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Gastroesophageal Motility and Reflux Following Bariatric Surgery for the Treatment of Severe Obesity

  • Author / Creator
    Sheppard, Caroline E
  • Obesity is a recognized complex chronic disease that impacts millions of people globally. Bariatric surgery is the only evidence-based method for sustainable weight loss and resolution of obesity associated morbidities. However, complications can occur after surgery, in particular gastroesophageal reflux (GERD) and esophageal motility disorders after laparoscopic sleeve gastrectomy (LSG). Existing literature describes many contradictory causes for symptoms of GERD and investigators remain uncertain whether reflux following LSG is present, and if present, whether it is alkaline/acidic, and what precise pathophysiology leads to these symptoms. In fact, patients are empirically treated with anti-secretory therapy based on heartburn symptoms. In addition, while literature points to higher rates of esophageal motility disorders in the obese and bariatric population, the relationship with body mass index (BMI) is poorly understood. A case of a patient with severe dysmotility syndrome and reflux symptoms initiated this thesis. The objective of this thesis was to determine the relationships between bariatric surgery and gastroesophageal motility and reflux. The hypothesis was that the anatomical changes after bariatric surgery created disturbances in esophageal and gastric motility causing non-acid gastroesophageal reflux and related symptoms. This thesis began by exploring this hypothesis by performing a chart review of surgical patients at the Edmonton Adult Bariatric Specialty Clinic to determine the prevalence of postoperatively treated or identified reflux and esophageal motility disorders. One in five LSG patients developed reflux, but there were very few reported cases of esophageal motility disorders before or after surgery. These patients were identified or treated based on symptoms, which prompted the following study, where patients were asked to complete the Gastrointestinal Symptom Rating Scale questionnaire to observe how symptoms changed before and after surgery and, how complications impact symptoms. There was no decisive pattern in symptoms observed after surgery and fewer than expected complications from which to draw firm conclusions. The symptomatic population was explored further at the Gastrointestinal Motility Laboratory and a prospective chart review of patients undergoing high-resolution esophageal manometry and 24h pH-impedance testing was performed. Body mass index (BMI) was not associated with esophageal motility disorders, nor were esophageal motility disorders more frequent in obese patients. BMI was also not traditionally linked to the DeMeester Score and had a logarithmic rather than linear relationship. Patients that had previous bariatric surgery were sub-grouped. There were no significant differences in esophageal motility abnormalities between symptomatic obese and bariatric patients. The mechanism for these abnormalities were not associated with BMI, but were associated with increased intragastric pressure after LSG, as previously hypothesized. Also, symptoms after bariatric surgery were not associated with esophageal motility disorders or reflux. To study this group of patients before and after bariatric surgery, a prospective cohort study to compare reflux, esophageal motility, and symptoms after LSG and laparoscopic Roux-en-Y gastric bypass (LRYGB) was performed. Although the parietal cell mass was removed, the sleeve remained acidic; however, it was non-acid reflux not acid reflux that was attributed to patients with reflux symptoms. Symptoms of reflux persisted after the number of reflux events reduced, which may indicate an esophageal hypersensitivity. Anti-secretory therapy, such as a proton-pump inhibitors (PPI), may alleviate symptoms to reduce the total number of reflux events for patients, but ultimately a therapy targeted at non-acid reflux and esophageal hypersensitivity would be more beneficial.

  • Subjects / Keywords
  • Graduation date
    2017-11:Fall 2017
  • Type of Item
    Thesis
  • Degree
    Doctor of Philosophy
  • DOI
    https://doi.org/10.7939/R3N58D07V
  • License
    This thesis is made available by the University of Alberta Libraries with permission of the copyright owner solely for non-commercial purposes. This thesis, or any portion thereof, may not otherwise be copied or reproduced without the written consent of the copyright owner, except to the extent permitted by Canadian copyright law.
  • Language
    English
  • Institution
    University of Alberta
  • Degree level
    Doctoral
  • Department
    • Department of Surgery
  • Supervisor / co-supervisor and their department(s)
    • Dr. Daniel W Birch, Department of Surgery
    • Dr. Karen Madsen, Department of Medicine, Division of Gastroenterology
  • Examining committee members and their departments
    • Dr. Christopher de Gara, Department of Surgery
    • Dr. Daniel C Sadowski, Department of Medicine, Division of Gastroenterology