Risk of PPI use higher after LSG vs. LRYGB

The risk of initiating and continuing proton pump inhibitors (PPI) treatment was significantly higher after laparoscopic sleeve gastrectomy (LSG), compared with laparoscopic Roux-en-Y gastric bypass (LRYGB), according to a study led by researchers from Zealand University Hospital, Køge, Denmark. They also found continuous increase in the utilisation of PPI was observed after both procedures, but the risk of gastroesophageal reflux disease (GERD) diagnosis was also significantly higher after LSG compared with LRYGB (11% of the patients undergoing a gastroscopy were diagnosed with GERD after LSG vs. with 4% after LRYGB).

The authors noted that in cases of GERD and severe obesity, the European Association of Endoscopic Surgery (EAES) guidelines recommend LSG with sphincter and hiatal repair for moderate cases, while LRYGB is recommended for severe cases. However, the literature shows a notable incidence of de-novo GERD has been reported after bariatric surgery and particularly following LSG. It is hypothesised that the lower risk for GERD after LRYGB is due to reduced intragastric pressure, combined with a smaller gastric reservoir and fewer parietal cells.

Further studies investigating the pathophysiological mechanisms of GERD after LSG, suggest that increased intragastric pressure due to the low-volume and low-compliance sleeve conduit can led to GERD. Additional hypotheses indicate the increased incidence of GERD after LSG include alterations in the oesophageal motility, widening of Hiss angle and the development of hiatal hernia. Despite lifestyle interventions and use of PPI, if GERD persists revisional surgery to LRYGB has proven effective in treating GERD after LSG. Therefore, the researchers sought to evaluate the development in PPI use and secondarily the risk of GERD diagnosis after both LRYGB and LSG.

Outcomes

In total, 17,740 patients were included in the study with 16,069 patients undergoing LRYGB, the median follow-up was 11 years, while the 1,671 patients undergoing LSG were followed for a median of 4 years. At the end of the study, 16,866 (95%) patients were available for follow up. Patients undergoing LRYGB were significantly younger, more likely to smoke, had a higher BMI and had a higher prevalence of type 2 diabetes. A significantly larger proportion of patients undergoing L-SG were preoperatively treated with PPI compared with patients undergoing L-RYGB (6% and 2%, respectively; p<0.0001).

After LSG, 37% of the patients started PPI vs. 21% of the patients undergoing LRYGB. The risk of initiating PPI treatment was significantly elevated (Figure 1) after LSG compared with LRYGB (p<0.0001) and a multivariate Cox regression model adjusted for sex, age, preoperative CCI, preoperative PPI treatment and postoperative occurrence of gastroenteric ulcer, the heightened risk after LSG persisted (95% CI 6.42–7.77).

Figure 1: Risk of (A) starting treatment with proton pump inhibitors and (B) being diagnosed with gastroesophageal reflux disease after laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy. Cumulative hazard (%); Time (years)

In a subgroup analysis including 11,494 patients adjusted for BMI, smoking, marital status, occupational status and educational level, the heightened risk of LSG patients persisted. Additional risk factors for initiation of PPI treatment additionally included female sex, higher age, smoking, higher CCI, unemployment or retirement, preoperative PPI treatment and incidence of postoperative gastroenteral ulcer.

Overall, the PPI use increased following bariatric surgery, with a tendency to increase more prominently after L-SG vs LRYGB and by year seven, the mean use increased from 0.05 to 0.94 DDD after LSG vs from 0.02 to 0.08 DDD after LRYGB (Figure 2). Among patients receiving preoperative PPI treatment, usage decreased from 1.6 DDD preoperatively to 0.3–0.8 DDD postoperatively and remained relatively constant throughout the follow up.

Figure 2: Use of proton pump inhibitors after laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy

Postoperatively, 9,556 gastroscopies were performed among 4,675 (26%) unique patients. Of those undergoing gastroscopy, 5% were diagnosed GERD (1% of the study population). Following LSG, 11% of the patients undergoing a gastroscopy were diagnosed with GERD, compared with 4% after LRYGB. Assessment with 24 h pH measurement was conducted in 74 patients, and 12 were diagnosed with GERD. After LSG, 27% of the patients assessed with 24 h pH measurement were diagnosed with GERD vs. 3% after LRYGB. Revisional procedures were performed in 99 patients, with significantly more LSG patients undergoing revisional surgery (p<0.0001). Five patients underwent anti-reflux surgery which consisted of modified laparoscopic cruroplasty.

“Future research should focus on severe consequences such as Barrett’s oesophagus and evaluation of surgical options for GERD treatment, particularly after LSG,” the authors concluded. “Incorporating patient related outcomes measures would contribute with valuable insights into symptom extent and severity, aiding in the identification of suitable patients for LRYGB and LSG.

The findings were reported in the paper, ‘Use of proton pump inhibitors after laparoscopic gastric bypass and sleeve gastrectomy: a nationwide register-based cohort study’, published in the International Journal of Obesity. To access this paper, please click here