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R. A. Saavedra and E. Auyang
After a sleeve gastrectomy, high pressure is often discussed
within the gastric lumen. HRM with impedance is a way to evaluate the pressure within the sleeve. In the gures above, high pressure is noted distal to the LES and hiatus (within the gastric lumen).
This may be helpful in determining whether conversion to RYGBP
(a decompressive procedure) will help in improving reux.
26 Normal Physiology Findings After Hiatal Hernia Repair…
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371
Dysphagia or Cough After Sleeve
In this study, the patient had a sleeve gastrectomy and did well
with weight loss. However, she presented 2years post-sleeve with
globus and cough. She was noted to have a hypotensive LES and
hiatal hernia. High pressure was noted between the LES and the
hiatus. The patient underwent hiatal hernia repair and LES augmentation with magnetic beads with relief of symptoms. Note
there is no high pressure seen within the gastric lumen.
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7. Bogte A, Bredenoord AJ, Oors J, Siersema PD, Smout AJPM.Normal
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R. A. Saavedra and E. Auyang
26 Normal Physiology Findings After Hiatal Hernia Repair…
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K.Normal Foregut Function
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After Bariatric Surgery
MeganLundgren andTalarTatarian
Introduction
Bariatric surgery has proven to be the most effective solution for
sustained long-term weight loss in patients with morbid obesity.
These procedures, while successful, have unintended consequences on the esophagus, esophageal motility, and GERD by
causing mechanical and functional changes of the upper gastrointestinal tract [1]. Postoperative alterations in gastric volume and
intraluminal pressure contribute to functional motility changes [1].
Each bariatric procedure uniquely alters intragastric volume, pressure, gastroesophageal pressure gradients, and gastric emptying
[2]. As such, each procedure will be discussed separately. Herein,
we review the impact of obesity and bariatric surgery on esophageal health, specically esophageal motility. Reux following bariatric surgery, the most notable outcome of functional motility
postoperatively, will be discussed in detail in a later chapter.
27
M. Lundgren
Department of Surgery, Penn Highlands Healthcare, Dubois, PA, USA
T. Tatarian (*)
Department of Surgery, Thomas Jefferson University Hospital,
Philadelphia, PA, USA
e-mail: talar.tatarian@jefferson.edu
© Society of American Gastrointestinal and Endoscopic Surgeons
(SAGES) 2023
A. D. Patel et al. (eds.), The SAGES Manual of Physiologic
Evaluation of Foregut Diseases,
https://doi.org/10.1007/978-3-031-39199-6_27
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M. Lundgren and T. Tatarian
The Lower Esophageal Sphincter
andEsophageal Function inPatients
withObesity
The natural anti-reux barrier is comprised of the lower esophageal sphincter (LES), diaphragmatic hiatus, phrenoesophageal
ligament, and angle of His [3]. This barrier relies predominantly
on a competent LES, which can be compromised by decreased
intrinsic pressure, overall length, intra-abdominal length, esophageal peristalsis, and gastric motility [4]. Obesity can contribute to
the breakdown of several of these components. Increased intraabdominal girth and pressure are thought to cause increased rates
of hiatal hernia, transient LES relaxation, and slower esophageal
clearance, all of which lead to the development of GERD [5].
Increased estrogen levels as a result of increased adipose tissue in
obesity may contribute to increased transient relaxation of the
LES [6]. Not surprisingly, patients with obesity have been shown
to have a 2.5-fold increase in the risk of hiatal hernia and a 50%
increase in the risk of GERD symptoms [7, 8].
High-resolution impedance manometry allows for detailed
evaluation of the crural diaphragm and LES, including their anatomic position and relationship during contraction. Preoperative
manometry in the bariatric population has identied disruption of
the natural anti-reux barrier with high rates of separation of the
crural diaphragm from the LES mechanism [9]. Manometric studies have also shown subclinical, asymptomatic ndings of esophageal dysmotility at higher rates than in the nonobese population
[10]. This includes hypertensive LES, nutcracker esophagus, diffuse esophageal spasm, and nonspecic esophageal disorders
[10]. These changes in the natural antireux barrier and the potential for higher rates of esophageal motility disorders need to be
taken into account in the planning stages of bariatric surgery.
Furthermore, procedure choice needs to be made with the knowledge of normal physiologic ndings postoperatively, which are
discussed below.
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377
Normal Physiologic Findings After Bariatric
Surgery
In this next section, we discuss the functional upper gastrointestinal motility changes that occur “normally” following the most
commonly performed bariatric procedures. Each procedure will
be discussed separately as the various anatomic congurations
contribute to differing effects.
Adjustable Gastric Banding
Adjustable gastric banding (AGB) involves the placement of an
inatable silicone band around the upper stomach to provide
restriction and affect satiety. Luminal distension of the cardia
above the gastric band causes gastric peristalsis until the lumen
above the band is emptied [11]. In an optimally lled gastric band,
passage of semisolids into the infraband compartment is briey
delayed without limiting total meal size. If the compartment
above the band is not fully cleared, residual bolus may reux back
into the esophagus until additional peristalsis allows for passage.
Following AGB, symptoms such as dysphagia and regurgitation are commonly reported. Recent studies using high-resolution
impedance manometry (HRM) have provided some insight into
the physiologic causes for these symptoms. Cruziat et al. used
HRM to evaluate esophageal motility and clearance in symptomatic patients a median of 6.3years after surgery [12]. Twenty of 22
patients were found to have abnormal manometric ndings
including pseudo-achalasia, functional EGJ obstruction, and
weak peristalsis. In this study, the most frequent disorder was a
functional esophageal gastric junction obstruction dened by
increased intra-bolus pressure. Band deation or removal resulted
in improvement of symptoms for the majority of patients. HRM
has also identied secondary contractions of the esophagus in
banded patients, which increase in frequency with higher lling
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of the band. These excessive contractions against a high-pressure
zone are hypothesized to lead to the trans-hiatal dilation of the
esophagus [12]. Due to the signicant resistance presented by the
band, esophageal peristalsis is required to mediate episodes of liquid or semisolid ow across the gastric band [11]. Band slippage,
a known complication of AGB, can augment these physiologic
changes and worsen dysphagia, esophageal dysmotility, and
trans-hiatal dilation.
M. Lundgren and T. Tatarian
Sleeve Gastrectomy
Sleeve gastrectomy (SG) is currently the most commonly performed weight loss procedure in the United States. It involves
resection of the greater curvature of the stomach, leaving a long
tubular stomach comprised of the lesser curvature and antrum. By
removing approximately two thirds of the stomach, there are
direct effects on both volume and distensibility as well as neurohormonal effects on receptive relaxation and the gastric pacemaker [13]. These changes not only directly affect the esophagus
and stomach, but also cause global alterations in gastrointestinal
motility. A recent systematic review of three studies found an
increase in small bowel transit time following SG [13]. However,
the most studied alterations in motility are in the stomach and
esophagus.
The anatomic and mechanical changes following SG have secondary effects on esophageal function. Gastric volume and compliance are decreased causing increased intragastric pressure [1].
Mion etal. found that on HRM, increased intragastric pressure
was present only after completion of the swallows, during the
LES after-contraction, and not during the relaxation period of the
esophagogastric junction [1]. The authors concluded that these
ndings are manometric markers for SG. Increased intragastric
pressure, however, has not been shown to decrease esophagogastric junction bolus transit. The reduced compliance of the gastric
sleeve may have an effect on esophageal bolus clearance and transit in certain cases, particularly in those with evidence of reux on
impedance [1].
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Gastric emptying after SG has been studied extensively. There
has been debate regarding the emptying of the so called
“tight- sleeve” versus “antral-sparing” sleeve gastrectomy. Initial
studies using gastric emptying found antral preservation to have
no effect on gastric emptying [14]. More recently, Baumann etal.
used dynamic MRI to better evaluate gastric motility before and
after SG.The authors found that following SG, movement of a
food bolus through the sleeve segment was passive with no propulsive motility, whereas the antrum maintained its motility with
active acceleration during bolus transit [15]. There is some indication that the amount of antrum remaining, in other words, the
number of centimeters from the pylorus at which the rst staple
line is taken, does affect emptying time– however no randomized
controlled trials have studied this specically.
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Roux-En-Y Gastric Bypass
The Roux-en-Y gastric bypass (RYGB) is both a restrictive and
malabsorptive procedure. It includes the creation of a small proximal gastric pouch which is then connected to a distal segment of
jejunum (Roux or alimentary-limb). Individual surgeon practice
varies with regard to the lengths of the Roux and biliopancreatic
limbs, but these function to decrease intestinal absorption whereas
the gastric pouch serves to restrict the volume of oral intake.
These subsequently induce weight loss.
More recently, alterations in motility and neurohormonal
changes after RYGB have been studied as drivers of weight loss.
Björklund etal. used manometry to better dene esophago- gastroRoux limb motor activity following RYGB [16]. The authors performed manometric measurements on eight patients with stable
weight loss at least 2years postoperatively. A manometric catheter was advanced across the GEJ, gastric pouch, and into the Roux
limb and intraluminal pressure differences and migrating motor
complexes of the Roux limb were measured. The authors found
signicant pressure differences between the gastric pouch and the
LES, as well as no pressure difference between the pouch and the
Roux limb at rest. After ingestion, food intake caused a moderate
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and gradual pressure increase in the gastric pouch as well as in the
Roux segment, which reached a peak pressure in the Roux limb
around 8min and then decreased from then on, independent of
further food intake. So, unlike previously proposed, there is no
hypertension of the gastric pouch after RYGB.The authors also
found interdigestive migrating motor complexes that started
beyond the gastrojejunal anastomosis and occurred aborally along
the Roux limb at regular intervals [16].
There have been several studies of esophageal motility in the
obese population as well as in postoperative patients after
RYGB.Studies have had conicting results. Early studies called
for preoperative evaluation of esophageal motility prior to bypass
[17] due to a high frequency of lower esophageal sphincter motor
dysfunction, motility disorders, and preoperative reux in patients
with obesity. More recent studies have suggested this preoperative
evaluation is unnecessary especially in asymptomatic patients
[18]. A recent study combining impedance pH and high- resolution
manometry found no change in esophageal peristalsis after RYGB
[19]. However, patients who report dysphagia to solid foods after
RYGB are more likely to have abnormal ndings on highresolution manometry, including incomplete lower esophageal
sphincter relaxation and hypertensive lower esophageal sphincter.
The causes, however, and direct relationship to the RYGB have
not been mapped, although effects on vagal innervation have been
suggested [20].
M. Lundgren and T. Tatarian
Duodenal Switch andSingle Anastomosis
Duodenoileal Bypass withSleeve Gastrectomy
Duodenal Switch (DS) combines a longitudinal sleeve gastrectomy with a small bowel bypass. The duodenum is transected
proximal to the ampulla and an anastomosis is created between
the proximal duodenum and the distal small bowel, usually 250–
300cm proximal to the terminal ileum. The distal end of the biliopancreatic limb is then anastomosed to the Roux limb
approximately 100–150 cm proximal to ileocecal valve. More
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