BACKGROUND: Sleeve gastrectomy (SG) is one of the most commonly performed bariatric procedures worldwide. Gastroesophageal reflux disease (GERD) is a major concern in patients undergoing SG and is a risk factor for Barrett's esophagus (BE). Studies have shown that the incidence of de novo BE after SG ranges between 4% to 17%, however long-term follow up data is scarce. We conducted a systematic review and meta-analysis to assess the incidence of and analyze predictive factors for post-SG BE.

METHODS: A comprehensive literature search was conducted in multiple databases up to November 2023, for observational studies and randomized controlled trials (RCTs) reporting on incidence of BE, erosive esophagitis (EE) and hiatal hernia (HH) post-SG. Only studies with endoscopic and histologic evidence of BE were included. Primary outcomes were post-SG pooled rates of BE, EE and HH. Sub-group analysis was performed among studies with ≥10 years follow up. Meta-regression analysis was performed to assess if patient factors influenced the rates of post-SG BE. Random effects model was used, and outcomes were reported as pooled rates and relative risk (RR) along with 95% confidence intervals (CI). Within study heterogeneity was assessed using the I² statistic.

RESULTS: Seventeen studies with 1720 patients (72.2% females) were included in the final analysis. Mean age ranged from 34.85 to 51 years. Post operative data was available for 1480 patients with mean follow up ranging from 2.5 to 10.5 years. None of the patients had BE prior to undergoing SG. The pooled rate of de novo BE in patients post-SG was 6.8% (CI 4.5-10.2; I² 72) [Figure 1]. Additionally, significantly higher pooled rates of EE [RR 0.24 (CI 0.19-0.30), p<0.001] [Figure 2] and HH [RR 0.21 (CI 0.15-0.28), p<0.001] were found among patients post-SG, 33.1% (CI 25.9-41.2; I² 89) and 32.1% (CI 21-45.6; I² 93) as compared to pre-SG, 6.4% (CI 3.6-11.3; I² 83) and 13.7% (CI 8.6-21; I² 80), respectively. Overall pooled rate of post-SG BE and EE, among studies with ≥10 years follow up, was 6.7% (CI 2.8-15.4; I² 56) and 26.7% (CI 18.8-36.4; I² 43), respectively. Finally, on meta-regression analysis, age as well as pre and postoperative BMI positively influenced the pooled rates of de novo BE post-SG, while gender did not.

CONCLUSION: Our analysis shows that regardless of gender, sleeve gastrectomy results in an increased risk of de novo BE even after ≥10 years of follow up. A signicant proportion of patients also developed EE and HH post-SG. Age as well as pre and postoperative BMI appear to influence the rates of post-SG BE. Our study, which is the largest one till date, supports councelling of all patients considering SG regarding these risks. Furthermore, screening guidelines for BE in patients undergoing SG must be formulated.

Syed Mohsin Saghir

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