Mild to moderate GERD before sleeve: Can we better predict post-operative GERD?

Gastroesophageal reflux disease (GERD) can be debilitating for patients after sleeve gastrectomy (SG). However, no clear numerical thresholds have been identified to help predict which patients will develop worsening symptoms post-operatively. We therefore sought to characterize which pre-operative wireless pH testing and endoscopy findings were associated with GERD after SG.

Patients with a history of SG and pre-operative wireless pH studies were identified. Abnormal DeMeester score was defined as > 14.7 and abnormal acid exposure time (AET) as > 4% of time with a pH < 4. Clinically meaningful post-operative GERD was defined as GERD symptoms requiring proton pump inhibitor (PPI) therapy. We performed a univariate analysis and a Youden's index analysis to determine when DeMeester score and AET become predictive of post-operative GERD.

Of 76 patients included, 41 patients (53.9%) reported pre-operative GERD symptoms. Of those with symptoms, 20% had LA Grade A or B esophagitis, 25% had a hiatal hernia, 56.1% had an elevated DeMeester score, and 58.5% had an elevated AET. Post-operatively, 13.2% (5/38) of patients with pre-operative symptoms required a PPI compared to 6.1% (p = 0.4) in patients without pre-operative symptoms. There was no difference in the rate of post-operative GERD between those with a normal vs abnormal pre-operative DeMeester (13.3% vs 13.0%, p > 0.9). In univariate analysis, abnormal DeMeester score (OR 1.25, p = 0.779), grade A or B esophagitis (OR = 1.70, p = 0.554), or abnormal AET (OR = 1.25, p = 0.779) were not predictive of post-operative GERD. However, a threshold of DeMeester score of ≥ 30 or AET ≥ 10.35 was predictive of post-operative GERD.

In patients with moderate GERD, standard cutoffs of abnormal DeMeester score or AET were not predictive of post-operative GERD, however a threshold DeMeester score of ≥ 30 or AET ≥ 10.35 was predictive. Patients with such findings should be particularly counseled about the risk of post-operative GERD and/or offered a Roux-en-Y gastric bypass.