Quantifying physiologic parameters of the gastroesophageal junction during robotic sleeve gastrectomy and identifying predictors of post-sleeve gastroesophageal reflux disease

Jacques A Greenberg; Federico Palacardo; Rodrigo C L Edelmuth; Caitlin E Egan; Yeon Joo Lee; Gregory Dakin; Rasa Zarnegar; Cheguevara Afaneh; Omar Bellorin

doi:10.1007/s00464-022-09450-0

Quantifying physiologic parameters of the gastroesophageal junction during robotic sleeve gastrectomy and identifying predictors of post-sleeve gastroesophageal reflux disease

Surg Endosc. 2023 Feb;37(2):1543-1550. doi: 10.1007/s00464-022-09450-0. Epub 2022 Jul 20.

Authors

Jacques A Greenberg¹, Federico Palacardo¹, Rodrigo C L Edelmuth¹, Caitlin E Egan¹, Yeon Joo Lee¹, Gregory Dakin², Rasa Zarnegar¹, Cheguevara Afaneh², Omar Bellorin³

Affiliations

¹ Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA.
² Department of Surgery, Division of Gastrointestinal Metabolic & Bariatric Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 520 East 70th Street, Starr Pavillion, 8th Floor, New York, NY, 10021, USA.
³ Department of Surgery, Division of Gastrointestinal Metabolic & Bariatric Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 520 East 70th Street, Starr Pavillion, 8th Floor, New York, NY, 10021, USA. Omb9006@med.cornell.edu.

PMID: 35859010
DOI: 10.1007/s00464-022-09450-0

Abstract

Background: Sleeve gastrectomy is among the most commonly-performed procedures for morbid obesity. However, patients occasionally develop post-sleeve gastroesophageal reflux disease (GERD). Identifying patients most at risk for this complication remains difficult. We aimed to correlate intra-operative physiologic measurements of the lower esophageal sphincter (LES) at the gastroesophageal junction (GEJ) during robotic sleeve gastrectomy in an attempt to identify predictors of post-sleeve GERD symptoms.

Methods: A retrospective chart review of a prospectively maintained database identified 28 patients in whom robotic sleeve gastrectomy was performed utilizing EndoFLIP™ technology between January and September 2021. Intraoperative LES measurements at the GEJ including cross-sectional area (CSA), distensibility index (DI), intra-balloon pressure, and high-pressure zone (HPZ length) were correlated with post-operative GERD.

Results: GEJ CSA, pressure, and DI increased over the course of the surgery (CSA pre-op: 31 (IQR 19.3-39.5) mm² vs. post-op: 67 (IQR 40.8-95.8) mm², p < 0.001; pressure: 25.8 (IQR 20.2-33.1) mmHg vs. 31.5 (IQR 28.9-37.0) mmHg, p = 0.007; DI 1.1 (IQR 0.8-1.8) mm²/mmHg vs. 2.0 (IQR 1.2-3.0) mm²/mmHg, p = < 0.001), whereas HPZ length decreased (2.5 (IQR 2.5-3) cm vs. 2.0 (IQR 1.3-2.5) cm, p = 0.022). Twenty-three patients (82.1%) completed a post-operative GERD questionnaire. Fifteen (65.2%) had no GERD symptoms before or after surgery; 5 (21.7%) reported new post-sleeve GERD symptoms; 3 (13.0%) reported exacerbation of pre-existing GERD symptoms. Patients with new or worsening GERD symptoms had higher post-sleeve DIs (3.2 (IQR 1.9-4.5) mm²/mmHg vs. 1.5 (IQR 1.2-2.4) mm²/mmHg, p = 0.024) and lower post-sleeve LES pressures (29.9 (IQR 26.3-32.9) mmHg vs. 35.2 (IQR 31.0-38.0) mmHg, p = 0.023) than those without.

Conclusions: An increase in GEJ CSA, pressure, and DI, and a decrease in GEJ length can be expected during robotic sleeve gastrectomy. Patients with new or worsening post-sleeve GERD symptoms have higher post-sleeve DI and lower post-sleeve LES pressure than their asymptomatic counterparts.

Keywords: EndoFLIP; Gastroesophageal reflux disease; Sleeve gastrectomy.

MeSH terms

Esophageal Sphincter, Lower / surgery
Gastrectomy / methods
Gastroesophageal Reflux* / surgery
Humans
Laparoscopy* / methods
Obesity, Morbid* / surgery
Retrospective Studies
Robotic Surgical Procedures* / adverse effects