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BOMSS 2013

Reflux is no barrier to sleeve gastrectomy

Simon Gibson presenting at BOMSS 2013
Sleeve gastrectomy improves symptoms of GORD in moderate to severe cases
Tight sleeve and agressive treatment of hiatal defects key to effective treatment

Gastro-oesophageal reflux disease (GORD) should not be considered a contraindication for sleeve gastrectomy, and is in fact improved by the operation in moderate to severe cases, according to research presented at the British Obesity and Metabolic Surgery Society’s meeting in Glasgow, Scotland.

Mr Simon Gibson, of University Hospital, Kilmarnock, UK, said that while patients in his study with mild GORD saw a small increase in their symptoms, those with more severe symptomatology experienced a significant decrease in the frequency and severity of their heartburn, particularly if a hiatal repair was performed.

Gibson’s study was informed by his experience of working in Australia, where, he said, sleeve gastrectomy is fast becoming the most popular operation, irrespective of comorbidities. Conversely, many units in the UK preclude patients from sleeve gastrectomy if the patient has GORD, preferring to recommend gastric bypass.

He said that the Australian consultants he worked with had a “very aggressive” attitude to hiatal management, performing a hiatal tightening if any defect whatsoever was discovered, or a hiatal hernia repair if necessary.

Out of the 268 patients included in the study, Gibson said that only 35% had no hiatal defect whatsoever. Thirty seven percent required hiatal tightening, and 28% needed hiatal hernia repair.

“We were interfering in quite a lot of the patients,” he said.

The study used a scoring system to measure the frequency and severity of the patients’ heartburn on a scale from 1 (never) to 4 (daily). When the study group was taken as a whole, the mean score for heartburn frequency dropped from 2.5 to 2.2 (p=0.035), and severity from 1.9 to 1.6 (p=0.017), 17 months after surgery.

However, when the patients were subdivided by the method by which they were treated, the results differed. Those who required a hiatal repair during the operation had previously reported a mean reflux severity score of 2.2, higher than the average score of 1.95 in those who required a hiatal suture, and 1.45 in those who did not require any kind of treatment.

After surgery, the average reported heartburn severity scores of both the group of patients who required hiatal repair and the group of patients who required suturing dropped significantly, to 1.85 and 1.65, respectively. The average severity score group that did not require hiatal treatment trended upwards, but not significantly so.

Gibson noted that across the board, the effect of the various treatments on heartburn frequency mirrored that for heartburn severity closely.

To establish the effect of the operation on patients with different preoperative levels of GORD, the study divided the group by their Visick scores, which range from one (no symptoms) to four (severe or daily symptoms requiring vigorous medical treatment or procedure).

Those who had a Visick score of three or four saw a dramatic drop in their mean reflux severity score, regardless of whether they needed a suture, hiatal repair, or no hiatus treatment at all. Conversely, those who had a Visick score of one or two saw a trend towards increased reflux severity, although this was only significant in the patients who did not undergo hiatal treatment.

Gibson concluded that in general, GORD symptoms improve for patients undergoing a sleeve gastrectomy, particularly if a tight sleeve was created (he used a 29F bougie) and if hiatal defects were routinely repaired. However, he said that patients with no or minimal amounts of reflux should be warned that they would be likely to experience a slight worsening of their symptoms post-surgery.

Gibson conducted his research with Dr Alison Lyon and Dr David Martin, of Concord Hospital, Australia, and Ms Katie De-Loyde, SOURCE Research Unit, Australia.

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