title: The effect of laparoscopic sleeve gastrectomy on the antireflux mechanism: can it be minimized?
abstract: BACKGROUND
  Laparoscopic sleeve gastrectomy (LSG) is a promising procedure for the treatment of morbid obesity. The stomach is usually transected near the angle of His; hence, the lower esophageal sphincter (LES) may be affected with consequences on postoperative gastroesophageal reflux disease (GERD). The purpose of this study was to examine the effect of LSG on the LES and postoperative GERD.
  
  
  METHODS
  Severely obese asymptomatic patients submitted to LSG underwent esophageal manometry and GERD evaluation preoperatively and at least 6 weeks postoperatively. Data reviewed included patient demographics, manometric measurements, GERD symptoms, and pathology. Statistical analysis was performed by SPSS software.
  
  
  RESULTS
  Twelve male and eleven female patients participated in the study. Mean age was 38.5 ± 10.9 years, and initial body mass index was 47.9 ± 5.1 kg/m(2). At follow-up examination, mean excess body mass index loss was 32.3 ± 12.7%. The LES total and abdominal length increased significantly postoperatively, whereas the contraction amplitude in the lower esophagus decreased. There was an increase in reflux symptoms postoperatively (p < 0.009). The operating surgeon who mostly approximated the angle of His resulted in an increased abdominal LES length (p < 0.01). The presence of esophageal tissue in the specimen correlated with increased total GERD score (p < 0.05).
  
  
  CONCLUSIONS
  LSG weakens the contraction amplitude of the lower esophagus, which may contribute to postoperative reflux deterioration. It also increases the total and the abdominal length of the LES, especially when the angle of His is mostly approximated. However, if this approximation leads to esophageal tissue excision, reflux is again aggravated. Thus, stapling too close to the angle of His should be done cautiously.
authors.affiliation: First Propaedeutic Department of Surgery, Hippocration Hospital, University of Athens, 13-15 Zichnis St., 11 527, Athens, Greece, ele.kleidi@gmail.com.
authors.forename: Eleftheria
authors.initials: E
authors.lastname: Kleidi
authors.forename: Dimitrios
authors.initials: D
authors.lastname: Theodorou
authors.forename: Konstantinos
authors.initials: K
authors.lastname: Albanopoulos
authors.forename: Evangelos
authors.initials: E
authors.lastname: Menenakos
authors.forename: Michail A
authors.initials: MA
authors.lastname: Karvelis
authors.forename: Joanna
authors.initials: J
authors.lastname: Papailiou
authors.forename: Konstantinos
authors.initials: K
authors.lastname: Stamou
authors.forename: Georgios
authors.initials: G
authors.lastname: Zografos
authors.forename: Stylianos
authors.initials: S
authors.lastname: Katsaragakis
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Leandros
mesh_terms: D000328:Adult; D049630:Esophageal Sphincter, Lower / Q000503:physiopathology / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D005743:Gastrectomy / Q000379:methods*; D005764:Gastroesophageal Reflux / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control*; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008365:Manometry; D009767:Obesity, Morbid / Q000150:complications / Q000601:surgery*; D011184:Postoperative Period; D011312:Pressure; D011446:Prospective Studies; D016896:Treatment Outcome