Clinical Scorecard: Prospective Evaluation of Modified One Anastomosis Gastric Bypass After Sleeve Gastrectomy for Severe Gastroesophageal Reflux and Delayed Gastric Emptying: Clinical and Physiological Outcomes

At a Glance

Key Highlights

• Modified one anastomosis gastric bypass (OAGB) with supra-incisural anastomosis aims to improve drainage of the supra-incisural gastric compartment to reduce reflux.
• Prospective evaluation includes nuclear scintigraphy, endoscopy, and 24-hour pH monitoring to assess physiological and clinical outcomes.
• Surgical technique involves transecting stomach above incisura and constructing a tension-free gastrojejunal anastomosis with a pouch length of at least 8 cm.

Guideline-Based Recommendations

Diagnosis

• Clinical interview confirming severe reflux symptoms post-SG refractory to maximal medical therapy.
• Nuclear medicine gastric emptying study showing gastric emptying half-time > 21 minutes indicating delayed emptying.
• High-resolution manometry to exclude large hiatus hernia (>4 cm axial separation).

Management

• Consider modified OAGB with supra-incisural anastomosis as revisional surgery for severe reflux and delayed gastric emptying post-SG.
• Post-operative protocol includes water-soluble contrast swallow on day 1 to assess anastomotic integrity and liquid to semi-solid diet progression over 6 weeks.
• Proton pump inhibitor therapy for at least 4 weeks post-operatively to promote anastomotic healing.

Monitoring & Follow-up

• Use of nuclear scintigraphy and 24-hour pH monitoring pre- and post-operatively to assess gastric emptying and esophageal acid exposure.
• Clinical symptom assessment to evaluate reduction in reflux frequency and severity.
• Endoscopic evaluation as indicated to monitor mucosal status.

Risks

• Potential for anastomotic leak necessitating early post-operative imaging.
• Risks associated with revisional bariatric surgery including surgical complications and nutritional deficiencies.

Patient & Prescribing Data

Adults post-sleeve gastrectomy with severe GERD and delayed gastric emptying unresponsive to medical therapy.

Modified OAGB may accelerate gastric emptying, reduce esophageal acid exposure, and improve reflux symptoms by improving supra-incisural gastric drainage.

Clinical Best Practices

• Careful patient selection excluding those with large hiatus hernia, grossly dilated sleeve, or poor weight loss as primary indication.
• Perform detailed pre-operative physiological assessment including gastric emptying and manometry.
• Use a modified surgical technique with supra-incisural anastomosis to optimize gastric drainage and reduce reflux.
• Implement structured post-operative diet progression and proton pump inhibitor therapy to support healing.
• Conduct prospective monitoring with objective physiological tests and symptom evaluation to guide outcomes.

References

• Johari et al. on pathophysiology of reflux post-SG
• Nuclear scintigraphy methodology
• Ethicon Endo-Surgery, Inc. Echelon Flex™ Stapler