Correlation of the Endoscopic Esophagogastric Junction Integrity with Symptomatic GERD in Patients Undergoing Work-Up for Metabolic and Bariatric Surgery

Abdullah Şişik; Muhammed Said Dalkılıç; Mehmet Gençtürk; Merih Yılmaz; Hasan Erdem; Ninh T Nguyen

doi:10.1007/s11695-024-07610-w

Correlation of the Endoscopic Esophagogastric Junction Integrity with Symptomatic GERD in Patients Undergoing Work-Up for Metabolic and Bariatric Surgery

Obes Surg. 2024 Nov 30. doi: 10.1007/s11695-024-07610-w. Online ahead of print.

Authors

Abdullah Şişik^{1

2}, Muhammed Said Dalkılıç³, Mehmet Gençtürk², Merih Yılmaz², Hasan Erdem^{1

2}, Ninh T Nguyen⁴

Affiliations

¹ Health Sciences Faculty, Gedik University Istanbul, Istanbul, Turkey.
² Dr. HE Obesity Clinic, Istanbul, Turkey.
³ Department of General Surgery, Marmara University School of Medicine, Istanbul, Turkey. saiddalkilic@hotmail.com.
⁴ Department of Surgery, University of California Irvine Medical Center, Orange County, Irvine, CA , USA.

PMID: 39614976
DOI: 10.1007/s11695-024-07610-w

Abstract

Background: Gastroesophageal reflux disease (GERD) is a common adverse effect after metabolic and bariatric surgery (MBS). Identifying patients with preexisting GERD is critical for preoperative planning. The American Foregut Society (AFS) recently proposed a new endoscopic classification system for objective assessment of the esophagogastric junction (EGJ) integrity, building upon the Hill classification. Grade 1 represents an intact EGJ, while grades 2, 3, and 4 represent partial, moderate, and complete disruption of the ARB. Unlike Hill classification, the AFS classification includes objective measurement of hiatal axial length and aperture diameter. The study aimed to evaluate the ability of the AFS hiatus classification to predict GERD severity using symptom questionnaires.

Methods: We performed a prospective study of obese patients who underwent endoscopy as work-up for MBS. The endoscopy was evaluated for esophagitis, Barrett's esophagus, and AFS grade. All patients were also surveyed preoperatively with the GERD-HRQL, GerdQ, and RSI. The correlation between AFS grades and questionnaire scores was analyzed using Spearman's test.

Results: A total of 393 patients were included in the study. There were 81% female, with a mean age of 36 ± 10.7 years and a mean BMI of 41.7 ± 7.2 kg/m². The AFS grades were distributed as follows: 11 (2.8%) patients had grade 1; 137 (34.9%) had grade 2; 162 (41.2%) had grade 3; and 83 (21.1%) had grade 4. There was a positive but weak correlation between AFS grades and all scoring systems, including GERD-HRQL (r = 0.201), heartburn (r = 0.203), regurgitation (r = 0.212), RSI (r = 0.110), and GerdQ scores (r = 0.202). However, the proportion of patients with esophagitis increased progressively with increasing grades (0% in grade 1, 2.2% in grade 2, 9.9% in grade 3, and 32.5% in grade 4, p = 0.01).

Conclusion: The AFS hiatus classification can stratify the population with obesity based on rate of esophagitis and symptom scores. This study supports the practical utility of the AFS classification as an adjunct in the detection of patients who are at risk for GERD after MBS. Further validation studies with pH testing are needed.

Keywords: Endoscopy; Esophagitis; Esophagogastric junction; Gastroesophageal reflux; Hiatal hernia; Metabolic and bariatric surgery.