Gastrectomía vertical laparoscópica y reflujo gastroesofágicoestudio radiológico, manométrico y pHmétrico. Determinación de factores pronósticos

Résumé

Introduction Bariatric Surgery has proven to be the most effective and long-lasting treatment for obesity and its comorbidities. Laparoscopic sleeve gastrectomy (LSG) has become the most frequently performed bariatric procedure around the world according to date. Its effectiveness and safety have been well documented and recent studies support its results, both in the short and medium term. However, its relationship with Gastroesophageal Reflux (GER) is still controversial and therefore must be studied through functional tests. Objectives: Determine, by quantifying GER with 24-hour pH monitoring, if the LSG globally considered is a refluxogenic operation or, on the contrary, it is a surgical technique that protects against GER Analyze epidemiological, radiological, manometryc, and clinical data after surgery and the characteristics of the subgroups based on the particular pH monitoring evolution of the patients. Identify epidemiological prognostic factors, and those derived from the tests carried out in order to be able to predict the evolution of GER in the obese patient who is going to undergo LSG. Patients and Methods: A prospective study was carried out that enrolled 71 patients with OM, operated by the General Surgery Service of the Virgen de la Arrixaca Hospital in Murcia between the years 2013-2017, through a LSG. All patients underwent a complete GER evaluation preoperatively and after LSG, comparing the data before and one year after the intervention. Likewise, 4 groups of patients were separated and studied according to the evolution of GER detected in the postoperative period and the search or identification of prognostic factors that could predict the evolution of GER after LSG was carried out. Results: In relation to the weight data, the mean BMI after the LSG was 30.40 ± 4.56, the% EWL was 67.48 ± 14.60, and the % TWL was 34.03 ± 7.12. After surgery, a non-significant increase in symptomatic patients was observed, being the heartburn the most frequent symptom. And a significant increase in the consumption of antisecretory drugs (70%). Radiological and endoscopic data showed a significant increase in HH in the postoperative period (30 versus 13 patients), and a slight non-significant increase in inflammatory lesions (14% versus 17%). Regarding functional tests, manometryc data showed a significant decrease in LES pressure (12.71 ± 6.01versus 15.81±5.58) and wave amplitude (97.37 ± 39.76 versus 104.75±40.57). All the parameters studied in a conventional pH monitoring underwent statistically significant changes after the LSG in the sense of becoming pathological, highlighting the DeMeester Score that goes from 24 to 40, and the % pH lower than 4 that from 6.3% goes to 9.25%. On the other hand, we obtained a reflux correction rate of 34.21%, a persistence of GER in almost 47% of patients, de novo reflux of almost 70% and a sustained absence of GER in 30% of patients . The presence of a positive pH monitoring and the presence the HH before surgery is related to a higher probability of developing pathological pH monitoring after LSG. Conclusions: LSG is a refluxogenic technique, quantified by 24-hour pH monitoring. Postoperative gastroesophageal reflux is associated with an increased presence of HH and a decrease in LES pressure. Although the de novo reflux rate is high in our series, there is also a considerable percentage of patients in whom the positive pH monitoring is negative after LSG and another group in which the absence of pathological reflux is maintained after LSG, therefore that its presence in the preoperative period should not be a contraindication to this technique. Regarding the preoperative prognostic factors predictive of having a positive pH monitoring after surgery, we have only identified the presence of a HH and a positive pH monitoring before surgery