Resolution of Erosive Esophagitis After Conversion from Vertical Sleeve Gastrectomy to Roux-en-Y Gastric Bypass

Abstract

Background: Laparoscopic sleeve gastrectomy (LSG) has become the preferred bariatric procedure in many countries. However, there is one shortcoming of LSG in the long-term follow-up, and this is the onset of gastro-esophageal reflux disease (GERD) and erosive esophagitis (EE). Conversion to Roux-en-Y gastric bypass (RYGB) is considered an option in patients unresponsive to medical therapy. Currently, there is no evidence of EE improvement or resolution after conversion surgery. In this study, we objectively evaluate the effectiveness of RYGB in management of EE with upper endoscopy (EGD) to identify the significant variables in patients with GERD symptoms post LSG refractory to medical therapy and require conversion surgery.

Methods: Over a period of 11 years (2008-2019) at Singapore General Hospital, we retrospectively reviewed a prospectively collected database of a cohort of patients whom had conversion surgery to RYGB for refractory GERD and EE after LSG. Patient's endoscopic findings and demographic and anthropometric data were analyzed.

Results: We identified a total of 14 patients who underwent LSG to RYGB conversions for endoscopic proven erosive esophagitis in our unit during the study period. Eight patients (57.1%) had concurrent hiatal hernia repaired. Nine (64.3%) patients were females. The median age of patients in this cohort was 44 (range 30-61) years. Mean weight and BMI were 87.7 kg (± 19.2) and 32.8 (± 3.09) kg/m2, respectively, on the day of conversion surgery. The median time between LSG and revision to RYGB was 36 (range 6-68) months. Seven patients (50%) had complete resolution of GERD symptoms after conversion, and 6 patients (42.9%) had partial resolution. Six out of 7 patients had complete resolution of EE. There were 4 anastomotic strictures (28.6%). Older patients, Indian ethnicity, present of hiatal hernia and lower weight loss after initial LSG were more likely to undergo conversion surgery.

Conclusion: Conversion to RYGB after LSG is clinically relevant and may be a feasible solution if patients have ongoing GERD refractory to medical therapy. Ninety-three percent of our patients achieved complete resolution of their GERD symptoms and significant improvement of erosive esophagitis with significant weight loss after conversion. This study has important implications as LSG is increasingly being performed and a proportion of these will need revision surgery for various reasons, particularly GERD which is extremely prevalent.

Keywords: Endoscopy; Erosive esophagitis; GERD; Revisional; Roux-e-Y gastric bypass; Sleeve gastrectomy.

Fig. 1

Los Angeles (LA) classification of erosive esophagitis. a Hiatal hernia, b grade A esophagitis, c grade B esophagitis, and d grade C esophagitis

Fig. 2

Hiatal hernia diagnosis is made based on the presence of a diaphragmatic indentation of at least 2 cm distal to the squamocolumnar junction or Z line

Fig. 3

Endoscopic findings of a patient post conversion to RYGB complicated by gastrojejunostomy stenosis. a Preoperative endoscopy, b erosive esophagitis 3 months post LSG, c anastomotic stricture 1 month post conversion to RYGB, d. Resolution of erosive esophagitis 1 month post conversion despite anastomotic stricture, e Patent gastrojejunostomy 2 years post conversion to RYGB with f. No evidence of erosive esophagitis