Once in a Bile - the Incidence of Bile Reflux Post-Bariatric Surgery

Abstract

Purpose: Excellent metabolic improvement following one anastomosis gastric bypass (OAGB) remains compromised by the risk of esophageal bile reflux and theoretical carcinogenic potential. No 'gold standard' investigation exists for esophageal bile reflux, with diverse methods employed in the few studies evaluating it post-obesity surgery. As such, data on the incidence and severity of esophageal bile reflux is limited, with comparative studies lacking. This study aims to use specifically tailored biliary scintigraphy and upper gastrointestinal endoscopy protocols to evaluate esophageal bile reflux after OAGB, sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB).

Methods: Fifty-eight participants underwent OAGB (20), SG (15) or RYGB (23) between November 2018 and July 2020. Pre-operative reflux symptom assessment and gastroscopy were performed and repeated post-operatively at 6 months along with biliary scintigraphy.

Results: Gastric reflux of bile was identified by biliary scintigraphy in 14 OAGB (70%), one RYGB (5%) and four SG participants (31%), with a mean of 2.9% (SD 1.5) reflux (% of total radioactivity). One participant (OAGB) demonstrated esophageal bile reflux. De novo macro- or microscopic gastroesophagitis occurred in 11 OAGB (58%), 8 SG (57%) and 7 RYGB (30%) participants. Thirteen participants had worsened reflux symptoms post-operatively (OAGB, 4; SG, 7; RYGB, 2). Scintigraphic esophageal bile reflux bore no statistical association with de novo gastroesophagitis or reflux symptoms.

Conclusion: Despite high incidence of gastric bile reflux post-OAGB, esophageal bile reflux is rare. With scarce literature of tumour development post-OAGB, frequent low-volume gastric bile reflux likely bears little clinical consequence; however, longer-term studies are needed.

Clinical trial registry: Australian New Zealand Clinical Trials Registry number ACTRN12618000806268.

Keywords: Bile reflux; One anastomosis gastric bypass; Roux-en-Y gastric bypass; Sleeve gastrectomy.

Fig. 1

Participant inclusion flowchart. (BMI, body mass index; HIDA, hepatobiliary iminodiacetic acid scintigraphy; UGIE, upper gastrointestinal endoscopy)

Fig. 2

Results from GerdQ questionnaire, by category

Fig. 3

a Scintigraphic image showing reflux into gastric pouch (red circle) and oesophagus (blue circle). b and d: coronal (b), sagittal (c) and axial (d)-fused CT images, confirming localisation of reflux in the gastric pouch (red circle)