Symptoms of gastroesophageal reflux disease in bariatric patients

Introduction

Gastroesophageal reflux disease (GERD) is a common condition, estimated to affect 10–28% of the population [1, 2]. In northern Poland, up to 40.5% of respondents reported occasional GERD symptoms. Precise estimation of GERD prevalence is challenging, as many individuals consider heartburn symptoms to be “normal” and use over-the-counter acid-reducing medications without consulting specialists [3].
The hallmark symptoms of GERD are heartburn and/or regurgitation of stomach contents into the esophagus. The clinical diagnosis can be made based on patient history and reported symptoms, which is considered the first step in GERD diagnosis according to recommendations. Further diagnostic evaluation is warranted in the presence of alarm symptoms, such as weight loss, dysphagia, odynophagia, anemia, gastrointestinal bleeding, persistent vomiting, or severe epigastric pain.
General recommendations for patients with GERD symptoms emphasize lifestyle modifications. These include weight reduction in overweight and obese individuals, elevating the head of the bed during sleep, and avoiding meals at least three hours before bedtime [4].

The relationship between obesity and gastroesophageal reflux disease

Epidemiological studies indicate that obesity significantly influences the occurrence of GERD, and the prevalence of obesity in the population continues to rise [5, 6]. For individuals who are overweight (body mass index [BMI] of 25–29.9 kg/m²) or obese (BMI ≥ 30), various mechanisms explain the increased risk of GERD. Obesity raises intra-abdominal pressure, leading to spontaneous transient relaxations of the lower esophageal sphincter (temporary lower esophageal sphincter relaxations – TLESRs). This condition exacerbates esophageal motility disorders and gastric emptying dysfunction, resulting in the backflow of stomach contents into the esophagus. Moreover, excess adipose tissue produces substances that promote and sustain inflammation in the esophagus caused by refluxed stomach contents [2, 7]. Elevated estrogen levels in obese women further increase the esophagus’s exposure to stomach acid [1].
Additionally, lifestyle factors common among obese individuals contribute to GERD development. These include diets high in processed foods, increased consumption of carbonated beverages, large meal portions (particularly before bedtime), and low physical activity levels [8, 9].

The impact of bariatric surgery on GERD

A systematic increase in obesity is being observed in many countries. Due to the limited effectiveness of lifestyle changes (diet, physical activity) and pharmacotherapy, bariatric surgery has been shown to be a safe and effective method for weight reduction and the treatment of comorbid conditions [10].
The aim of this study was to evaluate the impact of bariatric surgery on the symptoms of GERD.

Material and methods

This prospective study was conducted in the Surgery Clinic with a group of 115 patients scheduled for bariatric surgery. The first phase of the study was carried out before the surgical procedure. Consecutive patients hospitalized prior to their primary bariatric surgery were included. Individuals who had previously undergone bariatric surgery were excluded from the study. Participation required voluntary consent from the patients.
Before surgery, the patients completed survey forms independently and consented to follow-up surveys conducted by telephone three months after the surgery, forming the second phase of the study.
The initial survey collected demographic data, body weight and height measurements, comorbidities, and general information related to the surgical procedure. The standardized GERD Impact Scale (GIS) [11] was used as a research tool. The GIS comprises nine questions and provides a quality-of-life profile in three categories: Upper gastrointestinal symptoms (questions 1a, 1b, and 1d); Other symptoms related to stomach acid (questions 1c and 1e); The impact of the symptoms on the patient’s daily lives (questions 2, 3, 4, and 5).
Each dimension was scored with an average result. Responses were assigned points as follows: 4 points for no symptoms, 3 points for occasional symptoms, 2 points for frequent symptoms, 1 point for daily symptoms.
Data from 104 patients were included in the final analysis. The exclusion of 11 patients was due to the inability to establish phone contact during the second phase.
Appropriate statistical tests were used for data analysis, with results considered statistically significant at p < 0.05.
The study received ethical approval from the Bioethics Committee at Nicolaus Copernicus University in Toruń, Collegium Medicum in Bydgoszcz, with approval number KB 40/2024.

Characteristics of the study group

The study included 104 participants aged between 18 and 62 years, with a mean age of 40.34 years. Women constituted 76.9% of the group, while men made up 23.1%. Urban residents accounted for 72.1% of the participants. The majority of individuals (44.3%) had vocational education.
The most frequently reported comorbid conditions among the participants were: hypertension, hypothyroidism, insulin resistance and diabetes, GERD, sleep apnea, gallstone disease, degenerative joint disease, polycystic ovary syndrome (PCOS), and depressive disorders.
Bariatric treatment for obesity in the study group involved performing a sleeve gastrectomy (SG).

Results

Body mass index

The body weight of the participants before surgery was in the range 85–178 kg, with a mean weight of 117.41 kg. After surgery, body weight was in the range 61–150 kg, with a mean of 97.88 kg. The mean weight loss in the study group was 18.83 kg.
Analysis using the Wilcoxon test revealed a statistically significant reduction in body weight after surgery (Z = 8.86, p < 0.001, r = 0.87). Similarly, there was a statistically significant decrease in BMI after the procedure (Z = 8.85, p < 0.001, r = 0.87).

GIS scale

The GIS questionnaire was used to evaluate the presence of gastrointestinal symptoms among the study participants. Table 1 presents the comparative analysis of the frequency of individual symptoms before and after surgery, as well as their impact on sleep, eating habits, work, and the need for additional medications to alleviate reflux symptoms. Higher scores indicated lower severity of symptoms and, consequently, a higher quality of life.
Before surgery, 22 participants (21%) did not report any GERD symptoms listed in the scale. After surgery, this number increased to 58 participants (55.8%). However, symptoms appeared de novo in 7 (31.8%) of the 22 participants who were GERD symptom-free before surgery during the postoperative observation period. Among the entire group presenting GERD symptoms before the procedure, only 11 participants (13.4%) experienced complete symptom resolution after surgery.
Based on the average GIS scores, it was determined that the surgery had a statistically significant impact (p < 0.05) on reducing the frequency of reflux symptoms compared to the preoperative period. The most notable improvements were observed in the following areas: absence of difficulties falling asleep, ability to freely consume favorite foods and beverages, increased activity at work or in daily tasks due to symptom reduction.
According to the properties of the GIS scale, its three subscales were analyzed (Table 2). The differences in scores between the preoperative period and three months after the surgery proved to be statistically significant. This confirms the beneficial impact of the performed surgery on reducing the severity of GERD symptoms and improving the quality of life for the participants.
During data analysis (Spearman’s r correlation), a statistically significant weak negative correlation was observed between the participants’ age and upper gastrointestinal symptoms occurring after surgery (r = –0.22, p = 0.026). The frequency of symptoms was higher in older individuals.
Before the surgical procedure, symptoms related to stomach acid were less bothersome for patients with higher body weight (r = 0.21, p = 0.031). These individuals also experienced a lower impact of GERD symptoms on daily functioning (r = 0.23, p = 0.022).
The difference in body weight before and three months after the surgery did not significantly influence changes in the perception of GERD symptom severity or their impact on daily quality of life. However, as BMI decreased after surgery, the presence of GERD symptoms had a negative effect on the participants’ daily functioning (r = –0.21, p = 0.037).
Men, compared to women, more frequently reported GERD symptoms and their negative impact on daily functioning before surgery. However, after surgery, men experienced greater improvements in symptom resolution and quality of life. These differences, however, were not statistically significant (Table 3).

Discussion

Surgical methods for treating obesity are considered effective in addressing the disease. Currently, the most commonly performed surgery for obesity treatment is SG. Clinical studies have confirmed the benefits of this method in terms of excessive weight loss, improved quality of life for patients, and regression of obesity-related comorbidities. Furthermore, SG has a low complication rate, is technically simple to perform in a relatively short time, does not require the implantation of foreign bodies or gastro-jejunal anastomosis, and allows for future conversion to other bariatric procedures [12, 13]. However, this method carries a high risk of postoperative exacerbation of GERD symptoms or can lead to the development of GERD even in patients without prior symptoms [12, 14–16].
DuPree et al. reported that the majority of patients who underwent laparoscopic SG continued to have GERD symptoms postoperatively (84.1%), with symptom resolution observed in only 15.9% [17]. The results presented in this study indicate a lower percentage of GERD occurrence after surgery. Nearly 80% of patients reported GERD symptoms before the procedure, whereas three months after surgery, this number decreased to 44.2%. Notably, GERD symptoms appeared de novo in 7 (31.8%) of 22 symptom-free patients during the postoperative observation period. Among the entire group presenting GERD symptoms before surgery, only 11 patients (13.4%) experienced complete symptom resolution. Surprisingly, despite a significant overall improvement in quality of life as measured by the GIS scale after surgery, weight loss did not significantly influence severity of symptoms or their impact on daily functioning. Moreover, as BMI decreased after surgery, quality of life also diminished. This may be attributed to the systematic use of proton pump inhibitors (PPIs) and lifestyle and dietary changes prompted by the bariatric surgery.
Clinical studies report significant variability in GERD symptom occurrence after SG, attributed to the multifactorial and complex relationship between SG and GERD [18, 19]. Yuval et al. found that approximately 80% of patients experienced GERD symptoms postoperatively and were taking PPIs. Most patients reported good quality of life as assessed by the GERD Health-Related Quality of Life (GERD-HRQL) questionnaire, with better results in those with greater total weight loss and those who quit smoking [20]. Similarly, Alqahtani et al. observed improvements in health status in 55 out of 69 patients postoperatively, while GERD symptoms appeared de novo in 33. Over 80% of participants rated their quality of life after surgery as good, very good, or excellent [21].
A Polish population study involving 2,649 individuals identified higher prevalence of GERD among obese individuals, women, and older adults [3]. In our study, men reported slightly more frequent GERD symptoms and their negative impact on daily functioning. However, after surgery, they achieved greater benefits in terms of GERD symptom resolution and quality-of-life improvement compared to women. Abdulkhaleq et al. also noted that GERD symptoms were less severe in men and younger individuals after surgery, translating to better quality of life [22]. In a similar postoperative observation period (three months after SG), Himika et al. also reported significant improvements in GERD symptom relief. However, longer-term observation indicated an increase in GERD severity [23].
Long-term follow-up of SG patients has revealed that despite satisfactory weight loss, GERD symptoms persist or are diagnosed de novo in up to 50% of patients, according to various sources [24–26]. The distant effects of reflux may lead to complications such as esophagitis, hiatal hernia, Barrett’s esophagus, and even esophageal cancer. The bariatric efficacy of SG does not correlate with GERD symptom occurrence after surgery. However, the absence of clinical symptoms does not guarantee the absence of the disease. Thus, monitoring the clinical condition of SG patients according to current guidelines is crucial [27–30].
Predictive factors for postoperative GERD include preoperative reflux symptoms and positive preoperative 24-hour esophageal pH monitoring in asymptomatic patients [31]. The literature also provides strategies for managing GERD after SG, including lifestyle modifications, pharmacotherapy, and conversion to Roux-en-Y gastric bypass (RYGB), particularly in patients with insufficient weight loss [32]. Further research into GERD as a complication of bariatric surgery is warranted.

Conclusions

The results obtained using the GIS scale demonstrated that three months after bariatric surgery, there was a significant reduction in the frequency of GERD symptoms. At the same time, a small group of previously asymptomatic patients developed GERD symptoms following SG.

Disclosure

1. The study was approved by the Bioethics Committee at Nicolaus Copernicus University in Toruń, Collegium Medicum in Bydgoszcz. Approval number: KB 40/2024.
2. Assistance with the article: None.
3. Financial support and sponsorship: None.
4. Conflicts of interest: None.

References