Radiologic, Endoscopic and Functional Patterns in Patients with Symptomatic Gastroesophageal Reflux Disease after Roux-en-Y Gastric Bypass

Introduction:

Roux-en-Y gastric Bypass (RYGB) is considered as gold standard in treatment of morbid obesity and Gastroesophageal Reflux Disease (GERD). Resolution of GERD-Symptoms is reported to be around 85-90%. So far, data on evaluation for persistent GERD after RYGB is scarce.



Methods:

Data of patients evaluated for persistent GERD with a history of RYGB between 01/12 and 12/15 were reviewed. GERD was assessed with questionnaires, endoscopy, 24h-pH-impendance-manometry and barium swallow.



Results:

Of 39 patients, 34(87.2%) presented with typical GERD, 16(41%) with obstructive, 7(17.9%) with pulmonary symptoms and 15(38.5%) with pain. All patients were on at least daily PPI. The interval between RYGB and evaluation was a median 3.9 years (min 0.8 – max 12.6), the median patient age was 26.2 years (19.1-65.3). Median percentage of Excessive Body Mass Index Loss was 72.8% (27.4 - 123.8)

Gastro-gastric fistulae were seen in 2(5.1%) and hiatal herniae in 16 patients(41%); the gastric pouch was deemed too big in 3 (7.7%). Nine(23%) had esophagitis >LA grade B. PH-Manometry data was available from 37 patients(94.8%). Of those, 15 patients(40.5%) had esophageal hypomotility, a hypotensive lower esophageal sphincter (LES )was seen in 12 patients(32.4%). Increased esophageal acid exposure (>4% pH<4) was found in 6 patients (16.2%), an increased number of reflux episodes (>40) in 17 patients(46%), of which 13 patients(76.5%) had a positive symptom association. Symptoms were diagnosed as functional in 6 patients (15.4%).



Conclusion:

The evaluation for persistent GERD after RYGB revealed a high percentage of hiatal herniae, hypotensive LES and other esophageal motility disorders. These findings might have an influence on hiatal hernia closure concomitant to RYGB and the role of pH-manometry in the preoperative bariatric assessment.