Erosive Esophagitis after Bariatric Surgery: Banded VerticalGastrectomy versus Banded Roux-en-Y Gastric Bypass
Gustavo Peixoto Soares Miguel & João Luiz Moreira Coutinho Azevedo &Paulo Henrique Oliveira de Souza & João de Siqueira Neto & Felipe Mustafa &Évelyn Saiter Zambrana & Perseu Seixas de Carvalho
# Springer Science+Business Media, LLC 2010
the SRSG group to 14 (45.2%) and a decrease in the SRGB
Background Obesity is associated with gastroesophageal
group to two (6.3%), giving a total of 16 patients with EE
reflux disease. Roux-en-Y gastric bypass is the most
performed bariatric procedure in the world, whereas sleeve
Conclusions After 1 year of follow-up, we observed a
gastrectomy is an emerging procedure. Both can be
worsening evolution of EE in the SRSG group, but
combined with the use of a Silastic® ring. The aim of this
study was to compare the evolution of erosive esophagitis(EE) in patients who underwent Silastic® ring gastric
Keywords Bariatric surgery. Erosive esophagitis . Roux-en-Y
bypass (SRGB) and Silastic® ring sleeve gastrectomy
gastric bypass . Sleeve gastrectomy . Morbid obesity
(SRSG) after a 1-year postoperative period.
Methods We carried out a non-randomized, prospective,controlled clinical study. Sixty-five patients were enrolled
based on the following inclusion criteria: female gender,age 20–60 years old, BMI 40–45 and written informed
Obesity is a multifactorial disease with a growing preva-
consent. The exclusion criteria were secondary obesity,
lence worldwide. Surgical treatment of morbid obesity has
alcohol or drug use, severe psychiatric disorder, binge-
been shown to be superior to dieting and behavior
eating of sweets, and previous stomach or bowel surgery.
modification for long-term weight loss and improvement
The patients were divided into two groups—33 (51%)
of associated co-morbidities  (Fig. 1).
underwent SRSG and 32 (49%) patients underwent SRGB.
The most performed bariatric surgery procedure is the
All patients underwent an esophago-gastro-duodenoscopy
Roux-en-Y gastric bypass (RYGB) , whereas sleeve
during the preoperative period and at 12–14 months after
gastrectomy (SG) is an emerging restrictive procedure 
that has shown good results with regard to weight loss and
Results Preoperatively, 15 patients (23.8%) were found to
has some potential advantages, such as a lower probability
have EE, six (19.4%) in the SRSG group and nine patients
of vitamin and mineral deficiencies, access to the entire
(28.1%) in the SRGB group (p=0.7795). Postoperatively,
intestinal tract, no need for subcutaneous ports or adjust-
there was an increase in the number of patients with EE in
ments, the absence of dumping syndrome and a lowerprobability of intestinal obstruction. In addition, SG can beperformed in patients who have inflammatory bowel
G. P. S. Miguel (*) : P. H. O. de Souza : J. de Siqueira Neto :
disease and those who have undergone bowel surgery and
F. Mustafa : É. S. Zambrana : P. S. de Carvalho
can be converted into a RYGB [3, 4]. Both SG and RYGB
Federal University of Espírito Santo–UFES,
can be performed with or without the placement of a
Obesity has been associated with acid reflux in the lower
esophagus and gastroesophageal reflux disease (GERD),
Federal University of São Paulo–Unifesp,
and several mechanisms have been proposed for this
were divided into two groups, 33 (51%) underwent SRSG
(SRSG group) and 32 (49%) underwent SRGB (SRGB
group). All patients underwent an esophago-gastro-
duodenoscopy (EGD) both during the preoperative period
Two patients, both from the SRSG group, were excluded
due to the development of a fistula. One of them underwent
a total gastrectomy, leading to resolution of the fistula, and
Fig. 1 Evolution of EE, as a complication, by group. Chi-square test:
The surgical procedures were performed at the Hospital
Universitário Cassiano Antônio de Moraes of the Universi-dade Federal do Espírito Santo (HUCAM/UFES–Cassiano
association such as increased intra-abdominal pressure,
Antônio de Moraes University Hospital, Federal University
reduced esophageal clearance, increased transient relaxation
of Espírito Santo). All of the procedures were performed by
of the lower esophageal sphincter, distorted anatomy of the
the same surgeon in an open fashion and using a similar
gastroesophageal junction, and a high-fat containing diet .
anesthetic technique (i.e., peridural anesthesia with com-
Bariatric surgery has an impact on the frequency of
GERD in obese patients, although the prevalence of GERD
The patients in the SRSG group underwent the following
varies following different types of bariatric surgery . The
procedures: ligation of the vessels of the greater curvature
influence of these procedures on GERD is controversial,
of the body and fundus of the stomach, resection of the
and there are few studies that compare two techniques,
fundus and part of the body of the stomach using a linear
stapler (80 mm, Tyco®) and a 32-French (Fr) tube to
The aim of this study was to compare weight loss and
calibrate the remaining stomach and placement of a 6.2-cm
assess the evolution of erosive esophagitis (EE) in patients
Silastic ring around the stomach at 5.0 cm below the
who underwent either a Silastic® ring sleeve gastrectomy
(SRSG) or a Silastic® ring Roux-en-Y gastric bypass
The patients in the SRGB group underwent the follow-
ing procedures: creation of a small, proximal gastric pouchand exclusion of a large part of the stomach using a linearstapler (80 mm, Tyco®) and a 32-Fr tube to calibrate the
gastric pouch; creation of an intestinal loop of 150 cm and abiliopancreatic loop of 40 cm; and placement of a 6.2 cm
Silastic ring around the stomach 5.0 cm below theesophagogastric junction.
We carried out a non-randomized, prospective, controlled
In both groups, the stapled lines were reinforced, and a
clinical study. This study was approved by the Research
methylene blue test was performed to verify whether the
Ethics Committee of the University Hospital of the Federal
staple line was secure. The patients were given a liquid diet
University of Espírito Santo, Brazil (protocol number 049/06)
on the first postoperative day and were discharged on the
and registered at clinicaltrials.gov (NCT00873405). To
third postoperative day. They received dietary guidance and
normalize the study population, we adopted the following
instructions regarding physical activity. In addition, patients
inclusion criteria: female gender, age 20–60 years old, BMI
from both groups were prescribed similar vitamin and
40–45 (inclusive), and written informed consent. The exclu-
mineral supplementation. Also, they were given proton
sion criteria were secondary obesity, alcohol or drug use,
pump inhibitor (IBP; Omeprazole, 20 mg daily) up to
severe psychiatric disorders, binge-eating of sweets, and
90 days postoperatively. The patients, who were on IBP use
by the time of the protocol EGD, had its use discontinued2 weeks before the exam.
Sixty-five female patients were enrolled in the present studyand had a mean age of 36.03 years old, mean BMI of 42.47,
Weight loss, BMI reduction, and waist circumference were
and waist circumference of 119.62 cm. The 65 patients
assessed. The percentage of excess BMI loss was calculated
as follows: (preoperative BMI−current BMI) ÷ (preopera-
14 (45.2%) in the SRSG group and a decrease to two
tive BMI–25)×100. The presence of endoscopic esophagi-
(6.3%) in the SRGB group, giving a total of 16 patients
tis, defined by the finding of erosion at the esophageal
mucosa, was recorded in both the pre- and postoperative
Statistical analysis of each group separately, with regard
to EE, showed a significant difference between thepreoperative and postoperative periods only for the SRGB
Three patients from the SRSG group (9.7%) showed
Descriptive analyses were conducted, and the results were
improved EE; 17 (54.8%) showed maintained EE; and 11
expressed as means, standard deviations, medians, frequencies
(35.5%) showed worsened EE. A different scenario was
(%), and minimum and maximum values. The Mann–Whitney
observed in the SRGB group, in which only one patient
U test was used to assess sample variation and homogeneity
(3.1%) showed worsened EE, whereas 23 (71.9%) showed
between the groups. The Fisher exact and chi-squared tests
unaltered EE, and eight (25%) showed resolved EE. There
were used to compare results between the two groups. In
was a significant difference between the two groups, with
assessments between time and groups of categorical varia-
better EE evolution observed in the SRGB group (p=
bles, generalized estimating equations were used. A p value
<0.05 was considered to be statistically significant.
Although it was not the main focus of the present study,
it was noteworthy that a fistula developed at the staple linein two patients (6%) in the SRSG group (p=0.4936). Both
patients required reoperation: one of them died, and theother underwent a total gastrectomy that led to resolution of
In the preoperative period, no significant difference in age,
BMI, or waist circumference was found between patients inthe SRSG group vs. the SRGB group. Among the entirepatient sample, BMI decreased from 42.45±1.63 to 27.49±
2.65 kg/m2 (p<0.05). The percentage of excess BMI losswas 86.98±14.86%. In addition, we observed a reduction in
The SG procedure is increasingly being used in bariatric
waist circumference from 119.83±7.64 to 90.31±7.51 cm
surgery [3, 4, 9–12]. There are few prospective clinical
(p<0.05). The results obtained with both surgical proce-
studies in the literature, however, that compare this
dures were similar with regard to weight loss, BMI
emerging procedure with RYGB [3, 12].
reduction, percentage of excess BMI reduction, and waist
In the present study, SG was performed, and a Silastic®
ring was placed around the stomach. This procedure
Preoperatively, 15 patients (23.8%) from the total sample
resulted in a small, functional stomach, similar to that
were found to have EE, six (19.4%) in the SRSG group and
obtained with traditional vertical gastroplasty, and removal
nine (28.1%) in the SRGB group (p=0.7795).
of the principal site of ghrelin production, giving SRSG
In the postoperative period (12–14 months after surgery),
characteristics of both bariatric and endocrine surgery .
there was an increase in the number of patients with EE to
Removal of the principal site of ghrelin production leads to
Table 1 Weight loss (WL), percentage of excess BMI loss (%eBMI), and preoperative and postoperative body mass index (BMI), waistcircumference (WC), by group (mean ± standard deviation)
a t Student p=0.6914b t Student p=0.9004c ANOVA: group p=0.5731, period p=0.0000, group x period p=0.6205d ANOVA: group p=0.2476, period p=0.0000, group x period p=0.5649
a decrease in ghrelin levels, adding a hormonal element to
SRSG was demonstrated to be a risk factor for EE at 1 year
SRSG, that other restrictive procedures, such as adjustable
after surgery (p=0.0451). There was an increase in the
gastric banding lack . Some authors have reported the
prevalence of EE in the SRSG group and a decrease in the
use of added restriction in SG to increase the intensity and
SRGB group, despite a significant decrease in body weight
duration of weight loss [6, 14, 15]. In addition, by placing a
and waist circumference in both groups. There are only a
Silastic® ring around the stomach in all the patients in this
few studies analyzing EE in bariatric patients, and studies
study, both procedures were identical in terms of the
that include SG patients are even rarer.
portion of the stomach located above the ring.
Alexander et al. compared a group of 27 patients who
Gastric bypass is the most used procedure in bariatric
underwent a banded sleeve gastrectomy (BSG) using a
surgery and is considered the gold standard by many. Some
biological band with a sex-, age-, and initial BMI-matched
researchers have reported that SG is less risky than RYGB
control group of 54 patients who underwent RYGB. In
[3, 9, 10]. In this study, however, the most serious
addition to other results, a higher prevalence of GERD was
complications occurred in the SRSG group, which was
observed in the BSG group after 1 year of follow-up .
noteworthy, although not statistically significant.
In a retrospective observational study, Lakdawala et al.
Weight loss, BMI reduction, waist circumference reduc-
compared 50 laparoscopic SG patients to 50 laparoscopic
tion, and percentage of excess BMI loss were significant
RYGB patients at 1 year after surgery. Resolution of GERD
and similar in both groups. These findings are in accor-
was observed in all 13% of the patients who presented with
dance with some studies [3, 4, 12], but in disagreement
GERD preoperatively in the RYGB group, whereas the
with others [9, 10] that have regarded SG as the first stage
prevalence of GERD increased from 5% to 9% in the SG
of a definitive surgery. The positive results of the present
study were probably due to judicious selection of the
The evolution of EE over a longer-term follow-up is
patient sample, which excluded those with a BMI greater
controversial. Himpens et al. compared GERD in 40
than 45 and those with prior stomach or bowel surgery.
patients with laparoscopic gastric banding and 40 patients
Other factors that might have contributed to the results of
with SG. A higher incidence of GERD was observed in the
the present study include the calibration of the remaining
SG group (21.8%) at 1 year after surgery, but at 3 years,
stomach using a 32-Fr tube and the placement of a Silastic®
only one out of 40 patients (3.1%) in the SG group was still
ring. In other studies in which weight loss was less
taking a proton pump inhibitor medication . On the
pronounced, tubes with a greater caliber were used ,
other hand, Bohdjalian et al. observed a 31% rate of chronic
and a Silastic® ring was not placed [9, 10].
use of anti-acid medication at 5 years after surgery among
Suter et al. evaluated GERD in 345 morbidly obese
patients and found a 31.8% rate of EE , similar to our
As our results, the improvement in GERD has been
observations in this study in the preoperative period
shown by some studies with RYGB patients. Mejia-Rivas et
(23.8%). With regard to the evolution of EE in our study,
al. observed an improvement of GERD symptoms, areduction in esophageal acid exposure time and betteresophageal motility after 6 months of RYGB . Frezza et
al. also studied the symptomatic effects of laparoscopic
RYGB in GERD and found improvements in some of thetypical and atypical symptoms of GERD. Furthermore, the
authors suggested that obese patients might be better servedby RYGB than by fundoplication given the weight loss
effect . One hundred fifty RYGB patients were
compared with a control group in a Chinese study that
found a high prevalence of GERD among patients with
morbid obesity and a reduction in the number of patients
with EE, from 42.3% to 3.8% during the postoperative
period . Csendes at al. reported a reduction in EE from
translated into the superiority of this study over previous
97% preoperatively to 7.2% at 21 months after RYGB. The
work in which the groups investigated were not similar ,
authors suggested that acid suppression resulting from a
samples were not homogeneous , and included patients
reduction in parietal cell mass combined with the Roux-en-
often presented with a BMI <40 [3, 4, 12] and/or >50 [3, 4,
Y gastrojejunostomy, which protects the esophagus from
duodenal contents, led to the positive outcome .
To reduce interpretation bias by the endoscopist, we only
There have been some studies comparing RYGB with
recorded the presence or absence of EE without grading or
other surgical techniques. Fifteen RYGB patients were studied
classification. This study also could have been improved by
by Merrouche et al. with regard to esophageal function over
assessing GERD symptoms. We analyzed the endoscopic
an average follow-up period of 31 months. Improvements
findings, but it is critical to understand that, whereas an
were observed in GERD symptoms, 24-h pH-metry data,
endoscopy showing clear evidence of Barrett’s esophagus
total time with pH >4 and the DeMeester score. The
or esophagitis confirms the diagnosis of GERD, a normal
authors compared these results with those of an adjust-
endoscopy in no way excludes GERD . Thus, if we had
able gastric band group, which showed worse values for
considered symptomatic GERD patients with normal
some parameters such as pH-metry and occasional severe
endoscopies, our results may have been different. Even
though the role of preoperative endoscopy in bariatric
Our results show a 35.5% increase in the prevalence of
surgery is controversial , a more thorough preoperative
EE among SRSG patients at 1 year after surgery. This
evaluation was necessary in this study, as we were
finding was recently encountered in other SG studies [25,
assessing a relatively new procedure and were working
26] and probably occurred because of the creation of a high
with a lack of understanding of its complications and
pressure gastric chamber due to the pyloric function
associated with the destruction of anti-reflux cardia phys-iologic mechanisms. Other contributing factors include themaintenance of larger parietal cells contiguous with the
esophagus and the removal of a gastric pacemaker andgastric fundus, leading to dysmotility and no distention
In summary, GERD is a frequent co-morbidity associated
with obesity and has implications regarding which bariatric
Similar mechanisms were proposed by Bernstine and
procedure should be performed. The two techniques
colleagues, who performed a gastric emptying scintigraphy
compared in this study led to different outcomes with
in 21 patients before and 3 months after a laparoscopic
regard to the evolution of EE: SRSG worsened the
sleeve gastrectomy with preservation of the antrum using a
evolution of EE, whereas there was a decrease in the
48-Fr tube for calibration and no band. Their results,
prevalence of EE in the SRGB group. Thus, the use of
however, showed no difference between the preoperative
SRGB should be preferred in patients who present with
and postoperative periods, demonstrating the possible
signs and symptoms of GERD or with a hiatal hernia.
importance of antral integrity . Other authors have also
Given that both of the techniques studied here promoted
analyzed gastric emptying after SG and found different
similar weight loss and that their anatomical aspects were
results [28–30]. Despite gastric emptying has been affected
identical above the Silastic® ring, the pathophysiological
by band placement, it has not contributed to a different
mechanism behind the worsening of EE in SGSG should be
evolution observed between groups because both are
derived from the anatomy below the ring. In addition,
anatomically identical in the portion above the ring,
further studies with longer follow-up periods are needed.
meaning that the band itself does not lead to the differentoutcomes observed between SRSG and SRGB.
Acknowledgments The authors would like to thank Drs. Marcos
The greatest limitation of this prospective, controlled
Machado Reuter Motta and José Manoel Binda, endoscopists from
study was the lack of randomization. This occurred because
HUCAM-UFES, for performing the EGDs.
the Research Ethics Committee and the authors of this
Conflict of Interest Disclosure The authors declare that they have
study believed the often irreversible surgical procedures
performed could not have been decided upon withoutpatient consent. A similar ethical issue was reported by theauthors of the Swedish Obese Subjects study . To
overcome this limitation, we selected patients with verysimilar characteristics. Both groups were comprised of
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Fair of face, foul of heart - cardiotoxicity and drug development Dr. Nick Miller, Beremans Limited Drug-related cardiotoxicity is difficult to predict in the early stages of drug development, and now may be the primary cause of drug withdrawals. Here we examine some of the main issues pertinent to cardiotoxicity and new drug development. In a heartbeat An understandin
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