Surgery for Obesity and Related Diseases 12 (2016) 6269

Original article

Effects of omega-loop bypass on esophagogastric junction function

Salvatore Tolone, M.D. Ph.D.a,*, Stefano Cristiano, M.D.b, Edoardo Savarino, M.D., Ph.D.c,
Francesco Saverio Lucido, M.D.b, Domenico Ivan Fico, M.D.b, Ludovico Docimo, M.D.a
a

Division of General and Bariatric Surgery, Department of Surgery, Second University of Naples, Naples, Italy
b
General and Bariatric Surgery Unit, Camilliani Hospital, Casoria, Italy
c
Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
Received January 27, 2015; accepted March 22, 2015

Abstract

Background: At present, no objective data are available on the effect of omega-loop gastric bypass
(OGB) on gastroesophageal junction and reux.
Objectives: To evaluate the possible effects of OGB on esophageal motor function and a possible
increase in gastroesophageal reux.
Setting: University Hospital, Italy; Public Hospital, Italy.
Methods: Patients underwent clinical assessment for reux symptoms, and endoscopy plus highresolution impedance manometry (HRiM) and 24-hour pH-impedance monitoring (MII-pH) before
and 1 year after OGB. A group of obese patients who underwent sleeve gastrectomy (SG) were
included as the control population.
Results: Fifteen OGB patients were included in the study. After surgery, none of the patients reported
de novo heartburn or regurgitation. At endoscopic follow-up 1 year after surgery, esophagitis was
absent in all patients and no biliary gastritis or presence of bile was recorded. Manometric features and
patterns did not vary signicantly after surgery, whereas intragastric pressures (IGP) and gastroesophageal pressure gradient (GEPG) statistically diminished (from a median of 15 to 9.5, P o .01,
and from 10.3 to 6.4, P o .01, respectively) after OGB. In contrast, SG induced a signicant elevation
in both parameters (from a median of 14.8 to 18.8, P o .01, and from 10.1 to 13.1, P o .01,
respectively). A dramatic decrease in the number of reux events (from a median of 41 to 7; P o .01)
was observed after OGB, whereas in patients who underwent SG a signicant increase in esophageal
acid exposure and number of reux episodes (from a median of 33 to 53; P o .01) was noted.
Conclusions: In contrast to SG, OGB did not compromise the gastroesophageal junction function
and did not increase gastroesophageal reux, which was explained by the lack of increased IGP and
in GEPG as assessed by HRiM. (Surg Obes Relat Dis 2016;12:6269.) r 2016 American Society
for Metabolic and Bariatric Surgery. All rights reserved.

Keywords:

Omega-loop gastric bypass; One-anastomosis gastric bypass; GERD; Reux; High-resolution manometry; MIIpH; Impedance; Obesity; Bariatric surgery

Obesity is a growing epidemiologic problem in the Western countries, leading to important diseases and complications. Thus, several bariatric operations for morbid obesity
*
Correspondence: Salvatore Tolone, M.D., Ph.D., Division of General
and Bariatric Surgery, Department of Surgery, Second University of
Naples, Via Pansini 17, 80131, Naples, Italy.
E-mail: salvatore.tolone@unina2.it

have been developed to reduce excess weight. In particular,

gastric banding, gastric bypass surgery, and sleeve gastrectomy are the most commonly used at the moment.
More recently, omega-loop gastric bypass (OGB, also
known as mini-gastric bypass or one-anastomosis gastric
bypass), a modication of Masons loop gastric bypass,
consisting primarily of a long linear lesser-curvature gastric
tube with a terminolateral gastroenterostomy 180200 cm

http://dx.doi.org/10.1016/j.soard.2015.03.011
1550-7289/r 2016 American Society for Metabolic and Bariatric Surgery. All rights reserved.

Omega-loop Gastric Bypass and Reux / Surgery for Obesity and Related Diseases 12 (2016) 6269

distal to the ligament of Treitz, was introduced [1].

Thousands of these procedures have now been performed
globally and it is considered a well-tolerated and effective
option for morbid obese patients [2].
Despite positive effect in terms of weight loss and
improvement of obesity-related co-morbidities, there are
concerns about the reported complication rate and the
length of follow-up, with the recommendation to establish
a registry of complications and revision procedures [35].
In particular, symptomatic biliary reux gastritis and
esophagitis requiring revision surgery have been reported
[3]. Concerns have also been expressed about the risk of
gastric/esophageal cancer with this procedure because of
chronic biliary reux [6]. However, no data are available on
the effect of this type of procedure on gastroesophageal
reux.
Therefore, to verify if OGB can increase chronic
gastroesophageal reux, we designed a study that combined
high-resolution manometric measurements with 24-hour
pH-impedance monitoring before and after this bariatric
intervention. The primary objective was to assess the effect
of OGB on gastroesophageal reux and reux symptoms.
Other objectives included the assessment of the effect of
OGB on esophagogastric junction (EGJ) function parameters such as lower esophageal sphincter (LES) pressure and
on esophageal peristalsis.

Materials and methods

Study design and patient selection
In this prospective study, 15 obese adult (Z18 yr)
patients were included. All patients underwent OGB in
the Camilliani hospital in Casoria, Italy. Before and 1 year
after the surgical procedure, presence of reux-related
symptoms and dysphagia were evaluated using validated
questionnaires, and upper endoscopy, combined highresolution impedance manometry (HRiM), and combined
24-hour pH-impedance monitoring (multichannel intraluminal impedance pH monitoring [MII-pH]) of the esophagus
were performed.
The local Institutional Review Board approved the study
protocol, and informed consent was obtained from each
participant. The study was conducted according to the
Helsinki Declaration.
Bariatric surgery was indicated according to international
guidelines [7]. Exclusion criteria from the study were as
follows: symptoms and/or diagnosis of gastroesophageal
reux disease (GERD) during the preoperative evaluation
protocol; previous upper gastrointestinal surgery; paraesophageal (type 2), mixed (type 3), or sliding hiatal hernias Z3 cm; presence of esophagitis; and Barretts
metaplasia.
Patients without preoperative endoscopic evaluation or
with the absence of MII-pH or HRiM data were excluded

63

from the study. Patients lost to follow-up and those who

declined consent were excluded from the study as well.
Clinical evaluation
Anthropometric measurements were obtained in all
patients (weight, height, body mass index [BMI], body
composition determined by conventional quadripolar body
impedance analyzer [BIA], TANITA). The patients were
evaluated for symptoms using a validated questionnaire
incorporating a Likert visual analogue scale (03, where
0 absent, 1 mild, 2 moderate, and 3 severe) for
GERD-related symptoms (e.g., heartburn, regurgitation, and
chest pain) and dyspeptic symptoms (e.g., epigastric pain,
nausea, and abdominal pain) [8].
Endoscopy
High-magnication upper gastrointestinal endoscopy
before and 1 year after surgery was performed according
to international guidelines. Any visible lesions, including
esophagitis, gastritis, anastomotic inammation, ulcers, or
strictures, were recorded. Esophagitis was staged according
to the Los Angeles classication [9], whereas gastritis was
graded according to the Sidney system [10]. Biopsies were
performed only in the presence of macroscopic evidence of
inammation.
Evaluation of esophageal function
Patients had to observe fasting since the night before and
had to be off medication (any kind of proton pump
inhibitors [PPI], or drugs affecting the normal gastrointestinal motility) for at least 14 days. At the end of the
recording period, HRiM and MII-pH tracings were
reviewed manually by a single expert investigator (ST)
blinded for the conditions of the patients to ensure accurate
detection and classication of EGJ, motility patterns, and
reux episodes.
HRiM
Each patient underwent manometrical esophageal function testing using HRiM with a 32- channel probe (SandhillHRiM catheter InSight; Sandhill Scientic Inc., Highlands
Ranch, CO, USA). Data acquisition, display, and analysis
were performed using dedicated software (Sandhill Bioview, Sandhill Scientic), after a proper thermal compensation. The patients underwent transnasal placement of the
manometric assembly, and the catheter was positioned to
record from the hypopharynx to the stomach. Studies were
done in a supine position, and the manometric assembly
was positioned with at least 5 intragastric sensors to
optimize EGJ and intragastric recording. The catheter was
then taped to the nose. The manometric protocol included at

64

S. Tolone et al. / Surgery for Obesity and Related Diseases 12 (2016) 6269

least 10 5-mL swallows (.3% saline) and a 5-minute period

to assess basal sphincter pressure [11].
The LES was localized and its pressure and relaxations
(using the integrated relaxation pressure over 4 s, IRP)
evaluated; proximal and distal borders were marked according to pressure difference related to intraesophageal and
intragastric pressure marks. Crural diaphragm (CD) was
marked as the axial level characterized by maximal inspiratory pressure augmentation. In individuals with normal
anatomy, LES and CD were superimposed and indistinguishable. Patients were then classied to have normal EGJ
or hiatal hernia, based on the presence of axial cranial
separation between LES and CD, measured in centimeters
[12]. The gastroesophageal pressure gradient (GEPG) was
calculated using the average values of the simultaneous
intraesophageal and intragastric pressure measurements.
Patients were classied to have normal or abnormal
motility according to what has been established in the
literature: HRiM motility patterns were graded according
to the recently developed Chicago Classication by means
of esophageal pressure topography [13]. Other measured
parameters included the distal contractile integral (DCI)
and the distal latency (DL). For each liquid swallow,
complete bolus transit occurred when the bolus entered the
rst pair of impedance sensors and exited the second,
third, and fourth pair of sensors. The study was considered
abnormal if complete bolus transit occurred in o80% of
liquid swallows. Bolus transit time (BTT) was expressed
as time in seconds from the entrance of the bolus in the
area of the proximal channel placement to the exit across
the area where the most distal impedance channel was
placed [14].

(abnormal if total time with pH o4 was 46.3%, and/or

upright time with pH o4 was 44.2%, and/or recumbent
time with pH o4 was 41.2%), number and quality (acid,
weakly acid, and weakly alkaline) of reux detected at MII
(normal value o73), and symptom association probability
(SAP), as described elsewhere [15].
Surgical technique
All patients underwent laparoscopic OGB, using 45
ports (Fig. 1). In short, it consisted of a laterolateral
anastomosis between a sleeved gastric pouch 1518 cm
long and a jejunal loop 200 cm distal to the duodenal
ligament of Treitz. To create the gastric pouch, a 42F
bougie was used. The length of the jejunal loop was
measured to be 200 cm from the Treitz duodenal

24-hour MII-pH
All patients underwent outpatient 24-hour MII-pH. A
specic MII-pH catheter (with intraluminal impedance
segments positioned at 3, 5, 7, 9, 15, and 17 cm above
the LES) (Sandhill Scientic Inc., Highlands Ranch, CO,
USA) was placed transnasally, with the esophageal pH
sensor positioned 5 cm above the manometrically determined LES. Patients were invited to indicate and record 3 or
more predominant symptoms and their occurrence during
the recording time, as well as to record the times of every
meal and position changes between upright and recumbent
state, both on the device and on a written diary provided.
The information transmitted by the catheter was processed
using the devices software (Sleuth SystemSandhill Scientic Inc., Highlands Ranch, CO, USA). MII-pH data were
collected and analyzed with the Bioview GERD Analysis
Software (Sandhill Scientic Inc., Highlands Ranch, CO,
USA). Meal periods were excluded from the analysis.
By means of MII-pH, the following variables were
assessed: distal esophageal acid exposure as a percentage
(%) of time (acid exposure time [AET]) with pH o4

Fig. 1. Schematic representation of omega-loop gastric bypass (OGB). A

laterolateral anastomosis is created between a sleeved (with a 42F bougie)
gastric pouch 1518 cm long and a jejunal loop 200 cm distal to the
duodenal ligament of Treitz.

Omega-loop Gastric Bypass and Reux / Surgery for Obesity and Related Diseases 12 (2016) 6269

ligament. The gastrojejunal anastomosis was performed

with a 60-mm endoscopic linear stapler and the stapler
defect was closed by a double-layer running 20 suture. An
intraoperative methylene blue test was performed to exclude
anastomotic leaks. A perianastomotic drain tube was placed
in all the patients.
Control group
A group of morbid obese adult patients who underwent
sleeve gastrectomy (SG) was used as the control group. All
patients underwent HRiM and MII-pH before and after
surgery. Detailed data regarding this group have been
recently published by our group [16].
Statistical analysis
Statistical analysis was performed using SPSS for MAC
OSX (version 22; IBM Inc., Armonk, NY, USA). Continuous
data are expressed as median and interquartile (25th75th)
range, unless otherwise indicated. The Wilcoxon signed-rank
test for paired data was used for comparison of means in OGB
patients. Unpaired t test was used for comparison of means in
OGB patients versus the control group (SG). A 2-sided P
value of .05 was considered statistically signicant.
Results
In total, 15 patients (5 males/10 females), with a mean
age of 38 8.2 years, a median preoperative weight of
141.1 kg (121174), and a mean BMI of 46.4 (3860) kg/
m2, participated in the study. At the 1-year postoperative
follow-up, the median weight was 81.2 kg (72111), the
median BMI was 31 kg/m2 (28-42), and the excess weight
loss (EWL, %) was 63 (5669).
The control group was constituted by 25 adult patients
who underwent SG, age- and sex-matched with patients
who underwent OGB. Their median preoperative weight
was 130.8 kg (119156) and median BMI was 46.1 (38
58); 1-year postoperative median weight was 98 kg (72
110) and median BMI was 34.7 (2846), with 56% excess
weight loss.
Symptoms
At baseline, none of the patients who underwent OGB
and SG were reported on PPIs, although 2 of them reported
previous use (45 yr before the surgical evaluation) of
sodium alginate on demand. Moreover, none of the
patients reported typical or atypical symptoms suggestive
of GERD or dyspepsia-like symptoms before surgery. After
surgery, none of the OGB patients reported de novo
heartburn or regurgitation and the dyspepsia-like symptom
score did not change. Similarly, after SG, the incidence of
symptoms related to reux was not modied.

65

Endoscopy
At the preoperative upper endoscopy, mild, chronic,
Helicobacter pylorinegative gastritis was diagnosed in 2
patients and esophagitis was not observed in any of the
patients. One year after OGB, esophagitis was absent in all
patients and no enlargement or strictures were noted in the
gastric pouch of any patient. Persistence of mild mucosal
inammation (redness), without any sign of bleeding or
ulceration, was observed in 1 of the 2 patients with
preoperative chronic gastritis. No biliary gastritis or presence of bile was recorded during endoscopy with histologic
assessment. However, histologically proven mild perianastomotic inammation was present in 13 of 15 patients
(Table 1). In the SG group, endoscopic 12-month postoperative follow-up revealed the presence of grade A
esophagitis in 1 patient, and 2 patients presented a mild
gastric inammation.
HRiM
In the OGB group, median LES pressure varied, without
any statistically signicance, from 22.1 (19.532) to 22
(19.830.4) mm Hg (P .865) and median IRP varied
from 6.8 (3.211.1) to 6.5 (3.211.0) (P .732). Intragastric
pressure decreased from 15.5 (13.117.2) before to 9.5 (7.5
10.3) mm Hg after OGB (P o .01), and no gastric squeeze
was observed. Also, GEPG was found to be reduced from
10.3 (8.614.5) to 6.4 (4.08.1), P o .01. Before OGB, 2 of
15 patients had manometric evidence of a grade II hiatal
hernia (mean distance CDLES of .8 cm). Because of this
small defect, none of these patients needed a surgical crural
repair. After OGB, the 2 small hiatal hernias disappeared and
none of the remaining patients developed a hiatal hernia. The
percentage of normal peristaltic waves remained unchanged
after surgery. Likewise, no modication in DCI or DL was
recorded; complete bolus transit and BTT at impedance were
not modied after surgery. Comprehensive data of HRiM
ndings are presented in Table 2.
In the SG group, similar data were recorded in terms of
EGJ features, as shown in Table 2. However, in this group,
the intragastric pressure (IGP) and GEPG signicantly
increased after surgery (P o .01 and P o .01, respectively). Compared with SG, OGB resulted in similar LES
pressure modications, but the IGP and GEPG were
signicantly diminished in the latter procedure. Similar to
Table 1
Endoscopic ndings at 1 year after omega-loop gastric bypass (OGB)
Upper endoscopy features
Esophagitis
Present
Absent
Gastritis
Perianastomotic
Diffuse

Obese post-OGB (n 15)

(%)

0
15

0
100

13
1

86.6
6.6

66

S. Tolone et al. / Surgery for Obesity and Related Diseases 12 (2016) 6269

Table 2
Pre- and postoperative assessment at high-resolution impedance manometry in omega-loop gastric bypass (OGB) and in sleeve gastrectomy (SG) patients

Esophagogastric junction parameters

LESp
IRP
IGP
GEPG
Esophageal body parameters
DCI
DL
Ineffective (failed/weak) peristalsis (%)
Hyper-contractile peristalsis (%)
Bolus transit parameters at impedance
CBT
BTT

Obese pre-OGB
(n 15) median
(25th75th)

Obese post-OGB
(n 15) median
(25th75th)

P value*

Obese pre-SG
(n 25) median
(25th75th)

Obese post-SG
(n 25) median
(25th75th)

P value

22.6
6.8
15.5
10.3

(20.827.0)
(3.211.1)
(13.117.2)
(8.614.5)

23.0
6.5
9.5
6.4

(21.226.2)
(3.211.0)
(7.510.3)
(4.08.1)

.865
.732
.002
.001

21.3
6.5
14.8
10.1

(18.533.0)
(3.211.2)
(12.618.2)
(8.314.0)

22.0
6.3
18.8
13.1

(19.033.0)
(3.210.9)
(10.221.2)
(10.715.1)

.810
.856
.001
.001

1938
6.1
10
0

(16542456)
(5.57.2)
(1020)
(00)

1891
6.2
10
0

(16542241)
(5.57.5)
(1020)
(0-0)

.856
.961
.934

1880
6.2
10
0

(15252302)
(5.57.2)
(1020)
(00)

927
6.0
46
0

(3001478)
(5.57.0)
(3050)
(00)

.001
.821
.000

80 (7090)
8.38 (7.9110.1)

80 (7090)
8.37 (7.810.4)

.934
.657

90 (80100)
8.0 (7.89)

50 (3070)
8.4 (7.89)

.000
.856

LESp lower esophageal sphincter pressure in mm Hg; IRP integral relaxation pressure in mm Hg  cm  sec; IGP intragastric pressure in mm Hg;
GEPG gastroesophageal pressure gradient in mm Hg; DCI distal contractile integral in mm Hg  sec  cm; DL distal latency in seconds; CBT
complete bolus transit in percentage; BTT bolus transit time in seconds.
*
Wilcoxon rank sum test for paired data for pre- and post-OGB.

Unpaired t test comparing post-OGB results with post-SG results.

what observed in patients who underwent OGB, esophageal

motility patterns were not modied after SG.
24-hour MII-pH
Similar MII-pH monitoring times (both in prone and in
supine position) were available for all patients. Total time
(P o .01) and upright- (P o .01) and recumbent(P o .01) position AET were signicantly decreased after
surgery in the OGB group, paralleled by a signicant
decrease in DeMeester Score. A marked reduction of total
reux episodes (41 versus 7; P o .01) after OBG was
observed at MII. Both acid and weakly acid reuxes were
signicantly diminished in number (P o .01 and P o .01,
respectively). Moreover, the average number of weakly
alkaline reux episodes was signicantly reduced after
surgery (P o .01). In contrast, AET signicantly increased
in the recumbent position (P o .05), and the total number
of reux episodes signicantly increased (33 versus 53,
P o .01)in particular, episodes of weakly acid reux
(P o .01) after surgery in the SG group.
Compared with SG, OGB resulted in a more signicant
reduction of AET as well as acid and weakly acidic reux
episodes. Detailed ndings of MII-pH monitoring are
shown in Table 3.
Discussion
This is the rst study, to our knowledge, in which the
effects of OGB on esophagogastric junction and gastroesophageal reux are studied using the current goldstandard instruments for their assessment: high-resolution
impedance manometry and 24-hour pH-impedance

monitoring. The most prominent nding of the study was

that a signicant reduction both in esophageal acid exposure
and in reux episodes was observed in all patients after
OGB, whereas in patients who underwent SG, an increase
in both features was observed. This phenomenon may be
explained by the lack of increased IGP and in GEPG in the
OGB group, as assessed by HRiM.
Currently, Roux-en-Y gastric bypass (RYGB) is the
surgical procedure most commonly performed worldwide
for morbid obesity, but it still ranks as one of the most
challenging surgeries when performed laparoscopically
[17]. Although the risk of the previously mentioned
procedure is relatively low in the hands of experts, OGB
was developed to overcome operative difculties and risks
associated with Roux-en-Y gastric bypass. It offers the
advantages of a simple and reproducible technique, with
good outcome and low associated morbidity and mortality.
In a prospective, randomized controlled clinical trial, Lee
et al. found that OGB was effective for the treatment of
morbid obesity, with results that were comparable to those
obtained after RYGB for the resolution of metabolic
syndrome and for the improvement of quality of life. These
authors also regarded OGB as a simpler and better tolerated
procedure that has no disadvantage compared with RYGB
after a follow-up of at least 2 years [18].
Despite these promising results, many concerns have
been raised about this procedure, in particular about the
alimentary limb reconstruction, which usually recalls the
Billroth II reconstruction and could potentially increase
both acid and biliary reux. Although duodenogastric bile
reux is a physiologic phenomenon [19,20], excessive
duodenogastric biliary reux can lead to intestinal metaplasia, esophageal mucosal damage, symptomatic gastritis/

Omega-loop Gastric Bypass and Reux / Surgery for Obesity and Related Diseases 12 (2016) 6269

67

Table 3
Detailed ndings at multichannel intraluminal impedance pHmetry (MII-pH) before and after omega-loop gastric bypass (OGB) and sleeve gastrectomy (SG)
Obese pre-OGB
(n 15) median
(25th75th)
AET (%) pH o 4
Total
2.5 (1.83.4)
Upright
2.6 (2.03.7)
Recumbent
.8 (.51.0)
DeMeester score
13.1 (1024)
Number of reux at MII
Total
41 (2066)
Upright
32 (1551)
Recumbent
9 (216)
Acid reux pattern at MII
Total
32 (1550)
Upright
27 (1337)
Recumbent
5 (111)
Weakly acid reux pattern at MII
Total
9 (515)
Upright
5 (410)
Recumbent
4 (15)
Weakly alkaline reux pattern at MII
Total
0 (03)
Upright
0 (03)
Recumbent
0 (01)
Postprandial reux events at MII
Total
22 (1141)

Obese post-OGB
(n 15) median
(25th75th)

P value*

Obese pre-SG
(n 25) median
(25th75th)

Obese post-SG
(n 25) median
(25th75th)

P value

.0
.2
.0
.9

.000
.000
.000
.000

1.4
1.1
1.0
9

3.2
1.9
3.1
18.2

.000
.002
.003
.000

7 (314)
4 (35)
0 (02)

.000
.000
.000

33 (2039)
26 (1530)
7 (49)

53 (3057)
38 (2040)
15 (1017)

.000
.000
.000

3 (36)
3 (34)
0 (02)

.000
.008
.000

12 (914)
9 (810)
3 (24)

16 (9-18)
13 (715)
3 (06)

.000
.000
.000

2 (06)
1 (15)
0 (02)

.001
.000
.752

15 (820)
11 (612)
4 (25)

34 (1442.5)
27 (930)
7 (511.5)

.000
.000
.000

0 (02)
0 (02)
0 (00)

.000
.000
.459

0 (03)
0 (03)
0 (01)

2 (13)
2 (02)
1 (01.5)

.003
.045
.001

5 (29)

.000

12 (619)

28 (1740)

.000

(.0.8)
(.0.7)
(.0.1)
(.92.2)

(1.02.0)
(.11.2)
(.01.2)
(4.112.5)

(2.05.0)
(.22.6)
(.04.2)
(8.030.5)

MII multichannel intraluminal impedance; AET acid exposure time in percentage.

Wilcoxon rank sum test for paired data for pre- and post-OGB.

Unpaired t test comparing post-OGB results with post-SG results.

*

esophagitis, Barretts esophagus, and gastric/esophageal

cancer [2124].
To date, there are no studies that directly and properly
determine the amount of acid and weakly acidic reux,
including duodenogastric bile reux, after OGB, a procedure that could be potentially associated with major
esophageal and gastric pouch complications. In 2007,
Johnson et al. [3] performed a retrospective review of the
databases from 5 medical centers, identifying 32 patients
who needed surgical revision after an OGB procedure.
Indications for revision surgery were bile reux in 20,
malabsorption/malnutrition in 8, intractable marginal ulcer
in 5, gastrojejunostomy leak in 3, and weight gain in 2. The
most common complication reported in this study was bile
reux gastritis, which occurred in 20 patients. All patients
in whom surgical revision was performed required conversion to RYGB or Braun enteroenterostomy.
On the other hand, surgeons who have signicant
experience with OGB have not reported symptomatic reux
to be a major problem after this procedure. Rutledge
reported that 62% of patients suffering from reux preoperatively, whereas only 6 patients among 1274 (.6%) had
reux postoperatively [1]. Moreover, in a 6-year follow-up
study on 2410 patients, Rutledge and Walsh reported
signicant improvement (85%) in reux-related symptoms
[2]. However, caution is warranted when analyzing these

results, because no objective method for reux evaluation

was employed. More recently, Carbajo et al. evaluated a
cohort of patients who underwent laparoscopic 1anastomosis gastric bypass and reported that none had
reux symptoms postoperatively [25]. They studied reux
with 24-hour pH and manometry in conjunction with
endoscopy at 12 and 18 months after surgery, with normal
ndings in all. However, this study presents some limitations; because only patients with no symptoms were
studied, the results can only be applied to asymptomatic
patients and are hardly applicable to other groups of
patients. Also, it is not clear why only patients without
symptoms were chosen and what proportion of patients they
represented among OGB groups.
In our study, we did not nd any de novo GERD or any
increase in GERD symptom score, conrming the data of
Rutledge et al. regarding the low risk of reux symptom
development after OGB. Furthermore, it was not possible to
determine a possible protective antireux effect of OGB
because none of the patients in the study group had GERD
symptoms or endoscopic lesions that would suggest asymptomatic GERD. In line with Rutledge et al.s ndings, no
EGJ function and motility abnormalities were observed
after OGB. In addition, for the rst time we documented a
drastic reduction not only in esophageal acid exposure time
but also in all kinds of reuxes (acidic, weakly acidic, and

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S. Tolone et al. / Surgery for Obesity and Related Diseases 12 (2016) 6269

weakly alkaline), thanks to the use of the state-of-the-art

method for reux monitoring (i.e., impedance-pH). Thus, a
postoperatively median number of only 7 total reux
episodes can be interpreted as a nearly null esophageal
exposure to all kind of reux, even biliary reux. Also, at
upper endoscopy, all of our patients had a normal esophagus and gastric mucosa, with only 1 patient having gastritis
(redness, without evidence of biliary gastric content), and
the same hyperemic gastritis was also evident in 2 patients
after SG, supporting the concept that gastric inammation
can be present independently from the presence of biliary
content (e.g., Helicobacter pylori infection). Indeed, 13/15
patients had perianastomotic mild inammation; this can be
consistent with a normal passage of bile through the gut.
However, anastomotic inammation also can be due to
different mechanisms, as well as to the mechanical effect of
food bolus or to the direct passage of gastric juice into the
jejunum, worsened by the lack of neutralizing bicarbonate
from duodenum. Interestingly, anastomotic inammation or
marginal ulcers can also be found in Roux-en-Y reconstruction, although they are less common after this type of
surgery. Nevertheless, a recent systematic review by
Coblijn et al. [26] found that the incidence of marginal
ulcers as reported in different case series varies from .6% to
25%. In addition, the authors identied several risk factors
independent from biliary reux that are associated with
marginal ulcers, including the type of suture materials used,
the position of the gastric pouch, and the use of NSAIDs.
At HRiM, we found that neither OGB nor SG have a
negative impact on LES pressure. This differs from what
reported by Braghetto et al. [27], who demonstrated a
reduced LES pressure 6 months after SG, probably because
of the section of some LES bers, especially at the His
angle. A slight variation in the surgical SG technique,
performing the incision 1 cm lateral to the His angle,
probably spares more LES bers, resulting in the conserved
LES function as found in the present study with HRiM, a
modern diagnostic tool. Thus, we hypothesize that the long,
narrow sleeve gastric tube could have caused an increase in
intragastric pressure, triggering a rise in GEPG, which in
turn could result in an intensication of postprandial weakly
acidic reux, as we herein documented in SG. Instead, the
OGB group had a decrease in intragastric pressure after
surgery with respect to the presurgical elevated pressures
akin to those of normal BMI controls [28], with a
concomitant fall in GEPG values. This difference with SG
could be explained by the absence of pylorus, so that the
sleeved stomach of MGB can release the food bolus directly
into the alimentary limb, without an increase in intragastric
pressure. It is relevant to note that SG patients also did not
report symptoms after surgery despite the increased level of
reux recorded at pH-impedance testing. This may be
explained by the low sensitivity of obese patients to reux,
as has been previously noted [28]. A second explanation
may be the short-term follow-up period, which may have

missed patients who will develop reux symptoms in the

future, when the histologic lesions leading to symptoms in
the esophagus will be more marked [29].
Our study has several limitations. First, the number of
patients in this study was relatively small, primarily because
of the invasiveness of preoperative as well as postoperative
procedures required for the study protocol, including upper
gastrointestinal endoscopy, HRiM, and impedance-pH.
Second, only patients without GERD or hiatal hernia before
surgery were selected for the study. This particular selection
was chosen to test if OGB could induce de novo GERD.
Hence, this study was not powered to determine if OGB
improves EGJ function in patients with preoperative documented GERD or a large hiatal hernia. Moreover, this study
provided no direct measurement of esophageal or gastric
biliary reux, which is possible only with Bilitec. The latter
technique is not as widely used as pH-impedance monitoring and its usefulness is impaired by a low positive
predictive value. Moreover, pH-impedance provides information on all types of reux, and thus we were indirectly
able to obtain these data from impedance patterns.
Conclusions
In conclusion, OGB induced no modications in terms of
EGJ function and motility patterns in obese patients without
preoperative GERD or large hiatal hernia 12 months after
surgery. However, in contrast to SG patients, patients who
underwent OGB had signicantly diminished esophageal
acid exposure and total number of reux episodes, including acidic, weakly acidic, and weakly alkaline reux. This
phenomenon may be explained by the lack of increased IGP
and GEPG as assessed by HRiM. Further studies are
required to conrm the impact of OGT on obese patients
with preoperative documented GERD or hiatal hernia, 2
situations that are associated with both acid and biliary
reux. Because of the small number of patients and the
relatively short follow-up period of 12 months, the longterm relevance of these ndings requires further evaluation
and conrmation in larger prospective studies.
Disclosures
The authors have no commercial associations that might
be a conict of interest in relation to this article.
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