Feb. 13, 2021
With the prevalence of obesity increasing within the United States, bariatric surgery has become an effective tool for promoting weight loss and improving weight-related medical comorbidities. Currently, the two most commonly performed bariatric surgeries are Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG).
While bariatric surgery does provide significant potential benefits to patients and reduces the risks related to comorbidities associated with obesity, there are potential complications associated with surgery as well. Postoperative complications include nutritional deficiencies (influenced by surgery type), bone loss, nephrolithiasis, gastroesophageal reflux disease, and dysphagia and esophageal motility disorders (including secondary achalasia).
To define the prevalence of dysphagia and characterize its effects on esophageal motility after bariatric surgery, Mayo Clinic researchers recently conducted a large retrospective database review. The results of that study were published in 2020 in The American Journal of Gastroenterology (AJG).
Using a procedural database that included patients treated at three large tertiary care centers, the researchers identified 137 patients who underwent LSG or RYGB between June 2012 and February 2019. Within this group, 97 patients underwent diagnostic high-resolution impedance manometry (HRIM) after bariatric surgery at a median of 5.84 years postoperatively, and 40 patients with medically complicated obesity underwent HRIM preoperatively. The group of patients who underwent HRIM postoperatively included 39 (40.1%) patients who underwent LSG and 58 (59.8%) who underwent RYGB.
The research team documented patients' demographic and clinical features, and a blinded investigator interpreted HRIM studies using the Chicago classification of esophageal motility disorders, v3.0. Researchers also contacted a subset of 271 patients who underwent bariatric surgery between January 2014 and April 2015 and administered a validated symptom assessment survey to gauge the overall prevalence of dysphagia after surgery.
The study findings suggest that postoperative dysphagia is an underrecognized, long-term complication of bariatric surgery, and that both RYGB and LSG are associated with significant postsurgical esophageal dysmotility, including achalasia and a newly described condition similar to achalasia that they have termed post-obesity esophageal dysfunction (POSED).
"We suspect the new entity of POSED is the result of both the diminished compliance of the proximal gastric pouch that is associated with Roux-en-Y gastric bypass and the high pressure created by the restrictive laparoscopic sleeve gastrectomy procedure, which serve to functionally obstruct the esophagus," explains Karthik Ravi, M.D., corresponding author on the AJG article and a gastroenterologist at Mayo Clinic's campus in Rochester, Minnesota. "This obstruction, in turn, can lead to an absence of normal esophageal peristalsis and a condition similar to that seen with achalasia," explains Dr. Ravi.
The following data demonstrate the various forms of dysphagia identified in patients who underwent bariatric surgery:
- Overall, 12.4% of the patients in the postsurgical HRIM group and 0% of patients in the preoperative HRIM group had either achalasia or POSED.
- Seven (7.2%) patients in the postsurgical HRIM group and 0% of patients in the preoperative HRIM group had a manometric pattern consistent with achalasia.
- Five (5.2%) patients in the postsurgical HRIM group and 0% of patients in the preoperative HRIM group had a separate achalasia-like pattern defined by aperistalsis and increased intragastric pressure, referred to as post-obesity surgery esophageal dysfunction (POSED).
- Increasing time since surgery was independently associated with the development of achalasia, POSED and major motility disorders.
- The prevalence of clinically significant dysphagia was 13.7% at a mean 3.9 years after surgery among 271 patients surveyed after surgery for symptom assessment.
"Further studies are needed to elucidate potential risk factors and predictors associated with POSED and to identify patients at risk of developing this condition following bariatric surgery," says Dr. Ravi. "We also need to focus on developing effective treatment for patients in which POSED is diagnosed."
For more information
Miller AT, et al. Postobesity surgery esophageal dysfunction: A combined cross-sectional prevalence study and retrospective analysis. The American Journal of Gastroenterology. 2020;10:1669.