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Contains fulltext : 172797.pdf (Publisher’s version ) (Open Access) INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) is considered to be an effective procedure for patients with morbid obesity. Belching is frequently reported after this procedure, but it has not been well studied in the bariatric population. This study aims to assess the changes in belching before and after sleeve gastrectomy, as measured with impedance monitoring. METHODS: In a prospective study, patients underwent 24-h pH-impedance monitoring before and 3 months after LSG. Using this technique, belches can be identified. Preoperative and postoperative upper gastrointestinal symptoms were assessed using the Reflux Disease Questionnaire (RDQ). RESULTS: Fifteen patients (1 M/14 F, mean age 42.2 +/- 11.0 years, mean weight 134.5 +/- 21.1 kg, mean BMI 46.4 +/- 6.0 kg/m(2)) participated in this study. Belching occurred significantly more often after LSG, with an increase in symptom score from 2.9 +/- 2.6 before to 5.3 +/- 3.5 3 months after LSG (p = 0.04). The total number of gastric belches increased from 29.7 +/- 11.7 before to 59.5 +/- 38.3/24 h 3 months after LSG (p = 0.03). The total number of supragastric belches did not change after LSG. The number of swallows decreased from 746.9 +/- 302.4 before to 555.7 +/- 172.5 3 months after the procedure (p = 0.03). The number of air swallows tended to decrease (p = 0.08). Esophageal acid exposure increased significantly, from 3.7 +/- 2.9 % before to 12.6 +/- 10.5 % after LSG (p = 0.01). CONCLUSION: Subjectively (as reported by patients) and objectively (as measured by impedance monitoring), an increase in gastric belches is seen after LSG, while the number of (air) swallows tends to decrease after the procedure and the incidence of supragastric belches remains constant. The altered anatomy as well as increased gastroesophageal reflux after LSG may play a role in the increase of belching.

Contains fulltext : 151954.pdf (Publisher’s version ) (Closed access) BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is an effective bariatric procedure. However, postprandial symptoms can compromise its beneficial effect. It is not known if a changed gastric emptying and these symptoms are related. This study aimed to assess the association between postprandial symptoms and the gastric emptying pattern after LSG. METHODS: A gastric emptying study with a solid and liquid meal component was performed in the second year after LSG. Before the test, symptoms were assessed using a standardized questionnaire, and during the test, symptoms were scored on a visual analog scale (VAS). Gastric emptying results were expressed as lag phase, half time of gastric emptying (T(1/2)), and caloric emptying rate/minute. RESULTS: Twenty patients (14 F/6 M; age 45.6 +/- 7.7 years, weight 93.4 +/- 28.2 kg, BMI 31.6 +/- 8.1 kg/m(2)) participated in this study; 13 had a low symptom score (/=18, group II). VAS scores for epigastric pain, nausea, and belching were significantly higher in group II. Lag phase (solid) was 6.4 +/- 4.5 min in group I, 7.3 +/- 6.3 in group II (p = 0.94); T(1/2) (solid) was 40.6 +/- 10.0 min in group I, 34.4 +/- 9.3 in group II (p = 0.27); caloric emptying rate was 3.9 +/- 0.6 kcal/min in group I, 3.9 +/- 1.0 kcal/min in group II (p = 0.32). CONCLUSIONS: Patients with postprandial symptoms after LSG reported more symptoms during the gastric emptying study than patients without symptoms. However, there was no difference between gastric emptying characteristics between both groups, suggesting that abnormal gastric emptying is not a major determinant of postprandial symptoms after LSG.

OBJECTIVES This study aimed to investigate the association between BMI and esophageal acid exposure in a cohort of patients referred for esophageal pH monitoring. The contributing roles of hiatal hernia, lower esophageal sphincter (LES) pressure, and intragastric pressure (IGP) were investigated, with an emphasis on reflux in the supine position. METHODS Esophageal manometry and 24-h pH-metry results were extracted from a prospectively collected database, and supplemental data (body mass, endoscopy results) from patient files. RESULTS In total, 245 patients (mean age 52.2±14 years, 54% men) were included in this study. In the normal-weight subgroup (n=87), the median acid exposure time was 1.1% [0-8.1] in the supine position (with interquartile range 25-75%) and 7.7% [2.5-14.8] in the upright position; the total acid exposure time was 7.4% [2.7-11.7]/24 h. In the overweight subgroup (n=104), the median acid exposure time was 4.9% [0.3-13.3] in the supine position and 11.1% [5.4-16.9] in the upright position; the total acid exposure time was 8.9% [4.7-15.8]/24 h. In the obesity subgroup (n=54), the median acid exposure time was 4.1% [0.7-14.3] in the supine position and 10.5% [5-17.5] in the upright position; the total acid exposure time was 8.3% [5.3-14.7]/24 h. Supine acid exposure was significantly higher in overweight and obese patients than in normal-weight patients (both P=0.02). In overweight patients, a hiatal hernia was predictive of supine and total acid exposure, as was a decreasing LES pressure in both the supine and the upright position. In obese patients, increased IGP contributed toward an increased total acid exposure. Although an association between increasing BMI and acid exposure was observed, BMI was not independently predictive. CONCLUSION Overweight and obesity is associated with increased reflux, especially in the supine position. The most important factors that contribute toward reflux are the presence of a hiatal hernia and a lower LES pressure in overweight patients and an increased IGP in obese patients.

Summary Background Incidence rates of both obesity and gastro-oesophageal reflux disease (GERD) are increasing, particularly in the Western world. It has been suggested that GERD symptoms may be improved by weight reduction. Aim To review the literature on the effect of various weight reducing modalities on manifestations of GERD in obese patients. Methods A literature search was performed using PubMed, EMBASE and the Cochrane Library, combining the words obesity and gastro-oesophageal reflux with bariatric surgery, diet, lifestyle intervention and weight loss. Results With regard to diet/lifestyle intervention (conservative), four of seven studies reported an improvement of GERD. For Roux-en-Y gastric bypass, a positive effect on GERD was found in all studies, although this was mainly evaluated by questionnaires. In contrast, for vertical banded gastroplasty, no change or even an increase of GERD was noted, whereas the results for laparoscopic adjustable gastric banding were conflicting. Conclusions Dietary and lifestyle intervention may improve GERD in obese patients; however, the most favourable effect is likely to be found after bariatric surgery, especially after Roux-en-Y gastric bypass. Future studies need to elucidate for which GERD patients laparoscopic adjustable gastric banding might have a beneficial effect and how they can be identified preoperatively.

Background The adjustable gastric band is an effective surgical treatment to induce weight loss in patients with morbid obesity. We aimed to assess the effects of band placement and stepwise adjustment on esophageal motility, using high-resolution manometry (HRM). Methods Patients underwent esophageal HRM before and 6 weeks after gastric band placement. During postoperative assessment, HRM was combined with intraband pressure measurement at increasing filling volumes. Key Results In total, 15 patients were studied. Mean DCI (±SD) decreased from 1085.3 ± 1064.1 mmHg s−1 cm−1 before to 507 ± 347.2 mmHg s−1 cm−1 (P = 0.015) after band placement, mean IBP from 10.7 ± 1.7 mmHg to 7.7 ± 1.6 mmHg (P = 0.01). Stepwise band adjustment from 1 to 8 mL had an immediate and profound effect on swallow-induced esophageal contractions: DCI increased from 766 ± 590.4 to 7231 ± 6298.1 mmHg s−1 cm−1, IBP from 4.3 mmHg to 31.1 ± 17.3 mmHg, and intraband pressure increased from −109.1 ± 60.6 mmHg to 150.2 ± 65 mmHg. During band filling with volumes >5 mL, upward displacement of the LES was observed, indicative of shortening of the esophagus; the distance between the UES and LES decreased from 23.5 ± 1.3 cm at 0 mL to 19.9 ± 2 cm at 8 mL. Conclusions & Inferences Stepwise gastric band adjustment leads to immediate enforcement of esophageal peristalsis associated with an increase in intrabolus pressure and with pronounced esophageal shortening. Subjects who lack these responses to outflow obstruction may be more prone to dysphagia after band placement.