Beruflich Dokumente
Kultur Dokumente
Original article
Division of General and Bariatric Surgery, Department of Surgery, Second University of Naples, Naples, Italy
b
General and Bariatric Surgery Unit, Camilliani Hospital, Casoria, Italy
c
Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
Received January 27, 2015; accepted March 22, 2015
Abstract
Background: At present, no objective data are available on the effect of omega-loop gastric bypass
(OGB) on gastroesophageal junction and reux.
Objectives: To evaluate the possible effects of OGB on esophageal motor function and a possible
increase in gastroesophageal reux.
Setting: University Hospital, Italy; Public Hospital, Italy.
Methods: Patients underwent clinical assessment for reux symptoms, and endoscopy plus highresolution impedance manometry (HRiM) and 24-hour pH-impedance monitoring (MII-pH) before
and 1 year after OGB. A group of obese patients who underwent sleeve gastrectomy (SG) were
included as the control population.
Results: Fifteen OGB patients were included in the study. After surgery, none of the patients reported
de novo heartburn or regurgitation. At endoscopic follow-up 1 year after surgery, esophagitis was
absent in all patients and no biliary gastritis or presence of bile was recorded. Manometric features and
patterns did not vary signicantly after surgery, whereas intragastric pressures (IGP) and gastroesophageal pressure gradient (GEPG) statistically diminished (from a median of 15 to 9.5, P o .01,
and from 10.3 to 6.4, P o .01, respectively) after OGB. In contrast, SG induced a signicant elevation
in both parameters (from a median of 14.8 to 18.8, P o .01, and from 10.1 to 13.1, P o .01,
respectively). A dramatic decrease in the number of reux events (from a median of 41 to 7; P o .01)
was observed after OGB, whereas in patients who underwent SG a signicant increase in esophageal
acid exposure and number of reux episodes (from a median of 33 to 53; P o .01) was noted.
Conclusions: In contrast to SG, OGB did not compromise the gastroesophageal junction function
and did not increase gastroesophageal reux, which was explained by the lack of increased IGP and
in GEPG as assessed by HRiM. (Surg Obes Relat Dis 2016;12:6269.) r 2016 American Society
for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Omega-loop gastric bypass; One-anastomosis gastric bypass; GERD; Reux; High-resolution manometry; MIIpH; Impedance; Obesity; Bariatric surgery
Obesity is a growing epidemiologic problem in the Western countries, leading to important diseases and complications. Thus, several bariatric operations for morbid obesity
*
Correspondence: Salvatore Tolone, M.D., Ph.D., Division of General
and Bariatric Surgery, Department of Surgery, Second University of
Naples, Via Pansini 17, 80131, Naples, Italy.
E-mail: salvatore.tolone@unina2.it
http://dx.doi.org/10.1016/j.soard.2015.03.011
1550-7289/r 2016 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Omega-loop Gastric Bypass and Reux / Surgery for Obesity and Related Diseases 12 (2016) 6269
63
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S. Tolone et al. / Surgery for Obesity and Related Diseases 12 (2016) 6269
24-hour MII-pH
All patients underwent outpatient 24-hour MII-pH. A
specic MII-pH catheter (with intraluminal impedance
segments positioned at 3, 5, 7, 9, 15, and 17 cm above
the LES) (Sandhill Scientic Inc., Highlands Ranch, CO,
USA) was placed transnasally, with the esophageal pH
sensor positioned 5 cm above the manometrically determined LES. Patients were invited to indicate and record 3 or
more predominant symptoms and their occurrence during
the recording time, as well as to record the times of every
meal and position changes between upright and recumbent
state, both on the device and on a written diary provided.
The information transmitted by the catheter was processed
using the devices software (Sleuth SystemSandhill Scientic Inc., Highlands Ranch, CO, USA). MII-pH data were
collected and analyzed with the Bioview GERD Analysis
Software (Sandhill Scientic Inc., Highlands Ranch, CO,
USA). Meal periods were excluded from the analysis.
By means of MII-pH, the following variables were
assessed: distal esophageal acid exposure as a percentage
(%) of time (acid exposure time [AET]) with pH o4
Omega-loop Gastric Bypass and Reux / Surgery for Obesity and Related Diseases 12 (2016) 6269
65
Endoscopy
At the preoperative upper endoscopy, mild, chronic,
Helicobacter pylorinegative gastritis was diagnosed in 2
patients and esophagitis was not observed in any of the
patients. One year after OGB, esophagitis was absent in all
patients and no enlargement or strictures were noted in the
gastric pouch of any patient. Persistence of mild mucosal
inammation (redness), without any sign of bleeding or
ulceration, was observed in 1 of the 2 patients with
preoperative chronic gastritis. No biliary gastritis or presence of bile was recorded during endoscopy with histologic
assessment. However, histologically proven mild perianastomotic inammation was present in 13 of 15 patients
(Table 1). In the SG group, endoscopic 12-month postoperative follow-up revealed the presence of grade A
esophagitis in 1 patient, and 2 patients presented a mild
gastric inammation.
HRiM
In the OGB group, median LES pressure varied, without
any statistically signicance, from 22.1 (19.532) to 22
(19.830.4) mm Hg (P .865) and median IRP varied
from 6.8 (3.211.1) to 6.5 (3.211.0) (P .732). Intragastric
pressure decreased from 15.5 (13.117.2) before to 9.5 (7.5
10.3) mm Hg after OGB (P o .01), and no gastric squeeze
was observed. Also, GEPG was found to be reduced from
10.3 (8.614.5) to 6.4 (4.08.1), P o .01. Before OGB, 2 of
15 patients had manometric evidence of a grade II hiatal
hernia (mean distance CDLES of .8 cm). Because of this
small defect, none of these patients needed a surgical crural
repair. After OGB, the 2 small hiatal hernias disappeared and
none of the remaining patients developed a hiatal hernia. The
percentage of normal peristaltic waves remained unchanged
after surgery. Likewise, no modication in DCI or DL was
recorded; complete bolus transit and BTT at impedance were
not modied after surgery. Comprehensive data of HRiM
ndings are presented in Table 2.
In the SG group, similar data were recorded in terms of
EGJ features, as shown in Table 2. However, in this group,
the intragastric pressure (IGP) and GEPG signicantly
increased after surgery (P o .01 and P o .01, respectively). Compared with SG, OGB resulted in similar LES
pressure modications, but the IGP and GEPG were
signicantly diminished in the latter procedure. Similar to
Table 1
Endoscopic ndings at 1 year after omega-loop gastric bypass (OGB)
Upper endoscopy features
Esophagitis
Present
Absent
Gastritis
Perianastomotic
Diffuse
(%)
0
15
0
100
13
1
86.6
6.6
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S. Tolone et al. / Surgery for Obesity and Related Diseases 12 (2016) 6269
Table 2
Pre- and postoperative assessment at high-resolution impedance manometry in omega-loop gastric bypass (OGB) and in sleeve gastrectomy (SG) patients
Obese pre-OGB
(n 15) median
(25th75th)
Obese post-OGB
(n 15) median
(25th75th)
P value*
Obese pre-SG
(n 25) median
(25th75th)
Obese post-SG
(n 25) median
(25th75th)
P value
22.6
6.8
15.5
10.3
(20.827.0)
(3.211.1)
(13.117.2)
(8.614.5)
23.0
6.5
9.5
6.4
(21.226.2)
(3.211.0)
(7.510.3)
(4.08.1)
.865
.732
.002
.001
21.3
6.5
14.8
10.1
(18.533.0)
(3.211.2)
(12.618.2)
(8.314.0)
22.0
6.3
18.8
13.1
(19.033.0)
(3.210.9)
(10.221.2)
(10.715.1)
.810
.856
.001
.001
1938
6.1
10
0
(16542456)
(5.57.2)
(1020)
(00)
1891
6.2
10
0
(16542241)
(5.57.5)
(1020)
(0-0)
.856
.961
.934
1880
6.2
10
0
(15252302)
(5.57.2)
(1020)
(00)
927
6.0
46
0
(3001478)
(5.57.0)
(3050)
(00)
.001
.821
.000
80 (7090)
8.38 (7.9110.1)
80 (7090)
8.37 (7.810.4)
.934
.657
90 (80100)
8.0 (7.89)
50 (3070)
8.4 (7.89)
.000
.856
LESp lower esophageal sphincter pressure in mm Hg; IRP integral relaxation pressure in mm Hg cm sec; IGP intragastric pressure in mm Hg;
GEPG gastroesophageal pressure gradient in mm Hg; DCI distal contractile integral in mm Hg sec cm; DL distal latency in seconds; CBT
complete bolus transit in percentage; BTT bolus transit time in seconds.
*
Wilcoxon rank sum test for paired data for pre- and post-OGB.
Omega-loop Gastric Bypass and Reux / Surgery for Obesity and Related Diseases 12 (2016) 6269
67
Table 3
Detailed ndings at multichannel intraluminal impedance pHmetry (MII-pH) before and after omega-loop gastric bypass (OGB) and sleeve gastrectomy (SG)
Obese pre-OGB
(n 15) median
(25th75th)
AET (%) pH o 4
Total
2.5 (1.83.4)
Upright
2.6 (2.03.7)
Recumbent
.8 (.51.0)
DeMeester score
13.1 (1024)
Number of reux at MII
Total
41 (2066)
Upright
32 (1551)
Recumbent
9 (216)
Acid reux pattern at MII
Total
32 (1550)
Upright
27 (1337)
Recumbent
5 (111)
Weakly acid reux pattern at MII
Total
9 (515)
Upright
5 (410)
Recumbent
4 (15)
Weakly alkaline reux pattern at MII
Total
0 (03)
Upright
0 (03)
Recumbent
0 (01)
Postprandial reux events at MII
Total
22 (1141)
Obese post-OGB
(n 15) median
(25th75th)
P value*
Obese pre-SG
(n 25) median
(25th75th)
Obese post-SG
(n 25) median
(25th75th)
P value
.0
.2
.0
.9
.000
.000
.000
.000
1.4
1.1
1.0
9
3.2
1.9
3.1
18.2
.000
.002
.003
.000
7 (314)
4 (35)
0 (02)
.000
.000
.000
33 (2039)
26 (1530)
7 (49)
53 (3057)
38 (2040)
15 (1017)
.000
.000
.000
3 (36)
3 (34)
0 (02)
.000
.008
.000
12 (914)
9 (810)
3 (24)
16 (9-18)
13 (715)
3 (06)
.000
.000
.000
2 (06)
1 (15)
0 (02)
.001
.000
.752
15 (820)
11 (612)
4 (25)
34 (1442.5)
27 (930)
7 (511.5)
.000
.000
.000
0 (02)
0 (02)
0 (00)
.000
.000
.459
0 (03)
0 (03)
0 (01)
2 (13)
2 (02)
1 (01.5)
.003
.045
.001
5 (29)
.000
12 (619)
28 (1740)
.000
(.0.8)
(.0.7)
(.0.1)
(.92.2)
(1.02.0)
(.11.2)
(.01.2)
(4.112.5)
(2.05.0)
(.22.6)
(.04.2)
(8.030.5)
68
S. Tolone et al. / Surgery for Obesity and Related Diseases 12 (2016) 6269
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