Estudo comparativo randomizado entre gastrectomia vertical versus gastrectomia horizontal associada à hiatoplastia na prevenção do refluxo gastroesofágico

Abstract

Introduction: Sleeve gastrectomy (SG) has been associated with the development of gastroesophageal reflux disease (GERD) in the postoperative period. Consequently, some studies have proposed combining SG with an anti-reflux procedure for all patients, although results remain controversial. This study aimed to evaluate the effect of concomitant hiatoplasty on postoperative GERD control following SG. Methods: A single-center, single-blind clinical trial was conducted over a 10-month period, enrolling 43 consecutive volunteers (37 women and 6 men). Participants were randomized by simple drawing after every two inclusions, regardless of the presence of GERD symptoms or hiatal hernia, to undergo either SG (n=15) or SG with concomitant hiatoplasty (n=19). All patients underwent anthropometric measurements for excess weight loss (EWL) calculation, completed questionnaires on typical (RDQ) and atypical (RSI) GERD symptoms, and underwent high-resolution esophageal manometry (HRM) and 24-hour pH monitoring (PHM) both preoperatively and approximately six months after surgery. Nine participants were excluded due to loss to follow-up, resulting in 34 patients (29 women and 5 men) completing the study, with a mean age of 39.8 years and a mean BMI of 40.31 kg/m². Results: Both groups achieved a mean EWL greater than 60% at six months, with no significant differences between them. RDQ scores were comparable between groups. Although the total RSI score was higher in the SG + hiatoplasty group postoperatively, this difference was not reflected in the analysis of individual questionnaire items. Following surgery, acid exposure time (AET) and DeMeester scores significantly increased only in the SG group, while remaining stable in the SG + hiatoplasty group. Both groups demonstrated a reduction in intragastric pressure without significant changes in baseline esophagogastric junction pressures, except for an increase in maximal inspiratory pressure. Although not statistically significant, the SG + hiatoplasty group exhibited a trend toward a smaller decrease in maximal expiratory pressure, which was inversely correlated with postoperative AET. Conclusions: At six months postoperatively, no differences in GERD symptoms were observed between groups. However, concomitant hiatoplasty effectively prevented the postoperative increase in distal esophageal acid exposure, suggesting its efficacy in GERD prevention. Preservation of lower esophageal sphincter pressure was inversely associated with acid exposure.