Modified One Anastomosis Gastric Bypass Post-Sleeve Gastrectomy for Severe GERD

Overview

This prospective study evaluated the clinical and physiological outcomes of a modified one anastomosis gastric bypass (OAGB) performed above the incisura in patients with severe gastroesophageal reflux disease (GERD) and delayed gastric emptying after sleeve gastrectomy (SG). The intervention aimed to accelerate gastric emptying, reduce esophageal acid exposure, and alleviate reflux symptoms by improving drainage of the supra-incisural gastric compartment.

Background

Gastroesophageal reflux disease (GERD) is a common and challenging complication following sleeve gastrectomy, often associated with impaired quality of life and patient dissatisfaction. The pathophysiology of severe reflux post-SG is linked to pressurization of a non-compliant proximal gastric compartment and delayed gastric emptying, particularly stasis above the incisura. One anastomosis gastric bypass (OAGB) has emerged as a revisional procedure, but its efficacy for reflux symptoms and physiological improvement remains unclear. This study prospectively investigates the impact of a modified OAGB technique with an anastomosis above the incisura to address these issues.

Data Highlights

The study included patients aged 18-65 years with severe reflux post-SG, abnormal gastric emptying half-time (>21 min), and no large hiatus hernia. The modified OAGB involved transecting the stomach above the incisura and creating a tension-free gastrojejunal anastomosis with a bypass length of 150-200 cm. Postoperative assessment included nuclear scintigraphy for gastric emptying, 24-hour pH monitoring for acid exposure, and symptom evaluation. Proton pump inhibitors were prescribed for 4 weeks postoperatively, and diet was gradually advanced over 6 weeks.

Key Findings

• Modified OAGB with supra-incisural anastomosis effectively accelerates gastric emptying half-time and improves gastric clearance in patients with delayed emptying post-SG.
• There is a significant reduction in overall esophageal acid exposure and frequency of reflux events following the procedure.
• Reflux symptoms, including triggered deglutitive and post-prandial reflux, are markedly reduced after surgery.
• The surgical technique addresses the pathophysiological mechanism of reflux by eliminating stasis at the incisura and improving drainage of the proximal gastric pouch.
• Postoperative management with proton pump inhibitors and gradual diet advancement supports anastomotic healing and patient recovery.

Clinical Implications

The modified OAGB technique offers a promising revisional surgical option for patients with severe GERD and delayed gastric emptying after sleeve gastrectomy. By targeting the anatomical and physiological contributors to reflux, this approach can improve patient symptoms and reduce acid exposure, potentially decreasing the need for further medical or surgical interventions. Careful patient selection and adherence to postoperative protocols are essential for optimal outcomes.

Conclusion

This prospective evaluation demonstrates that a modified OAGB with an anastomosis above the incisura effectively ameliorates severe reflux and delayed gastric emptying following sleeve gastrectomy. The findings support its use as a targeted revisional procedure to improve physiological and clinical outcomes in this challenging patient population.

References

1. Johari et al. -- Pathophysiological mechanisms of gastro-esophageal reflux following SG
2. Alfred Human Research and Ethics Committee (HREC) no. 380/16 and The Avenue Hospital HREC no. 236 -- Ethics approval
3. Siemens Symbia™ Evo Excel Gamma Camera -- Nuclear scintigraphy methodology