Impact of pre-operative manometry results on surgical decision making for laparoscopic sleeve gastrectomy in the context of GERD.
*Hannah White, *Susan Campbell, *Berna Buyukozturk, Wasef Abu-Jaish
University of Vermont, Colchester, VT, United States.
Background
Esophageal dysmotility has been reported in the literature in 20-61% of people with obesity (1). As the prevalence of obesity continues to rise, laparoscopic sleeve gastrectomy (LSG) has become more prevalent (1). However, cases of de novo GERD following LSG have been reported as high as 56% (2). The identification of patients at risk for developing de novo GERD after LSG remains challenging. At our institution, patients with abnormal upper GI studies undergo esophageal manometry to evaluate risk factors for GERD prior to LSG. Our aim is to examine the impact of manometry screening on surgical decision-making and investigate the effects of LSG on GERD.
Study Design
A retrospective chart review was performed at our institution of bariatric patients who had abnormal upper GI findings between 2011 and 2023 during their pre-operative evaluation. 67 met our inclusion criteria. Patients < 18 years of age and patients who did not undergo manometry were excluded. Descriptive data were collected. Normal esophageal manometry was defined as both normal peristalsis and lower esophageal sphincter (LES) pressure. The electronic health records were reviewed for surgical decision-making following abnormal manometry results and any operative interventions that patients received. Incidence of pre and post-operative subjective GERD was also collected, defined as PPI use > 3 months post-operatively.
Results
67 patients underwent manometry. Of those, 29 (29/67, 43.3%) had abnormal findings. Of those with abnormal manometry, 14 (16/29, 55.2%) did not proceed with surgery. A total of 38 (38/67, 56.7%) patients had normal manometry, of which 15 (15/38, 39.5%) did not undergo surgery. The 31 total patients who did not proceed with surgery were characterized by the following: 19 (61.3%) were lost to follow up or chose not to continue, 8 (25.8%) had esophagogastric junction outflow obstruction or other significantly abnormal manometry findings, and 3 (9.68%) had a disqualifying medical history. 1 (3.2%) patient was ineligible due to failure to lose weight. 36 total patients underwent LSG. 20 (20/36, 55.5%) had pre-operative GERD. Of those, 14 (14/20, 70.0%) had post-operative GERD, and 6 (6/20, 30.0%) had resolution of GERD. 16 (16/36, 44.4%) did not have pre-operative GERD. 6 (6/16, 37.5%) developed de-novo GERD after LSG. Logistic regression analysis controlling for patient variables will be performed.
Conclusions
Our findings suggest that pre-operative manometry can identify patients with abnormal anatomy, such as EGJ outflow obstruction, and should play a role in identifying appropriate patients for LSG. However, many patients chose not to undergo bariatric surgery despite normal manometry, highlighting the importance of external factors in patient decision making. We identified an incidence of 37.5% of de-novo GERD in our cohort. Almost 1/3 of patients in our cohort with pre-operative GERD experienced resolution of symptoms after LSG.
Patient Surgical Decision Making
| Reason for No Surgery | # of Patients |
| Abnormal manometry | 8 (25.8%) |
| Disqualifying PMH | 3 (9.7%) |
| Lost to follow up/Chose not to continue | 19 (61.3%) |
| Could not qualify | 1 (3.2%) |
GERD and LSG
| Patient Condition | # of Patients |
| No pre-op GERD | 16 |
| De-novo GERD | 6 (37.5%) |
| Pre-op GERD | 20 |
| Persistent GERD | 14 (70%) |
| Resolution of GERD | 6 (30%) |
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