERY: ASSESSMENT OF THE CLINICAL UTILITY OF SMALL INTESTINAL BACTERIAL OVERGROWTH (SIBO) TESTING RESULTS IN GUIDING POSTOPERATIVE MANAGEMENT.
Inanc Sarici
*1,3, Sven Eriksson
1,3, Kelsi J. Swanson
1, Sarah Scott
1, Ann M. DeWitt
1, Ping Zheng
1, Shahin Ayazi
1,3,21Foregut Division, Surgical Institute, Allegheny Health Network, Pittsburgh, PA; 2Department of Surgery, Drexel University, Philadelphia, PA; 3Chevalier Jackson Research Fellowship, Esophageal Institute, Western Pennsylvania Hospital, Allegheny Health Network, Pittsburgh, PA
Introduction: Gas-bloat symptoms following antireflux surgery (ARS) are frequently reported and are generally presumed to result from impaired gas venting due to surgical alteration. However, small intestinal bacterial overgrowth (SIBO), a microbiome dysbiosis potentially linked to chronic PPI use may also contribute to these symptoms. Despite this, there is a paucity of data regarding the impact of SIBO testing and management on clinical outcomes in patients with gas-bloat symptoms after ARS. The aim of this study is to evaluate the clinical utility of SIBO testing in patients with persistent gas-bloat symptoms following ARS.
Methods: A cohort of patients who underwent primary antireflux surgery at our center and complained of persistent postoperative gas-bloat symptoms were offered SIBO hydrogen and methane breath testing and gastric emptying scintigraphy. Patients who completed postoperative SIBO testing and had no evidence of delayed gastric emptying were included. A score ?4 on the gas-bloat-specific question of the GERD-Health-Related Quality of Life (GERD-HRQL) questionnaire was considered severe. Gas-bloat and satisfaction rates were compared between the SIBO-positive and SIBO-negative patients after surgery. SIBO-positive patients were then treated with antibiotics and all patients were reassessed.
Results: The study population consisted of 71 patients who presented with gas-bloat symptoms 19.2 (21.2) months after ARS. Mean (SD) age was 57.7(14); 81.7% were female. GERD-HRQL score was 10.1(14) with 40.8% satisfaction and 82.9% freedom from PPIs. A total of 40 (56.3%) patients were SIBO positive. Gas-bloat symptoms were worse in SIBO-positive patients as shown in
Figure 1, with severe gas-bloat (77.5% vs. 41.9%, p=0.003) being more common. However, there were no differences in GERD-HRQL total scores (p=0.815), freedom from PPIs (p=0.750) or patient satisfaction (p=0.811).
Antibiosis for SIBO was most frequently neomycin and rifaximin (77.5%) followed by cephalexin and metronidazole (12.8%). After treatment, gas-bloat symptoms improved (
Figure 1), debilitating gas-bloat dropped from 77.5% to 23.1% (p<0.001) and satisfaction improved from 42.5% to 69.2% (p=0.016). Compared to SIBO-negative patients, SIBO-positive patients had more severe gas-bloat before antibiotics (77.5% vs. 41.9%, p=0.003), but this difference was eliminated after treatment (p=0.427).
Conclusion: SIBO testing identified a clinically distinct group of patients with gas-bloat symptoms after ARS. These patients had more severe symptoms than SIBO-negative patients; however, symptom severity and patient satisfaction markedly improved following antibiotic treatment. These findings suggest SIBO testing and treatment can guide management of persistent gas-bloat symptoms and improve outcomes after ARS.
Among patients with gas-bloat symptoms after antireflux surgery, those who tested positive for SIBO had significantly more severe gas-bloat [median (IQR) 4.0 (4-5) vs 3.0 (2-4) p=0.0002]. Following antibiotic treatment of SIBO, gas-bloat severity significantly improved to 2.0 (1-3), p=0.001.
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