Esophageal Functional Disorders in the Pre-Operatory Evaluation of Bariatric Surgery

Abstract

BACKGROUND: Obesity is an independent risk factor for esophageal symptoms, gastroesophageal reflux disease (GERD), and motor abnormalities. When contemplating bariatric surgery, patients with obesity type III undergo esophagogastroduodenoscopy (EGD) and also esophageal manometry (EMN), and prolonged pHmetry (PHM) as part of their pre-operative evaluation. OBJECTIVE: Description of endoscopy, manometry and pHmetry findings in patients with obesity type III preparing for bariatric surgery, and correlation of these findings with the presence of typical GERD symptoms. METHODS: Retrospective study in which clinical symptoms of GERD were assessed, focusing on the presence of heartburn and regurgitation. All patients underwent EMN, PHM and most of them EGD. RESULTS: 114 patients (93 females-81%), average age 36 years old, average BMI of 45.3, were studied. Typical GERD symptoms were referred by 43 (38%) patients while 71 (62%) were asymptomatic. Eighty two patients (72% of total) underwent EGD and 36 (42%) evidenced esophageal abnormalities. Among the abnormal findings, hiatal hernia was seen in 36%, erosive esophagitis (EE) in 36%, and HH+EE in 28%. An abnormal EMN was recorded in 51/114 patients (45%). The main abnormality was a hypotensive lower esophageal sphincter (LES) in 32%, followed by ineffective esophageal motility in 25%, nutcracker esophagus in 19%, IEM + hypotensive LES in 10%, intra-thoracic LES (6%), hypertensive LES (4%), aperistalsis (2%) and achalasia (2%). Among the 43 symptomatic patients, 23 (53%) had abnormal EMN and 31/71 asymptomatic cases (44%) also presented this finding (P=0.30). PHM showed abnormal reflux in 60/114 patients (53%), with a predominance of bi-positional reflux (42%), followed by supine reflux (33%) and upright reflux (25%). Abnormal PHM was found in 26/43 symptomatic cases (60%) and also among 34/71 asymptomatic cases (48%) (P=0.19). CONCLUSION: Manometric abnormalities were common in obesity type III patients, the most frequent being hypotensive LES, followed by IEM. Most patients were asymptomatic. There was no correlation between the finding of motor abnormalities and the presence of symptoms. More than half the patients had abnormal reflux at PHM. We found no significant correlation between abnormal reflux and the presence of symptoms.

Esophageal Manometry and pHmetry Profile in Obese Patients Selected for Bariatric Surgery

“…10,11 GERD symptoms were present in less than half (43.3%) of patients undergoing bariatric surgery. This percentage is similar to the one found by Lemme et al 12 (38%). but other studies report percentages as high as 62.5%.…”

“…Few studies assess manometric changes in patients subjected to bariatric surgery. The average LES pressure registered by Mora et al 12 in a 224 patients population (Table 4) with a mean BMI of 50.2 was higher (16 mmHg) than the mean encountered in the present study (9.79 ± 0.33 mmHg). Although esophageal dysmotility was found in 22.7% of our population (Table 5), other studies have reported a prevalence ranging between 33.4% and 66.1%.…”

Prevalence and Pathophysiology of Gastroesophageal Reflux Disease According to the Lyon Consensus in Patients With Morbid Obesity

“…Our results confirm an important GERD prevalence of 21.6% among people with MO who are bariatric surgery candidates, a prevalence that can reach 29.4% if AET is taken into account together with the number of reflux episodes and MNBI. There are only a few prevalence studies based on pHmetric findings on patients with obesity, the most recent of which identify a GERD prevalence in MO around 35% taking into account the Lyon Consensus [30], or 52%-67% [31][32][33] with less strict AET cut-off points. However, there are no population studies on GERD prevalence based on pHmetric findings.…”