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27 K.Normal Foregut Function After Bariatric Surgery
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recently, Single Anastomosis Duodenoileal Bypass with Sleeve
Gastrectomy (SADI-S) has gained popularity, during which a
single loop anastomosis is created between the proximal duodenum and the small bowel, 250–300cm proximal to the ileocecal
valve.
Both procedures reduce caloric intake and induce fat malabsorption by diverting bile and pancreatic secretions. The changes
in esophageal motility are similar to those seen with sleeve gastrectomy, as described in the section above. Studies of gastrointestinal motility following DS or SADI-S are limited. In the Ellias
etal. studies using a wireless motility capsule, gastric emptying
was found to be rapid in about 30% of patients 1 year after
DS.This is in keeping with earlier studies of SG alone. The maximum pressures in the antrum and stomach increased slightly,
while small bowel pressures declined signicantly postsurgery
[21].
In a quality of life study after DS, patients reported more atus,
number of loose bowel movements, urgency, and fecal incontinence compared to patients who had undergone RYGB [22]. This
would suggest faster transit, but may also be related to the length
of the common channel which is shorter in DS.
381
Abnormal Physiologic Findings After Bariatric
Surgery
While some degree of physiologic and manometric changes are
expected after bariatric surgery, occasionally pathologic changes
can contribute to worsening reux, dysphagia, and regurgitation.
When this occurs, a thorough workup should commence consisting of upper endoscopy, upper gastrointestinal series with small
bowel follow through, pH studies, and manometry. Depending on
the ndings, a patient should be referred to a bariatric surgeon for
consideration of revision surgery. For more detailed review of
abnormal ndings after bariatric surgery and subsequent management, please refer to the chapter “Reux After Bariatric Surgery”.
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M. Lundgren and T. Tatarian
Conclusion
Bariatric surgery, while highly effective for weight loss and management of obesity related comorbidities, has unintended consequences on foregut physiology. Advances in high-resolution
manometry have led to a better understanding of esophageal
motility and the anti-reux barrier in patients with obesity, both
pre- and postoperatively. Preoperative workup is paramount to
ensuring that the appropriate procedure is selected for each
patient. Procedure choice should be made with thorough understanding of the anticipated physiologic and manometric effects as
well as each patient’s baseline esophageal health and symptoms.
Editors’ Note
Reux/Dysphagia After aSleeve Gastrectomy
27 K.Normal Foregut Function After Bariatric Surgery
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383
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 Roux-en-Y
gastric bypass (a decompressive procedure) will help in improving reux.
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M. Lundgren and T. Tatarian
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.
References
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after sleeve gastrectomy: increased Intragastric pressure and reux are
frequent events. Obes Surg. 2016;26(10):2449–56.
2. Salvatore T. Esophageal high-resolution manometry can unravel the
mechanisms by which different bariatric techniques produce different
reux exposures. J Gastrointest Surg. 2020;24(1):1–7.
3. Tatarian T, Pucci MJ, Palazzo F.A modern approach to the surgical treatment of gastroesophageal reux disease. J Laparoendosc Adv Surg Tech
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6. Nilsson M, Johnsen R, Ye W, Hveem K, Lagergren J.Obesity and estrogen as risk factors for gastroesophageal reux symptoms. JAMA.
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8. Wilson LJ, Ma W, Hirschowitz BI.Association of obesity with hiatal hernia and esophagitis. Am J Gastroenterol. 1999;94(10):2840–4.
9. Tolone S, Savarino E, de Bortoli N, etal. Esophagogastric junction morphology assessment by high resolution manometry in obese patients’ candidate to bariatric surgery. Int J Surg. 2016;28:S109–13.
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on gastric emptying, supra- and infraband transit and satiety: a randomized double-blind crossover trial using a new technique of band visualization. Obes Surg. 2010;20(12):1690–7.
12. Cruiziat C, Roman S, Robert M, et al. High-resolution esophageal
manometry evaluation in symptomatic patients after gastric banding for
morbid obesity. Dig Liver Dis. 2011;43(2):116–20.
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ingestion of liquids reveals motility changes after laparoscopic sleeve
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16. Björklund P, Lönroth H, Fändriks L.Manometry of the upper gut following roux-en-Y gastric bypass indicates that the gastric pouch and roux
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17. Merrouche M, Sabaté J-M, Jouet P, etal. Gastro-esophageal reux and
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bariatric surgery. Obes Surg. 2007;17(7):894–900.
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analysis of combined impedance-pH and high-resolution manometry
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WW.Mo1731 incomplete lower esophageal sphincter relaxation on highresolution manometry is an independent predictor of solid diet failure in
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21. Elias K, Semler JR, Webb D-L, Sundbom M, Hellström PM. Gastric
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M. Lundgren and T. Tatarian
Normal Physiologic Findings
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After Esophageal Myotomy
AbdulazizAliKaram
andMohammedAl Mahroos
Introduction
Gastrointestinal motility disorders are considered rare conditions
worldwide, and this may lead to a lack of full understanding of
multiple aspects related to these disorders. Achalasia is by far the
best understood foregut motility disorder. It is estimated to have
an annual incidence rate of 0.5–1.5 per 100,000 population with a
predilection to affect young women [1–3]. The main diagnostic
feature of achalasia is incomplete lower esophageal sphincter
(LES) relaxation with associated varying degrees of esophageal
aperistalsis [4]. The consequence is failure of food to transit
smoothly through the esophagus into the stomach, leading patients
to experience dysphagia, regurgitation, and chest pain due to food
stasis. Even though the understanding of most motility disorders
28
A. A. Karam
Department of Surgery, St Mary’s Hospital, McGill University,
Montreal, QC, Canada
M. Al Mahroos (*)
Department of Surgery, McGill University, Montreal, QC, Canada
Department of Surgery, St Mary’s Hospital, McGill University,
Montreal, QC, Canada
e-mail: Mohammed.Almahroos@mail.mcgill.ca
© 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_28
387
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is poor, the pathogenesis for achalasia is thought to be loss of
inhibitory neurons in Auerbach’s plexus. Theories suggesting the
cause to be idiopathic or infectious were both proposed. The
diagnosis of achalasia requires an esophagram and endoscopic
examination. However, esophageal manometry studies are the
gold standard modality to conrm the diagnosis. The ndings in
these studies may vary based on the type and severity of achalasia.
Unfortunately, there is no denitive treatment that can restore
LES function and esophageal peristalsis. Most available successful therapeutic options are targeted to disrupt the lower esophageal sphincter to help relieve the symptoms yielded from the
functional obstruction. The conventional way to treat achalasia is
through a surgical myotomy, a method called Heller myotomy.
However, in 2010, Inoue et al. described the rst per oral endoscopic myotomy (POEM) as a new approach to treating achalasia.
Since then, the utilization of POEM has only grown and we have
learned more about the physiological changes after per oral myotomy.
Post-myotomy normal physiological ndings are widely arguable, because of the lack of xed post-op normal standardized
thresholds [5]. To simplify the process of postoperative follow-up
and to achieve better understanding for post-myotomy physiologic ndings, we will categorize the ndings based on the type of
diagnostic study.
A. A. Karam and M. Al Mahroos
Normal Physiologic Findings inDiagnostic Tests
Post-Myotomy
Radiological Findings after Myotomy
Most experienced foregut surgeons who treat achalasia on a regular basis investigate the response to treatment at 6–12months
after myotomy. This can serve as the new baseline for future
follow- ups. Multiple studies have looked at the radiological ndings post-myotomy including Stephen etal. and Yoo etal. in 1988
and 2004, respectively. Both stated that 50–65% of patients will
show normal esophageal caliber in early post-op course, as radio-
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389
logical studies were performed within 7 days of myotomy [6].
However, about one third of the patients will show mild dilatation
of the esophagus and a smaller group of patients will show
moderate dilation. The size of the esophagus in imaging does not
always correlate with the presence of symptoms. Expected ndings post successful myotomy include free passage of contrast
through the lower esophageal sphincter into the stomach, usually
without the previous bird’s beak-like appearance. In some
instances, the body of the esophagus will increase in caliber,
which is called ballooning of the esophagus, and the lower gastroesophageal junction will be larger, within rst month postmyotomy [7].
Stephen etal. examined esophageal focal outpouching along
the myotomy. In their study published in 1988, they noted postoperative outpouching when they examined their patients using
upper GI studies. They reported it as a normal postoperative nding [7]. The reported incidence of this nding varies between 33%
and 95% in post-myotomy; however, it also did not correlate with
the presence of symptoms or lack thereof [8]. Although the study
reported no consequences of this nding, in theory it can act as a
potential site for stasis of food or rarely food impaction.
It is important for upper GI surgeons and radiologists not to
confuse post-myotomy esophageal ballooning with epiphrenic
diverticulum which is a saccular protrusion that has a discrete
neck. It should also not be mistaken for residual dilatation of the
aperistaltic esophagus. The outpouching has an eccentric and
focal characteristic.
After POEM, one would still expect a small amount of pneumoperitoneum immediately after the procedure with no clinical
signicance. This could be attributed to the lack of a serosal layer
on the esophagus. Some centers prefer to do a close follow-up
X-ray on the rst or second day after the procedure [9]. However,
it is unlikely to change management if the patient is not showing
any worrisome symptoms or signs.
During POEM, the mucosotomy site is usually closed with
endoscopic clips. These might be seen if radiological examination
is performed during the rst few weeks after the procedure. These
clips loosen and fall off spontaneously at a later stage. It is worth
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noting that mucosal edema surrounding the clips can be seen as a
rounded small focal lucency and this image can remain even after
the clips loosen and disappear [10].
Similar ndings were observed in a number of studies using
CT-scan on the rst day after undergoing POEM. In these
instances, the common radiological nding on CT scan was pneumomediastinum (87%), pneumoperitoneum (66%), subcutaneous
emphysema (52%), and pleural effusion (46%) [11].
As discussed earlier, most radiological ndings which are considered expected post-POEM do not require any intervention.
Upper GI surgeons and radiologists should be aware of these ndings and their signicance or lack thereof. However, these ndings might not represent an expected outcome if patients are
experiencing unexpected symptoms such as worsening dysphagia, severe pain, or high-grade fever. In cases where symptoms
recur, previous ndings seen in preoperative imaging might reappear. An esophagogram is an important modality in patients with
new onset dysphagia. A patient suffering from recurrent dysphagia might show delayed emptying of esophageal content or esophageal dilatation.
A. A. Karam and M. Al Mahroos
Manometric Findings Post-Myotomy
Manometry is the gold standard test for diagnosing achalasia. It
not only helps differentiate it from other esophageal motility disorders, but also helps determine the type of achalasia [12]. There
are no specic guidelines for surveillance after a patient undergoes myotomy for achalasia. In most instances, manometry is an
important tool to evaluate patients with persistent or recurrence of
symptoms.
Attempts have been made to quantify normal values in both
manometry and pH studies at 6 months after myotomy. While
there is still no consensus regarding specic values, new manometric readings were considered the new baselines after surgery
[8]. In part, the new ndings may depend on the type of antireux repair post-laparoscopic myotomy or the lack of an antireux component post-POEM.In 2018, Torres-Villalobos etal.,
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