Laparoscopic sleeve gastrectomy (SG) has gained popularity as a primary bariatric procedure
in the past decade. According to the International Federation for the Surgery of Obesity and
Metabolic Disorders (IFSO), 43.6% of all bariatric procedures performed worldwide were SG
between 2013 and 2017. Long term data of SG have shown that the procedure is able to achieve
adequate weight loss and metabolic outcomes compared with other bariatric procedures.
Furthermore, it has gained popularity due to its relatively simpler procedure, shorter
operative time, avoidance of intestinal anatomy rearrangement, anastomosis, risk of internal
hernia, and lower risk of malnutrition.
One major drawback to SG is potential development of gastrointestinal reflux disease (GERD).
According to the Montreal Classification, GERD is defined as heartburn and regurgitation
because of reflux contents of the stomach into the esophagus, causing symptoms that
interferes with physical activity, disturbs sleep and reduce productivity at work . It has
been shown to significant impact on patients' post-operative quality of life negatively .
Currently there are discrepancy in the medical literature, while some studies found worsening
of GERD or development of GERD (de novo GERD) after SG, some found improvement of GERD
post-operatively. From a recent meta-analysis by Yeung et al comprising 10, 718 patients with
follow-up period from 3 to 132 months, 19% of patients experienced worsening of GERD while
23% developed de novo GERD after SG.
Furthermore, long term complications of GERD include the development of erosive esophagitis,
Barret's esophagus and even esophageal adenocarcinoma. From the same meta-analysis, the
long-term prevalence (>24 months) of erosive esophagitis and Barret's esophagus were 28% and
8% respectively. There have also been isolated case reports of development of esophageal
adenocarcinoma after SG. From the investigators' literature review, four cases were reported.
Two of the cases had no pre-operative endoscopy, one case had pre-operative diagnosis of
Barret's esophagus. The other case developed esophageal adenocarcinoma despite normal
pre-operative endoscopy 5 years after SG.
The epidemiology of GERD is different in Western countries and in Asian countries. Although
the incidence of GERD has increased in the past decades, the prevalence of GERD was 5.2-8.5%
base on symptoms. Prevalence of Barret's esophagus remained rare at 0.06-0.85%. In patents
who have received SG, Tai et al showed that the prevalence of GERD increased from 12.1 to 47%
based on Reflux Disease Questionnaire at one year after SG. The prevalence of erosive
esophagitis also increased from 16.7 to 66.7%. based on upper gastrointestinal endoscopy
findings at one year. In the long run, the prevalence of de novo GERD was 17-45% based on
symptoms and proton pump inhibitors use from the case series by Pok et al. and Chang et al.
with a follow-up period up to 7 years and 10 years respectively.
From the current Asian literature, data on long term incidence of GERD after SG based on
objective assessment tools and endoscopy findings was lacking. There is also no adequate data
on the long-term occurrence of erosive esophagitis and Barret's esophagus after SG, which
would have important significance in pre-operative counselling.
The objective of the study is to evaluate the long-term incidence and effects of
gastroesophageal reflux disease in the Chinese population after laparoscopic sleeve
gastrectomy.