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JAMA Network Insights
December 2018

Gastroesophageal Reflux After Sleeve Gastrectomy

Author Affiliations
  • 1Department of Medicine and Surgery, University of North Carolina at Chapel Hill
  • 2Department of Surgery, Hospital Alemán of Buenos Aires, University of Buenos Aires, Argentina
JAMA Surg. 2018;153(12):1147-1148. doi:10.1001/jamasurg.2018.2437

In a recent Research Letter published in JAMA, Hales and colleagues1 describe the trends based on National Health and Nutrition Examination Survey data between 2007 and 2016 of obesity and severe obesity in the United States. Their results showed that although the prevalence did not increase significantly among youth (2-19 years old, from 16.8% to 19.8%), it escalated among adults (20 years or older). Specifically, the prevalence increased from 33.7% to 39.6%, particularly among women and among individuals 40 years or older. This is a particularly worrisome trend because obesity is associated with comorbid conditions, such as diabetes and hypertension, and with decreased life expectancy. Those data suggest that the problem is getting worse and that lifestyle changes such as dieting and exercising among individuals with obesity represent the exception rather than the rule. Therefore, until an effective pharmacologic treatment is available, bariatric surgery is the only viable treatment for many.

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1 Comment for this article
Samer Mattar, FACS | Swedish Medical Center
Dear Professor Patti,

I read with interest your piece in JAMA Highlights, but came away somewhat disappointed with the rather biased and preconceived conclusions that you make.

You make a strong case for avoiding offering Sleeve gastrectomy (SG) to patients with pre-existing GERD for the presumed risk of further increasing the severity of this disease.

While you make a good point that the commonest indication for re-operations after SG is the treatment of either persistent or de novo GERD, you do not mention the actual incidence of such re-operations. MBSAQIP is collecting more granular information
regarding the nature of revision surgery, and hopefully we should be able to more accurately gauge the actual incidence of revisional surgery for post-SG GERD, but my intuitive estimation is that this is a low number, far lower than revisional surgery for other bariatric operations.

As you eloquently describe in your piece, the causes of GERD in the obese patient are multifactorial, and you emphasize the role of the transdiaphragmatic pressure gradient, as well as that of increased abdominal pressure, in addition to the negative thoracic pressure, particularly when obstructive sleep apnea is present. As we know, all these factors dramatically improve, even resolve, with the signficant weight loss and the reversal of inflammatory status that is achieved after SG, probably accounting for the non-arrival of the anticipated tidal wave of GERD-related revisions after SG.

You do reference Genco's paper on the alarming inciodence of Barrett's epithelium, yet this article does carry several deficiencies, such as the fact that histological exainations were not corroborated by a second pathologist. Moreover, there is no accurate description of the exact locations of the biopsy sites, or whether the examined patients may have had hiatal hernias. And frankly, if a BE incidence of 17% was indeed an accurate assessment, we would have been inundated with alarm bells ringing from endoscopy suites across the country.

While gastric bypass (GB) is an excellent bariatric/metabolic operation, it is not entirely benign. You have mentioned its association with life-threatening internal hernias, but there is also a 3% - 5% incidence of marginal ulcers and their consequences, to which SG patients are mostly immune. This has an important bearing when selecting the optimal operation for patients, particularly in a population burdened by a high incidence of degenerative joint disease who rely on NSAIDs for relief from pain and inflammation.

I do agree that we should closely follow all bariatric patients, particlarly with regards to GERD-related problems, but suggest that we be less stringent with the broad, blanket classification of GERD being a contraindication to SG. More data is warranted before such conclusions are made.