title: Esophagogastric junction morphology assessment by high resolution manometry in obese patients candidate to bariatric surgery.
abstract: BACKGROUND
  Obesity is a strong independent risk factor of gastroesophageal reflux disease (GERD) symptoms and hiatal hernia development. Pure restrictive bariatric surgery should not be indicated in case of hiatal hernia and GERD. However it is unclear what is the real incidence of disruption of esophagogastric junction (EGJ) in patients candidate to bariatric surgery. Actually, high resolution manometry (HRM) can provide accurate information about EGJ morphology. Aim of this study was to describe the EGJ morphology determined by HRM in obese patients candidate to bariatric surgery and to verify if different EGJ morphologies are associated to GERD-related symptoms presence.
  
  
  METHODS
  All patients underwent a standardized questionnaire for symptom presence and severity, upper endoscopy, high resolution manometry (HRM). EGJ was classified as: Type I, no separation between the lower esophageal sphincter (LES) and crural diaphragm (CD); Type II, minimal separation (>1 and < 2 cm); Type III, >2 cm separation.
  
  
  RESULTS
  One hundred thirty-eight obese (BMI>35) subjects were studied. Ninety-eight obese patients referred at least one GERD-related symptom, whereas 40 subjects were symptom-free. According to HRM features, EGJ Type I morphology was documented in 51 (36.9%) patients, Type II in 48 (34.8%) and Type III in 39 (28.3%). EGJ Type III subjects were more frequently associated to Symptoms than EGJ Type I (38/39, 97.4%, vs. 21/59, 41.1% p < 0.001).
  
  
  CONCLUSIONS
  Obese subjects candidate to bariatric surgery have a high risk of disruption of EGJ morphology. In particular, obese patients with hiatal hernia often refer pre-operative presence of GERD symptoms. Testing obese patients with HRM before undergoing bariatric surgery, especially for restrictive procedures, can be useful for assessing presence of hiatal hernia.
authors.affiliation: Division of Surgery, Department of Surgery, Second University of Naples, Naples, Italy; GISE, Gruppo Italiano per lo Studio dell'Esofago, Italy. Electronic address: salvatore.tolone@unina2.it.
authors.forename: Salvatore
authors.initials: S
authors.lastname: Tolone
authors.affiliation: Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy; GISE, Gruppo Italiano per lo Studio dell'Esofago, Italy. Electronic address: edoardo.savarino@unipd.it.
authors.forename: Edoardo
authors.initials: E
authors.lastname: Savarino
authors.affiliation: Division of Gastroenterology, Department of Internal Medicine, University of Pisa, Pisa, Italy; GISE, Gruppo Italiano per lo Studio dell'Esofago, Italy. Electronic address: nick.debortoli@gmail.com.
authors.forename: Nicola
authors.initials: N
authors.lastname: de Bortoli
authors.affiliation: Division of Gastroenterology, Baggiovara Hospital, Modena, Italy; GISE, Gruppo Italiano per lo Studio dell'Esofago, Italy. Electronic address: m.frazzoni@ausl.mo.it.
authors.forename: Marzio
authors.initials: M
authors.lastname: Frazzoni
authors.affiliation: Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy; GISE, Gruppo Italiano per lo Studio dell'Esofago, Italy. Electronic address: manuelefurnari@gmail.com.
authors.forename: Manuele
authors.initials: M
authors.lastname: Furnari
authors.affiliation: Division of Surgery, Department of Surgery, Second University of Naples, Naples, Italy. Electronic address: antodalex@gmail.com.
authors.forename: Antonio
authors.initials: A
authors.lastname: d'Alessandro
authors.affiliation: Division of Surgery, Department of Surgery, Second University of Naples, Naples, Italy. Electronic address: roberto.ruggiero@unina2.it.
authors.forename: Roberto
authors.initials: R
authors.lastname: Ruggiero
authors.affiliation: Division of Surgery, Department of Surgery, Second University of Naples, Naples, Italy. Electronic address: giovanni.docimo@unina2.it.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Docimo
authors.affiliation: Division of Surgery, Department of Surgery, Second University of Naples, Naples, Italy. Electronic address: luigibrusciano@tin.it.
authors.forename: Luigi
authors.initials: L
authors.lastname: Brusciano
authors.affiliation: Division of Surgery, Department of Surgery, Second University of Naples, Naples, Italy. Electronic address: simogili@yahoo.it.
authors.forename: Simona
authors.initials: S
authors.lastname: Gili
authors.affiliation: Division of Surgery, Department of Surgery, Second University of Naples, Naples, Italy. Electronic address: raffale.pirozzi@studenti.unina2.it.
authors.forename: Raffaele
authors.initials: R
authors.lastname: Pirozzi
authors.affiliation: Division of Surgery, Department of Surgery, Second University of Naples, Naples, Italy. Electronic address: simona.parisi@studenti.unina2.it.
authors.forename: Simona
authors.initials: S
authors.lastname: Parisi
authors.affiliation: Division of Surgery, Department of Surgery, Second University of Naples, Naples, Italy. Electronic address: carmine.colella@studenti.unina2.it.
authors.forename: Carmine
authors.initials: C
authors.lastname: Colella
authors.affiliation: Division of Surgical Pathophysiology, Department of Surgery, Second University of Naples, Naples, Italy. Electronic address: mariachiara.bondanese@studenti.unina2.it.
authors.forename: Mariachiara
authors.initials: M
authors.lastname: Bondanese
authors.affiliation: Division of Surgical Pathophysiology, Department of Surgery, Second University of Naples, Naples, Italy. Electronic address: beniamino.pascotto@studenti.unina2.it.
authors.forename: Beniamino
authors.initials: B
authors.lastname: Pascotto
authors.affiliation: Division of Surgical Pathophysiology, Department of Surgery, Second University of Naples, Naples, Italy. Electronic address: nunziomattia.buonomo@studenti.unina2.it.
authors.forename: NunzioMattia
authors.initials: N
authors.lastname: Buonomo
authors.affiliation: Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy; GISE, Gruppo Italiano per lo Studio dell'Esofago, Italy. Electronic address: vsavarin@unige.it.
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Savarino
authors.affiliation: Division of Surgery, Department of Surgery, Second University of Naples, Naples, Italy. Electronic address: ludovico.docimo@unina2.it.
authors.forename: Ludovico
authors.initials: L
authors.lastname: Docimo
mesh_terms: D000328:Adult; D050110:Bariatric Surgery; D004943:Esophagogastric Junction / Q000473:pathology* / Q000503:physiopathology; D005260:Female; D005764:Gastroesophageal Reflux / Q000175:diagnosis* / Q000209:etiology; D006551:Hernia, Hiatal / Q000175:diagnosis* / Q000209:etiology; D006801:Humans; D008297:Male; D008365:Manometry / Q000379:methods*; D009765:Obesity / Q000150:complications* / Q000473:pathology* / Q000601:surgery; D011446:Prospective Studies; D012307:Risk Factors; D011795:Surveys and Questionnaires
keywords: Bariatric surgery; Hiatal hernia; High resolution manometry; Obesity