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Special findings in high-resolution manometry prior to metabolic surgery: obesity as a risk factor for esophagogastric junction outflow obstruction or achalasia? #MMPMID41381892
Surg Endosc 2025[Dec]; ? (?): ? PMID41381892show ga
BACKGROUND: The influence of obesity on the function of the upper gastrointestinal tract is still a matter of discussion. Clearly, there is a higher risk for hiatal hernia and gastroesophageal reflux disease (GERD) in obesity. However, the association between obesity and changes in the lower esophageal sphincter (LES) and esophageal motility disorders is insufficiently understood. The clinical impact of obesity on the gastroesophageal junction, like esophagogastric junction outflow obstruction (EGJOO), remains unclear. METHODS: All obese patients who underwent High-Resolution Manometry (HRM) before metabolic surgery between 2017 and 2021 were investigated. The findings in HRM were analyzed using the Chicago Classification version 3.0 and transferred to an Excel sheet. For the calculation of p-values, Fisher's exact test, chi-square test, or Student's t-test was applied. RESULTS: In total, 188 patients were included: There were more female (f = 132) than male (m = 56) patients (70.2% vs. 29.8%), median age was 41.1 years, and median Body Mass Index (BMI) was 45.1 kg/m(2) at surgery. The majority (58.1%) of the patients had normal findings in HRM; the most common pathology in HRM was EGJOO in 70 (36.6%) patients, followed by ineffective esophageal motility (IEM) in seven (3.7%) patients, achalasia Type III in two (1%) patients, and nutcracker esophagus in one patient (0.5%). A hiatal hernia was diagnosed in seven patients (3.7%) in HRM. In the patients' history, GERD symptoms were frequent, and the two patients with achalasia Type III had symptoms of dysphagia. None of the patients with EGJOO in HRM had symptoms of EGJOO. CONCLUSION: EGJOO is markedly more prevalent on HRM in patients with obesity than in the general population, with male sex and very high BMI as significant risk factors, likely mediated by increased intra-abdominal pressure. Because most cases are asymptomatic, EGJOO should often be regarded as an incidental finding, and management should be guided by symptoms (e.g., chest pain and/or dysphagia). Given resource constraints, our preoperative HRM is now selective: It is routinely performed in sleeve gastrectomy candidates and in patients with dysphagia-type complaints. We therefore recommend extending CCv4.0-based manometry testing primarily in symptomatic patients prior to surgery, while asymptomatic patients can proceed to metabolic-bariatric surgery without evidence of increased perioperative risk.
Surg+Endosc 2025 ; ? (?): ?
