Gastroesophageal reflux disease, obesity and laparoscopic sleeve gastrectomy: The burning questions

Table 1 Prospective studies on the prevalence of erosive esophagitis in obese patients

Publication	Year	Number of subjects	Prevalence of EE (%)	Comments
Verset et al[18]	1997	147	30.6	High incidence of peptic lesions that were mainly asymptomatic
Ortiz et al[9]	2006	138	18.8	Sensitivity of heartburn as diagnostic criterion of GERD was 29.3%, with a specificity of 85.7%
				Asymptomatic GER (abnormal esophageal acid exposure and/or EE) more common than symptomatic GER
Csendes et al[10]	2007	426	26.3	Out of the 112 EE patients, 77 (68.7%) reported GERD symptoms
Merrouche et al[11]	2007	94	6.4	46% of patients had abnormal 24-pH study
Dutta et al[19]	2009	101	8.9	6.9% EE in age- and sex-matched non-obese control subjects
Tai et al[20]	2010	260	32.3	Increased waist circumference, insulin resistance, and presence of reflux symptoms independent risk factors for EE
Martin-Perez et al[21]	2014	88	4.5	Esophageal pH monitoring tests positive in 65% of patients
				Absence of symptoms did not rule out abnormal esophageal function tests
Carabotti et al[24]	2015	142	4.2	Majority of endoscopic lesions were asymptomatic
Mora et al[23]	2016	196	17.3	Esophageal pH-metry abnormal in 54.2% of patients
				Symptoms not enough to diagnose underlying GERD or EE
Sharara et al[24]	2019	242	33.9	Anthropometric data and GERD questionnaires have limited accuracy for EE
				12.3% of patients with low GERDQ (< 8) had EE

GERD: Gastroesophageal reflux disease; EE: Erosive esophagitis.

Table 2 Putative pathophysiological mechanisms of gastroesophageal reflux disease post laparoscopic sleeve gastrectomy

Hypotensive lower esophageal sphincter[48]

Loss of angle of His flap valve[55]

Increased gastro-esophageal pressure gradient and intra-thoracic migration of the remnant stomach[56]

Reduction in the compliance of the gastric remnant provoking an increase in transient lower esophageal sphincter relaxations[57]

Lack of gastric compliance and emptying during the first postoperative year[58]

Relative gastric stasis in the proximal remnant and increased emptying from the antrum (suggested on time-resolved MRI studies)[59]

Excessively large or dilated sleeve retaining increased acid production capacity leading to reflux[60]

Overly narrowed or strictured sleeve resulting in reflux and decreased esophageal acid clearance[61]

MRI: Magnetic resonance imaging.