Postobesity Surgery Esophageal Dysfunction: A Combined Cross-Sectional Prevalence Study and Retrospective Analysis

Abstract

INTRODUCTION: Esophageal dysmotility including features of achalasia may develop because of bariatric surgery. However, the prevalence of these complications is unknown. We sought to define the prevalence of dysphagia and major esophageal motility disorders including achalasia after bariatric surgery through a large retrospective database review. METHODS: Patients with a history of laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass who underwent a diagnostic high-resolution impedance manometry (HRIM) either before or after bariatric surgery across 3 large tertiary referral sites from June 2012 through February 2019 were identified from a procedural database. HRIM studies were interpreted per the Chicago classification v3.0 by a blinded investigator (K.R.). Demographic/clinical features were collected. In addition, patients who underwent bariatric surgery from January 2014 to April 2015 were contacted and administered a validated symptom assessment survey to gauge the overall prevalence of dysphagia in a postbariatric population. RESULTS: A total of 137 patients were identified, including 97 who underwent HRIM after bariatric surgery (laparoscopic sleeve gastrectomy [n = 39, 40.1%]; Roux-en-Y gastric bypass [n = 58, 59.8%]) at a median of 5.84 years (interquartile range 2.1–12.5) postoperatively and 40 preoperative bariatric surgery candidates with medically complicated obesity. A manometric pattern consistent with achalasia was identified in 7 (7.2%) postsurgical patients compared with none in the preoperative group (P = 0.08). We further identified a separate achalasia-like pattern defined by aperistalsis and increased intragastric pressure (postobesity surgery esophageal dysfunction [POSED]) in 5 (5.2%) postsurgical patients vs none found preoperatively (P = 0.14). Achalasia or POSED was associated with postbariatric surgery (12.4% vs 0%, P = 0.02). Increasing time since surgery was independently associated with the development of achalasia (median 12.5 vs 5.8 years, P = 0.02), POSED (median 15.0 vs 5.8 years, P = 0.02) and major motility disorders (6.6 vs 4.9 years, P = 0.01). Furthermore, among 271 postbariatric surgery patients contacted for symptom assessment via survey, the prevalence of dysphagia was 13.7% at a mean 3.9 years after surgery. DISCUSSION: Postoperative dysphagia is a common long-term complication of bariatric surgery. This is potentially the consequence of a time-dependent association with the development of postoperative esophageal dysmotility, particularly achalasia and POSED. Consequently, esophageal dysmotility may be an important under-recognized complication of bariatric surgery.

Esophageal Motility Disorders: Current Approach to Diagnostics and Therapeutics

“…Dysphagia has been reported in 51% of patients after laparoscopic sleeve gastrectomy and 46% of patients after Roux-en-Y gastric bypass. 146 In a recent study of 97 patients who underwent high resolution impedance manometry (HRIM) after bariatric surgery, 61.5% had manometric abnormalities per CC v3.0 with 29.9% of them being major motility disorders (achalasia, EGJOO, DES, and jackhammer). 146 The remaining had ineffective esophageal motility.…”

“…146 In a recent study of 97 patients who underwent high resolution impedance manometry (HRIM) after bariatric surgery, 61.5% had manometric abnormalities per CC v3.0 with 29.9% of them being major motility disorders (achalasia, EGJOO, DES, and jackhammer). 146 The remaining had ineffective esophageal motility. They also found that 5.2% had a unique achalasialike pattern defined by aperistalsis and increased intragastric pressure, which was defined as postobesity surgery esophageal dysfunction.…”

“…Hence, secondary esophageal dysmotility may be an under-recognized complication of bariatric surgery because up to 13.7% of patients continued to have dysphagia at a mean of 3.9 years after surgery. 146 Treatment in this group of patients should be focused toward assessment of the gastric pouch, sleeve, and/or anastomosis and improving any source of mechanical or functional outflow obstruction.…”

The Impact of Bariatric Procedures on Esophageal Motility

“…Esophageal body motility is mostly unaffected by RYGB according to most series. 20,36,41-43 Miller et al 46 showed an almost 9% incidence of achalasia after RYGB. This high incidence, however, may be biased, as manometry was performed in symptomatic patients only.…”

“…There is ample literature on sleeve gastrectomy and motility, since it is considered a bariatric operation that may cause GERD, with an incidence of persistent postoperative GERD in 19% and de novo reflux in another 23%. According to a recent metanalysis, de novo GERD may even be as high as 50% in post-sleeve patients according to a recent metanalysis, 46 but that may reach 50%. 1 The effects of sleeve gastrectomy on GERD pathophysiology are: (1) the angle of His may be disrupted during the creation of a narrow gastric tube; (2) the LES frequently becomes hypotensive owing to the resection of sling fibers; (3) gastric emptying may be accelerated or delayed; and (4) the population of parietal cells is decreased.…”