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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 46  |  Issue : 4  |  Page : 245-248

Pediatric and adolescent new-onset gastroesophageal reflux after laparoscopic sleeve gastrectomy


Department of General Surgery, Faculty of Medicine, Tanta University, Tanta, Egypt

Date of Submission23-Aug-2017
Date of Acceptance01-Dec-2017
Date of Web Publication02-Aug-2019

Correspondence Address:
MSc Amir I AboMostafa
Elatawah Elkebliah, Qutour, Gharbiah
Egypt
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DOI: 10.4103/tmj.tmj_78_17

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  Abstract 


Background Sleeve gastrectomy has gained popularity since then as a definitive bariatric surgical procedure due to low-morbidity and mortality rates and short operation and hospitalization times.
Aim The aim of this retrospective study is to evaluate the incidence of new-onset gastroesophageal reflux in pediatric and adolescent morbidly obese patients following a standardized laparoscopic sleeve gastrectomy (LSG) and to revise our option plans.
Patients and methods Files of all operated morbidly obese pediatric and adolescent patients less than or equal to 20 years of age who underwent standardized LSG by a single surgeon in the Pediatric Surgery Unit, Surgery Department, Tanta University Hospital between January 2013 and December 2016 were retrospectively reviewed.
Results The incidence of new-onset gastroesophageal reflux disease after LSG in our study (5.65–16.67%).
Conclusion The incidence of new-onset gastroesophageal reflux disease after LSG in our study is small but deserves attention.

Keywords: laparoscopic sleeve gastrectomy, new-onset gastroesophageal reflux, pediatric


How to cite this article:
AboMostafa AI, El Attar AA, Mohamed AE, Shalaby MM, Atteyia MA. Pediatric and adolescent new-onset gastroesophageal reflux after laparoscopic sleeve gastrectomy. Tanta Med J 2018;46:245-8

How to cite this URL:
AboMostafa AI, El Attar AA, Mohamed AE, Shalaby MM, Atteyia MA. Pediatric and adolescent new-onset gastroesophageal reflux after laparoscopic sleeve gastrectomy. Tanta Med J [serial online] 2018 [cited 2020 Feb 29];46:245-8. Available from: http://www.tdj.eg.net/text.asp?2018/46/4/245/263921




  Introduction Top


Obesity-related comorbidities including type 2 diabetes mellitus, hypertension, dyslipidemia, coronary artery disease, certain types of cancer, and gastroesophageal reflux disease (GERD) develop in obese patients [1],[2],[3],[4],[5].

Sleeve gastrectomy (SG) was initially considered a purely restrictive weight-loss procedure but there is evidence that alteration in gastrointestinal hormones plays a role [6], the effect of SG on pre-existing GERD in obese patients is controversial and even more controversial is the incidence of new-onset GERD after SG, which has been reported in various studies [7].

Currently, evidence of the effect of SG on GERD is inconsistent. No clear data exist in the pediatric and adolescent age groups.


  Patients and methods Top


Patients

After approval from the Human Research Ethics Committee Tanta Faculty of Medicine, the files of morbidly obese patients who underwent standardized laparoscopic sleeve gastrectomy (LSG) by a single surgeon in the Pediatric Surgery Unit, Surgery Department, Tanta University Hospital between January 2013 and December 2016 were retrospectively reviewed.

Inclusion criteria

The study included all operated morbidly obese pediatric and adolescent patients less than or equal to 20 years of age.

Exclusion criteria

Patients who had evidence of preoperative gastrointestinal reflux disease (GERD), long-term antireflux medications and/or hiatus hernia were excluded from this study. Other exclusion criteria included previous gastric surgery, patients with antireflux procedure added to the standardized LSG and patients who were converted to open surgery or who had a complicated postoperative course.

Preoperative data

A meticulous search for GERD symptomatology (typical symptoms such as heartburn, regurgitation and dysphagia or atypical symptoms such as chronic cough, chest pain) in all candidates was done and all patients with a GERD score more than or equal to 4 (will be discussed later) were excluded.

Follow-up

Data from early postoperative visits at the first, third, and sixth months were reviewed for patients’ weight, BMI, and excess weight loss percentage (%EWL).

As a protocol, all cases were instructed to stay on proton pump inhibitors (PPI) for 3 months, the new-onset (de-novo) GERD symptoms could only be assessed after cessation of PPI therapy, which was designed to be 1 week prior to the follow-up visit at the third month, new-onset (de-novo) GERD after LSG was evaluated by one of the surgeons, who filled in a standard questionnaire for every patient at the third, and if symptoms persisted at the sixth month follow-up visit. He recorded the presence and severity of the following six symptoms (heartburn, regurgitation, epigastric fullness, epigastric or chest pain, dysphagia, and chronic cough), the severity of each symptom was scored from 0 to 3, where grade 0=no symptoms, grade 1=mild symptoms with spontaneous remission, grade 2=moderate symptoms with spontaneous, but slow remission and mild interference with normal activity and sleep, and grade 3=severe symptoms without spontaneous remission and marked interference with normal activity and sleep, the frequency of symptoms was scored from 0 to 3 where grade 0=absent symptom, grade 1=occasional (˂2 days per week), grade 2=frequent (2–4 days per week), and grade 3=very frequent (>4 days per week), and the final score for each symptom was obtained by multiplying the scores for severity and frequency. The total GERD score was obtained by adding the final scores of individual symptoms and noted as GERD score or severity score [8].

A GERD score more than or equal to 4 was considered positive for GERD. Those patients were continued on PPI for 3 further months and were reassessed again at the sixth month follow-up visit, patients whose symptoms resolved were followed up, and those who had high GERD scores (≥4) or persistent reflux symptoms of sufficient severity, further management plans (whether medical or surgical) were considered. The GERD resolution was considered when the patient was able to stop reflux medications post-LSG and remained symptom free (symptom disappearance without PPI), while the GERD improvement was considered when symptoms decreased or disappeared with lower PPI doses.

Statistical analysis

Statistical analysis of our data was performed through calculation of the mean, SD, or performing the analysis of variance and χ2 tests by using the SPSS packs (UK), version 20.


  Results Top


From January 2013 to December 2016, the data of 18 out of 21 patients who underwent LSG, in our Pediatric Surgical Unit, Surgery Department, Tanta University Hospital, fulfilled our inclusion criteria. The other three patients were excluded; one due to leakage and the other two due to presence of reflux esophagitis. Surgery was performed by the same surgeon.

Our study included 18 patients: six (33.33%) males and 12 (66.67%) females, with a male to female ratio of 1 : 2; the age of our patients ranged between 13 and 20 years with a mean±SD age of 17.5±2.47 years.

Preoperatively, two (11.11%) patients had GERD symptoms with a score above 4; one patient suffered heartburn and another patient suffered regurgitation. Findings of the preoperative upper gastrointestinal tract endoscopy in both patients showed the presence of antral gastritis and severe reflux esophagitis, so both cases were excluded from the study. None of the included patients experienced atypical symptoms such as dysphagia, chest pain, epigastric pain, or fullness.

Three months post-LSG, from an initial mean±SD of 139.39±25.84 kg, the weight ranged between 83 and 141 kg with a mean±SD of 116.2±16.8 kg. At the sixth month, the weight ranged between 74 and 120 kg with a mean±SD of 100.3±13.2 kg. The reduction in mean body weight (MBW) at 3 months was found to be statistically significant when compared with the preoperative MBW (P<0.001). Also, the reduction in MBW at 6 months was found to be statistically significant when compared with the initial and 3 months’ MBW (P<0.001) ([Table 1]).
Table 1 Weight, BMI, and excess weight loss percentage changes at 3 and 6 months postoperatively

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Our data showed that from a preoperative BMI range between 42.2 and 62.7 kg/m2, with a mean±SD of 53.1±5.9 kg/m2, this was reduced at 3 months postoperatively to range between 36.9 and 49.8 kg/m2 with a mean±SD of 44.4±3.5 kg/m2. At 6 months, it ranged between 32.9 and 42.4 kg/m2 with a mean±SD of 38.4±2.85 kg/m2. The reduction in BMI at 3 months was found to be statistically significant when compared with the preoperative BMI (P<0.001). Also, the reduction in BMI at 6 months was found to be statistically significant when compared with the initial and 3 months’ BMI (P<0.001) ([Table 1]).

Also, our data showed that the postoperative %EWL at the third month ranged between 18.6 and 44.6% with a mean±SD of 30.2±7.7. The %EWL ranged between 38.7 and 66.9%, with a mean±SD of 51.7±8.2 at the sixth month post-LSG. The increase in %EWL at 6 months was found to be statistically significant when compared the third month values (P<0.001) ([Table 1]).

As all patients were required to stay on oral PPI for the first 3 months postoperatively, assessment of the occurrence of de-novo GERD symptoms was only possible after cessation of PPIs. The patients were instructed to stop them 1 week prior to their third month follow-up appointment. Three (16.67%) of our patients developed new-onset GERD symptoms that were severe enough to interfere with their normal activity and sleep with GERD score 8.

The three patients were instructed to continue on oral PPI for the next 3 months. Before the sixth month, the patients were instructed to stop the PPI therapy 1 week prior to the follow-up appointment. Complete regression of GERD symptoms occurred in two patients. They were able to stop the antireflux medications and remained symptom free. In the third patient (5.56%), discontinuation of PPI caused a rebound in reflux symptoms. In our study, de-novo GERD incidence was 16.67% at the third postoperative month. Persistent de-novo symptoms were in 5.56% by the sixth postoperative month. This incidence was found to be statistically nonsignificant (P>0.05) ([Table 2]).
Table 2 Incidence of de-novo gastroesophageal reflux disease at 3 and 6 months after laparoscopic sleeve gastrectomy

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  Discussion Top


Diagnosis of GERD is usually based on symptoms, as in the regular clinical practice, but several tests can aid the diagnosis of GERD, such as the 24-h pH study, upper gastrointestinal endoscopy, and manometry.

Our study was conducted to assess the incidence of new-onset GERD after LSG and included 18 patients. Their ages ranged between 13 and 20 years, with a mean of 17.5 years. In the pediatric age group, especially in our region, cultural issues, traditions and the limited physical exercise allowed for young women contribute to this higher incidence. This has also been documented in similar studies in our region, as this performed on a younger age group from 5 to 21 years, at King Saud University Hospitals, Riyadh, Saudi Arabia [9].

Women constituted the majority of our patients. The study included 12 (66.67%) women and six (33.33%) men, with a female to male ratio of 2 : 1. The female ratio varies in the various studies. Casella et al. [10] reported a female to male ratio of 2.1 : 1 in his study on 182 patients. Nocca et al. [11], reported a female to male ratio of 1.1 : 1 in his study on 25 patients.

In our study, the incidence of de-novo GERD was 16.67% at 3 months and 5.56% at 6 months postoperatively. It must be noted that 66.67% of the de-novo GERD at the third month resolved by the sixth month post-LSG. None of our patients had preoperative documented GERD, hiatus hernias, anatomical predisposing factors postoperatively as large fundus or twists or narrowing and none of the included cases were complicated or had stent insertion. There are few other studies which focused on the de-novo GERD. Weiner et al. [12] encountered few patients (2%), with de-novo GERD following LSG. The decreased rate in his work is explained by the attention to resolute GERD and its predisposing factors in his patients prior to surgery. Nocca et al. [11] demonstrated a 5.7% increase in GERD prevalence after LSG. Howard et al. [13] demonstrated a 14% increase with a mean follow-up time of 32 weeks.

On the other hand, many other studies showed improved incidence of GERD postoperatively, especially in patients who suffered from GERD before surgery. Daes et al. [14] reported a very low incidence of 1.5% GERD in a series of 234 patients. He insisted that by detecting and systematically repairing hiatus defect and by careful attention to surgical technique, avoiding torsion or narrowing of the sleeve, all will improve the incidence of postoperative GERD. Also, in a prospective study of Melissas et al. [15], they reported a 5% decrease in GERD prevalence after LSG.

Although, our study is one of very few conducted in the pediatric and adolescent age groups and despite our ability to collect data from all patients even by phone, one of the strong limitations of our study is the short term of follow up of our patients. Follow up for only 6 months is not a sufficient period to judge the final incidence of new-onset GERD.

In addition to the short follow-up span, our study has several other limitations. Its retrospective and the subjective design prevented the addition of useful tools such as postoperative endoscopy, pH, and motility studies. The initial small number of the included patients and the strict exclusion criteria prevented adding further arms to the study and limited our ability to analyze any subgroups or adding different arms of management.


  Conclusion Top


LSG is a safe procedure in the pediatric age group, it achieves excellent weight loss, even on the short term, and has a profound effect in improving all the obesity-related comorbidities, the incidence of new-onset GERD after LSG in our study (5.65–16.67%) is small but deserves attention, although most of the new-onset GERD can be improved by medication, yet a small proportion might get benefit from the surgical options, although our study is one of very few conducted in the pediatric and adolescent age groups.

The small number of our series, the short follow-up span, as well as our other limitation precluded subgroup analysis and surgical arm trials. So further larger and more objective studies are still warranted to document the relation between GERD and LSG in the pediatric age group.

Recommendation

We recommend to avoid the following: twisting of the sleeve, narrowing at the junction of the vertical and horizontal parts of the sleeve, and dilation of the fundus.

Acknowledgements

The authors acknowledge the participants who have helped during this study

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Sharma A, Aggarwal S, Ahuja V, Bal C. Evaluation of gastro esophageal reflux before and after sleeve gastrectomy using symptom scoring, scintigraphy, and endoscopy. Surg Obes Relat Dis 2014; 10:600–605.  Back to cited text no. 8
    
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Alqahtani AR, Antonisamy B, Alamri H, Elahmedi M, Zimmerman VA. Laparoscopic sleeve gastrectomy in 108 obese children and adolescents aged 5 to 21 years. Ann Surg 2012; 00:1–8.  Back to cited text no. 9
    
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Nocca D, Skalli EM, Boulay E, Nedelcu M, Michel Fabre J, Loureiro M. The Nissen Sleeve (N-Sleeve) operation: preliminary results of a pilot study. Surg Obes Relat Dis 2016; 12:1832–1837.  Back to cited text no. 11
    
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Weiner RA, Weiner S, Pomhoff I, Jacobi C, Makarewicz W, Weigand G. Laparoscopic sleeve gastrectomy—influence of sleeve size and resected gastric volume. Obes Surg 2007; 17:1297–1305.  Back to cited text no. 12
    
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Howard DD, Caban AM, Cendan JC, Ben-David K. Gastroesophageal reflux after sleeve gastrectomy in morbidly obese patients. Surg Obes Relat Dis 2011; 7:709–713.  Back to cited text no. 13
    
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Daes J, Jimenez ME, Said N, Daza JC, Dennis R. Laparoscopic sleeve gastrectomy: symptoms of gastro esophageal reflux can be reduced by changes in surgical technique. Obes Surg 2012; 22:1874–1879.  Back to cited text no. 14
    
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Melissas J, Daskalakis M, Koukouraki S, Askoxylakis I, Metaxari M, Dimitriadis E et al. Sleeve gastrectomy-a ‘food limiting‘ operation. Obes Surg 2008; 18:1251–1256.  Back to cited text no. 15
    



 
 
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