Evaluation of the Lower Esophagus Sphincter Using High-resulation Manometry (Hrm) Before and After Sleeve Gastrectomy Operation

Evaluation of the Lower Esophagus Sphincter Using High-resulation Manometry (Hrm) Before and After Sleeve Gastrectomy Operation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluation of the Lower Esophagus Sphincter Using High-resulation Manometry (Hrm) Before and After Sleeve Gastrectomy Operation Mehmet Emin Gönüllü, Mehmet Fuat Çetin, Erman Yekenkurul, Mevlüt Pehlivan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8569141/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Purpose Laparoscopic sleeve gastrectomy (LSG) is one of the most commonly preferred surgical treatments for obesity; however, disruption of the angle of His and gastric fundus during the procedure may increase the risk of gastroesophageal reflux. This study aimed to evaluate the effect of LSG on lower esophageal sphincter (LES) resting pressure and its potential relationship with reflux development. Methods Lower esophageal sphincter resting pressure was assessed using high-resolution manometry in 28 patients who underwent LSG. Preoperative and postoperative LES pressure values were compared. Additionally, the relationship between changes in LES pressure, sex, and body mass index (BMI) reduction was analyzed. Results Postoperative evaluation demonstrated a significant decrease in LES resting pressure compared to preoperative values (p = 0.048). No statistically significant difference was observed between sexes (p > 0.05). The reduction in LES pressure was significantly more pronounced than the decrease in BMI (p = 0.026). Conclusion LSG is associated with a significant postoperative reduction in LES resting pressure, which may increase the risk of gastroesophageal reflux. Therefore, patients undergoing LSG should be carefully monitored for reflux and reflux-related complications, including esophagitis and Barrett’s esophagus. Laparoscopic Sleeve Gastrectomy High-Resolution Manometry Lower Esophageal Sphincter Pressure Reflux Figures Figure 1 INTRODUCTION Obesity is a growing global health crisis, with its prevalence and associated comorbidities increasing worldwide. Since 1975, the global obesity rate has nearly tripled. According to World Health Organization (WHO) statistics from 2022, 2.5 billion adults aged 18 and older were classified as overweight, with 890 million meeting the criteria for obesity. This translates to 43% of adults being overweight and 16% living with obesity. 1 Bariatric surgery has emerged as a highly effective intervention for obesity, leading to improvements in related health conditions and reductions in obesity-related mortality. Among the various surgical techniques, sleeve gastrectomy (SG) is currently the most frequently performed. Initially introduced in 1988 as part of the biliopancreatic diversion with duodenal switch (BPD-DS), SG gained prominence when Regan et al. performed it laparoscopically (LSG) as a preparatory step before Roux-en-Y gastric bypass (RNYGB) in patients with super-obesity. However, subsequent clinical outcomes revealed that LSG alone could result in significant weight loss, allowing it to become a standalone treatment for morbid obesity without the need for a second procedure. 2 The popularity of LSG has surged over the years. Data from the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) show that LSG accounted for 27.8% of bariatric surgeries in 2011, a figure that rose to 55.4% by 2018. Its widespread adoption can be attributed to its safety, efficacy, and technical simplicity compared to other bariatric techniques. 3 Despite its benefits, LSG is associated with complications, including bleeding (up to 1.2%), gastroesophageal reflux disease (GERD; 22%), stricture formation (around 0.6%), and staple line leaks. The average incidence of leaks is approximately 2.4%, with rates climbing to 7% in patients with a BMI above 50. 4 Obesity itself is a major risk factor for GERD and its complications, such as erosive esophagitis, Barrett's esophagus, and esophageal adenocarcinoma. Studies have reported that between 62.4% and 73% of individuals considered for bariatric surgery already experience GERD. Abdominal obesity particularly increases the risk of erosive esophagitis, which is linked to prolonged acid exposure in the distal esophagus and frequent reflux episodes reaching the proximal esophagus. Although reflux symptoms are a common indicator, their absence does not rule out erosive esophagitis; one study showed that 12.3% of patients with obesity had this condition despite low symptom scores (GerdQ < 8). 5,6 Research indicates that LSG can exacerbate reflux symptoms in about 19% of patients and lead to new-onset GERD in approximately 23%. Since persistent GERD may lead to complications such as Barrett’s esophagus—which has an annual progression risk of 0.12%-0.43% to esophageal adenocarcinoma—early diagnosis and management following LSG are increasingly emphasized. 7,8 This study aimed to investigate the effectiveness of using high-resolution manometry (HRM) to evaluate lower esophageal sphincter (LES) function before and after LSG surgery. HRM is a method developed to evaluate esophageal motility and LES functions more precisely. The results of this study may help identify changes in LES function following LSG and develop appropriate treatment strategies. This could, in turn, contribute to improved follow-up and treatment of patients after bariatric surgery, encouraging widespread use of the HRM method by demonstrating its effectiveness in the evaluation of LES function. Therefore, our study aimed to help patients achieve a better quality of life and minimize postoperative health complications. MATERIALS AND METHODS STUDY POPULATION AND SURGICAL PROCEDURES The study included individuals who underwent LSG surgery at the General Surgery Clinic. The patients underwent HRM before and after LSG surgery. All individuals were informed about the study, and written consent was obtained. Patients were eligible for the study if they met the following inclusion criteria: • Aged between 18 and 65 years • Body mass index (BMI) > 40 kg/m 2 , or BMI between 35–40 kg/m 2 with at least one comorbidity • Undergoing primary LSG • Undergoing upper gastrointestinal system endoscopy (UGE) at our clinic prior to surgery Participants were excluded if they met the following exclusion criteria: • Presence of hiatal hernia or findings suggestive of hiatal insufficiency during preoperative evaluation • History of previous bariatric procedures • Undergoing bariatric surgery other than LSG (such as mini gastric bypass) • Undergoing revisional bariatric surgery after LSG • Diagnosis of hypertension (HT) requiring treatment with calcium channel blockers During the study period, HRM was performed on 50 patients. A total of 22 patients were excluded (4 had achalasia or hiatal hernia, 6 had an external center or clinic request, and 12 patients did not accept to be included in the study postoperatively). All patients included in the study underwent preoperative gastroscopy at the Endoscopy Unit of our hospital, under the supervision of three gastroenterologists and three general surgeons. All patients were sedated with 0.03 mg/kg midazolam and 0.5 mg/kg propofol before the procedure. Additional doses of 0.3 mg/kg propofol were administered as needed to maintain adequate sedation. During gastroscopy, the esophagus, stomach, and duodenum (up to the second part) were examined. Hill's classification was performed on patients with hiatus hernia. These patients were not included in the study. HRM assessments were conducted using the MMS SolarGI system, which operates with a catheter containing 20 pressure points. All procedures were performed by one general surgeon. The following parameters were recorded during the HRM assessment: IRP, DL, DCI, and LES resting pressure. During the study period, HRM was performed on 50 patients, 40 of whom underwent LSG. Of these, 12 did not want to undergo HRM again in the postoperative period. As a result, HRM measurements were repeated postoperatively in the remaining 28 patients. All patients' surgeries were performed by one general surgeon with extensive experience in LSG. For LSG anesthesia, patients were administered 0.03 mg/kg midazolam, 1 mcg/kg fentanyl, 2-2.5 mg/kg propofol, and 0.6 mg/kg rocuronium. Anesthesia was maintained with 2% sevoflurane and a remifentanil infusion at a rate of 0.05–0.5 mcg/kg/min. When skin sutures were started, analgesia was provided with 1,000 mg paracetamol and 1.5 mg/kg tramadol. Patients were positioned on the operating table in the “obesity position,” with both legs separated. For antibiotic prophylaxis, 2 g cefazolin was administered. After decompression of the stomach with a nasogastric tube, the tube was removed. A 12 mm trocar was inserted approximately 15 cm below the xiphoid and 1–2 cm to the left of the midline using the direct trocar method. Pneumoperitoneum was provided via CO 2 insufflation through the camera trocar. The liver retractor was placed with a 5 mm trocar through an incision made 1 cm below the xiphoid under telescopic guidance. Under camera visualization, 5 and 10 mm working trocars were inserted at the midclavicular line in the right and left upper quadrants, respectively. Additionally, a 5 mm trocar was inserted at the level of the left anterior axillary line to be used by the first assistant. Following trocar placement, the patient was placed in the reverse Trendelenburg position. The surgeon stood between the patient's legs, while the first assistant was positioned on the patient's left side. The gastrocolic ligament was gently stretched to the left and inferior side by the first assistant, while the surgeon released the greater curvature down to the level of the left crus using an energy device. An orogastric bougie was inserted by the anesthesia team and advanced to the pylorus. The camera was passed to the 10 mm trocar in the left midclavicular line as a trocar. The first stapler firing was performed approximately 4–6 cm proximal to the pylorus, initiating gastric resection around the bougie. Then, the resection was completed along the greater curvature using five or six stapler cartridges. Bleeding foci seen in the staple line were controlled with metallic clips. In some patients, the staple line was reinforced with a continuous 2/0 V-Loc suture. The bougie was pulled to the esophagogastric junction and approximately 100 cc of methylene blue and SF were injected into the stomach to check for leakage in the staple line. The stomach sample was removed from the abdomen through the 12 mm trocar site. All trocars were removed and bleeding control was performed. The incision sites were generally closed with the mattress suture technique using 3/0 prolene sutures and the operation was concluded. In the postoperative period, patients with good general condition and stable vitals were given a clear diet approximately six hours after surgery. Patients with adequate fluid intake on the first postoperative day were discharged. Patients were scheduled for follow-up visits on postoperative day 7, at one month, and every three months during the first year. HRM procedures were performed on patients who attended their follow-up visits, and BMI was recorded. STATISTICAL ANALYSIS All data were analyzed using IBM SPSS Statistics version 22 (IBM SPSS, Turkey). The normality of the parameters was assessed using the Shapiro-Wilk test. Descriptive statistics, including mean, standard deviation, median, and frequency, were calculated. One-way ANOVA was used to compare quantitative data. The Pearson Chi-Square test was employed to compare qualitative data. Statistical significance was set at p < 0.05. RESULTS Between May 5, 2023, and November 15, 2023, a total of 28 patients who met the inclusion criteria were included in the study. The mean age of the patients was 33.8 years (range: 23–51 years; standard deviation: 7.57). Of the participants, 10 were male (35.7%) and 18 were female (64.3%). The mean age of female patients was 32.5 ± 3.27 years, while the mean age of male patients was 31.2 ± 3.3 years, with no statistically significant difference between the sexes (p > 0.05). The mean BMI values were 45.82 kg/m² in the preoperative period and 30.87 kg/m² in the postoperative period. The reduction in BMI in the postoperative period was statistically significant (p = 0.018). (Table 1) Preoperative HRM was performed 7–18 days (standard deviation: 9.73) before surgery. LES resting pressure ranged from 7.1 mmHg to 175.2 mmHg, with a mean value of 21.45 mmHg and a standard deviation of 37.2 mmHg. Postoperative HRM measurements were performed between 33–212 days after surgery. LES resting pressure ranged from 6.7 mmHg to 37.2 mmHg, with a mean value of 21.35 mmHg and a standard deviation of 36.6 mmHg. Among the 28 patients evaluated, LES pressure decreased postoperatively in 22 patients, while it remained the same or increased in 6 patients. This change was statistically significant (p = 0.048), indicating a postoperative reduction in LES resting pressure compared to the preoperative period. (Table 2) When the relationship between BMI and LES pressure was examined, a postoperative decrease in both parameters was observed in all 28 patients (100%). Then, a statistical comparison was made between the change in LES pressure and the reduction in BMI. Patients with a higher percentage decrease in BMI also demonstrated a statistically significant decrease in LES pressure (p = 0.026). When examining the relationship between sex and LES pressure, no statistically significant difference was observed. Among the 18 female patients, the mean preoperative LES pressure was 21.85 mmHg (standard deviation: 37.7), while the postoperative pressure was 21.75 mmHg (standard deviation: 36.3). For the 10 male patients, the mean preoperative LES pressure was 21.05 mmHg (standard deviation: 36.8), and the postoperative pressure was 20.95 mmHg (standard deviation: 36). In conclusion, no statistically significant differences were found in the changes of preoperative and postoperative LES pressure between female and male patients (p > 0.05) (Graph 1). DISCUSSION In this study, the effect of LSG on the development of GERD and hiatal insufficiency in patients with morbid obesity was investigated. While investigating this, quantitative results were tried to be revealed with HRM. It was in the form of investigating the reflux symptoms shown in the studies conducted so far after LSG. Many studies have investigated the prevalence of GERD after LSG. Although there are conflicting results, most studies show that GERD tends to increase. Studies investigating the development of postoperative reflux identified two primary causes: the decrease in LES pressure and the deterioration of the sensory angle. In addition, Coupaye et al. reported that increased intragastric pressure due to decreased gastric compliance may also cause reflux. 9 In the study conducted by Viscido et al. in 2017, it was found that the prevalence of GERD increased from 33% in the preoperative period to 44% in the postoperative period and the development of de novo GERD reached 36.9%. 10 In a study conducted in 2010, in which patients with pathological findings or GERD symptoms were excluded from preoperative endoscopy, the development of de novo reflux was found to be 27%. 11 While there are studies that have found that LSG increases GERD, there are also studies that show that it improves it. In a study conducted by Daes et al. in 2014, a preoperative GERD rate of 44.5% decreased to 2.6% in the postoperative period. 12 Pallati et al., who investigated the changes in GERD after different bariatric surgical interventions, showed that GERD symptoms improved in 41% of patients after LSG, while the rate of de novo GERD development was 9.2%. 13 As the number of studies exploring the relationship between LSG and GERD has increased, systematic reviews and meta-analyses have been published on this topic. In a systematic review and meta-analysis by Oor et al., which analyzed 24 studies investigating LSG and GERD, the rate of newly developed reflux following LSG was reported to be 34.9%, with an overall average incidence of 20%. 14 A 2020 systematic review and meta-analysis by Yeung et al. reported an incidence of new-onset GERD after LSG of 23%. 15 However, these meta-analyses lack consistent standardization due to differing diagnostic criteria for reflux, making it difficult to draw firm conclusions regarding the impact of LSG on GERD. In this study, evaluations were made using HRM measurements. In addition to assessing the patients' active complaints about reflux, HRM testing was performed on all patients in order to ensure standardization. The results demonstrated that LES pressure significantly decreased postoperatively compared to the preoperative period. The necessity of preoperative upper gastrointestinal endoscopy (UGE) before bariatric surgery has been discussed for many years. However, recent guidelines have established that all patients undergoing LSG should undergo preoperative UGE. Although there are still disagreements about the need for routine postoperative endoscopic surveillance in patients who underwent bariatric surgery, the 2020 guidelines published by the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) recommend routine postoperative endoscopy specifically for LSG patients.. In a 2020 systematic review and meta-analysis, Yeung et al. reported that, following gastrectomy, 36% of patients required PPI, 28% developed esophagitis, and 8% developed Barrett's esophagus. Based on these results, the authors stated that GERD, esophagitis, and Barrett's esophagus are inevitable after LSG. Therefore, they emphasized the need for routine surveillance, nothing that complication rates may be even higher if all patients are screened. 16 The aim of this study was to investigate the development of hiatal hernia and reflux due to the decrease in LES pressure after disruption of the angle of His during LSG. It is important to recognize that esophagitis and Barrett's esophagus may occur due to chronic reflux. Research on the incidence of newly developed hiatal hernia following LSG remains limited. In a 2020 study by Saba et al., de novo HH was observed in 60% of patients with follow-up periods shorter than 18 months, and in 84.6% of those with longer follow-up periods. Similarly, a 2017 study by Viscido et al. reported a 16.4% incidence of de novo HH after LSG. 10 A systematic review and meta-analysis by Yeung et al., published in 2020, reported that 41% of patients developed hiatal hernia following sleeve gastrectomy. 16 In the study conducted by Genco et al. in 2016, UGE was applied to all patients regardless of GERD symptoms before and after LSG. At the end of the average follow-up period of 58 months, the prevalence of esophagitis increased in postoperative PPI, but Barrett's esophagus was not observed in any patient in the preoperative period, while 17.2% developed Barrett's esophagus in the postoperative period. No correlation was found between the degree and frequency of reflux and esophageal lesions and Barrett's esophagus. 17,18 In our study, HRM demonstrated that LES pressure decreased following LSG. This suggests that the risk of developing Barrett's esophagus due to reflux may increase postoperatively. The most important risk factor for esophageal adenocarcinoma is Barrett's esophagus. There are very few cases of esophageal adenocarcinoma developing after LSG in the literature. Genco et al. presented a case series of three patients on this topic. All patients were subjected to endoscopic control in the preoperative period and no pathology was detected in any patient. Importantly, all the patients stopped being followed up 3.7 ± 1.4 months after LSG. The patients were diagnosed with esophageal adenocarcinoma an average of 27.3 ± 7.6 months after LSG. They also found four more cases in their literature review. Preoperative endoscopic examination was not performed in two of these cases, normal endoscopy was performed in one patient and short-segment Barrett's esophagus was detected in one patient. The authors reported that the patients were diagnosed with esophageal adenocarcinoma an average of 32.5 ± 23 months after LSG. In light of these data, it is very important to follow up the patients in the postoperative period. 18 In a systematic review and meta-analysis conducted by Qumseya et al. in 2020 on the prevalence of Barrett's esophagus in LSG patients, the prevalence was found to be 11.4%, and none of the Barrett's esophagus cases had dysplastic pathology. There was no correlation between the development of Barrett's esophagus and postoperative GERD. Additionally, no association was observed between the prevalence of Barrett's esophagus and the length of the follow-up period. The study also concluded that all detected cases of microscopic Barrett's were non-dysplastic, and, like in other studies, no link was found between GERD symptoms, esophagitis, and Barrett's esophagus. 19 Our study has some limitations. Manometry, which is recommended as the gold standard in the diagnosis of GERD, was performed, but the other gold standard procedures, pH impedance and postoperative UGE, were not performed. In addition, the number of patients included in the study was insufficient. Conversely, unlike in other studies, we systematically assessed reflux and used HRM. We were able to detect a decrease in LES pressure with HRM, regardless of the patients' active reflux complaints. However, no relationship was found between the severity of reflux and the development of esophagitis and Barrett's esophagus. In the vast majority of studies, Barrett's esophagus examination after LSG was performed after long follow-up periods. This study shows that increased reflux symptoms and the development of Barrett's esophagus can be expected due to the decrease in LES pressure after LSG. Therefore, screening of patients for esophagitis and Barrett's esophagus should be considered in the early period after LSG. CONCLUSIONS In this study, we investigated whether LSG had an effect on LES pressure by performing preoperative and postoperative HRM. We observed that LES pressure decreased in the postoperative period in patients who underwent LSG. It is obvious that some reflux complications will also occur with the decrease in LES pressure. As LSG popularity continues to increase every year worldwide, complications related to LSG should also be monitored carefully. It is very important to follow patients closely to prevent the development of esophageal adenocarcinoma due to Barrett's esophagus or to make an early diagnosis. The fact that some patients with Barrett's esophagus are asymptomatic suggests that routine endoscopic control should be performed in all patients regardless of symptoms after LSG. In order to increase patient compliance with follow-up, the importance of postoperative endoscopic follow-up should be emphasized to all patients in the preoperative period. Until IFSO obtains sufficient and accurate data on post-LSG cancer incidence, it may be advisable to recommend routine control endoscopy for all patients in the first postoperative year and every 2–3 years thereafter, to facilitate the early detection of Barrett's esophagus or upper gastrointestinal system cancers. Further studies are needed to determine the pathophysiology of Barrett's esophagus after LSG and to recommend endoscopic follow-up in the postoperative period. The addition of pH impedance studies to HRM will further elucidate these post-LSG complications. The authors declare no conflict of interest. Declarations Ethics Statement: This study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval was obtained from the Düzce University Clinical Research Ethics Committee (Approval No: 2023/58, Date: 02.05.2023). Written informed consent was obtained from all participants prior to their inclusion in the study. Author Contribution M.E.G. was responsible for study conception, conducted the experimental work, overall supervision, and critical revision of the manuscript.M.F.Ç. data acquisition and analysis, and prepared the initial draft.E.Y. contributed to methodological design, result interpretation, and figure preparation.M.P. supported the literature review, data validation, and manuscript proofreading. References World Health Organization, Obesity (2024) and overweight. Mar 1. Available from: https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight World Health Organization. Obesity: prevention and management of the global epidemic. Report of a WHO Consultation. WHO Technical Report Series 894. Geneva: WHO (2000) pp. 1–253 Hess DS, Hess DW (1998) Biliopancreatic diversion with a duodenal switch. 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Can J Surg 57(2):139–144. 10.1503/cjs.030612 Daes J, Jiménez ME, Said N, Daza JC, Dennis R (2014) Improvement of gastroesophageal reflux symptoms after standardized laparoscopic sleeve gastrectomy. Obes Surg 24(4):536–540. 10.1007/s11695-013-1117-6 Pallati PK, Shaligram A, Shostrom VK, Oleynikov D, McBride CL, Goede MR (2014) Improvement in gastroesophageal reflux disease symptoms after various bariatric procedures: review of the Bariatric Outcomes Longitudinal Database. Surg Obes Relat Dis 10(3):502–507. 10.1016/j.soard.2013.07.018 Oor JE, Roks DJ, Ünlü Ç, Hazebroek EJ (2016) Laparoscopic sleeve gastrectomy and gastroesophageal reflux disease: a systematic review and meta-analysis. Am J Surg 211(1):250–267. 10.1016/j.amjsurg.2015.05.031 Yeung KTD, Penney N, Ashrafian L, Darzi A, Ashrafian H (2020) Does sleeve gastrectomy expose the distal esophagus to severe reflux? A systematic review and meta-analysis. Ann Surg 271(2):257–265. 10.1097/SLA.0000000000003275 Yeung KTD, Penney N, Ashrafian L, Darzi A, Ashrafian H (2020) Does sleeve gastrectomy expose the distal esophagus to severe reflux? A systematic review and meta-analysis. Ann Surg 271(2):257–265. 10.1097/SLA.0000000000003275 Saba J, Bravo M, Rivas E, Fernández R, Pérez-Castilla A, Zajjur J (2020) Incidence of de novo hiatal hernia after laparoscopic sleeve gastrectomy. Obes Surg 30(10):3730–3734. 10.1007/s11695-020-04742-7 Genco A, Soricelli E, Casella G, Maselli R, Castagneto-Gissey L, Di Lorenzo N, Basso N (2017) Gastroesophageal reflux disease and Barrett's esophagus after laparoscopic sleeve gastrectomy: a possible underestimated long-term complication. Surg Obes Relat Dis 13(4):568–574. 10.1016/j.soard.2016.11.029 Qumseya B, Gendy S, Wallace A, Yang D, Estores D, Ayzengart A, Draganov PV (2020) Prevalence of Barrett's esophagus in obese patients undergoing pre-bariatric surgery evaluation: a systematic review and meta-analysis. Endoscopy 52(7):537–547. 10.1055/a-1145-3500 Tables Table 1 and 2 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table1.png Table2.png Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 12 May, 2026 Reviewers agreed at journal 26 Apr, 2026 Reviewers invited by journal 01 Feb, 2026 Editor assigned by journal 20 Jan, 2026 Submission checks completed at journal 19 Jan, 2026 First submitted to journal 10 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8569141","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":572543882,"identity":"d411c6d4-010a-4c0d-b3b1-d930275fb23b","order_by":0,"name":"Mehmet Emin 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1","display":"","copyAsset":false,"role":"figure","size":56158,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e","description":"","filename":"Graph1.png","url":"https://assets-eu.researchsquare.com/files/rs-8569141/v1/fcd8f1e4c081e4fed6aac5d1.png"},{"id":100411906,"identity":"c92cb8c6-e7a4-41d0-b19b-1e608c8ecdc1","added_by":"auto","created_at":"2026-01-16 13:13:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":426445,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8569141/v1/66bdeafb-ca80-4504-b5c7-15197e98c323.pdf"},{"id":100399430,"identity":"e2c3acb2-64e5-4165-84bc-be4747622ba2","added_by":"auto","created_at":"2026-01-16 11:56:57","extension":"png","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":37321,"visible":true,"origin":"","legend":"","description":"","filename":"Table1.png","url":"https://assets-eu.researchsquare.com/files/rs-8569141/v1/8f6b0651b578a4ea61276dba.png"},{"id":100399510,"identity":"0ed7dadc-bf48-4aab-88c4-0398861f1ce8","added_by":"auto","created_at":"2026-01-16 11:57:09","extension":"png","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":71367,"visible":true,"origin":"","legend":"","description":"","filename":"Table2.png","url":"https://assets-eu.researchsquare.com/files/rs-8569141/v1/9ca76e270847a5961dbc9d75.png"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eEvaluation of the Lower Esophagus Sphincter Using High-resulation Manometry (Hrm) Before and After Sleeve Gastrectomy Operation\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eObesity is a growing global health crisis, with its prevalence and associated comorbidities increasing worldwide. Since 1975, the global obesity rate has nearly tripled. According to World Health Organization (WHO) statistics from 2022, 2.5\u0026nbsp;billion adults aged 18 and older were classified as overweight, with 890\u0026nbsp;million meeting the criteria for obesity. This translates to 43% of adults being overweight and 16% living with obesity. \u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eBariatric surgery has emerged as a highly effective intervention for obesity, leading to improvements in related health conditions and reductions in obesity-related mortality. Among the various surgical techniques, sleeve gastrectomy (SG) is currently the most frequently performed. Initially introduced in 1988 as part of the biliopancreatic diversion with duodenal switch (BPD-DS), SG gained prominence when Regan et al. performed it laparoscopically (LSG) as a preparatory step before Roux-en-Y gastric bypass (RNYGB) in patients with super-obesity. However, subsequent clinical outcomes revealed that LSG alone could result in significant weight loss, allowing it to become a standalone treatment for morbid obesity without the need for a second procedure. \u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe popularity of LSG has surged over the years. Data from the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) show that LSG accounted for 27.8% of bariatric surgeries in 2011, a figure that rose to 55.4% by 2018. Its widespread adoption can be attributed to its safety, efficacy, and technical simplicity compared to other bariatric techniques. \u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eDespite its benefits, LSG is associated with complications, including bleeding (up to 1.2%), gastroesophageal reflux disease (GERD; 22%), stricture formation (around 0.6%), and staple line leaks. The average incidence of leaks is approximately 2.4%, with rates climbing to 7% in patients with a BMI above 50. \u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eObesity itself is a major risk factor for GERD and its complications, such as erosive esophagitis, Barrett's esophagus, and esophageal adenocarcinoma. Studies have reported that between 62.4% and 73% of individuals considered for bariatric surgery already experience GERD. Abdominal obesity particularly increases the risk of erosive esophagitis, which is linked to prolonged acid exposure in the distal esophagus and frequent reflux episodes reaching the proximal esophagus. Although reflux symptoms are a common indicator, their absence does not rule out erosive esophagitis; one study showed that 12.3% of patients with obesity had this condition despite low symptom scores (GerdQ\u0026thinsp;\u0026lt;\u0026thinsp;8). \u003csup\u003e5,6\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eResearch indicates that LSG can exacerbate reflux symptoms in about 19% of patients and lead to new-onset GERD in approximately 23%. Since persistent GERD may lead to complications such as Barrett\u0026rsquo;s esophagus\u0026mdash;which has an annual progression risk of 0.12%-0.43% to esophageal adenocarcinoma\u0026mdash;early diagnosis and management following LSG are increasingly emphasized. \u003csup\u003e7,8\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThis study aimed to investigate the effectiveness of using high-resolution manometry (HRM) to evaluate lower esophageal sphincter (LES) function before and after LSG surgery.\u003c/p\u003e \u003cp\u003eHRM is a method developed to evaluate esophageal motility and LES functions more precisely.\u003c/p\u003e \u003cp\u003eThe results of this study may help identify changes in LES function following LSG and develop appropriate treatment strategies. This could, in turn, contribute to improved follow-up and treatment of patients after bariatric surgery, encouraging widespread use of the HRM method by demonstrating its effectiveness in the evaluation of LES function. Therefore, our study aimed to help patients achieve a better quality of life and minimize postoperative health complications.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSTUDY POPULATION AND SURGICAL PROCEDURES\u003c/h2\u003e \u003cp\u003eThe study included individuals who underwent LSG surgery at the General Surgery Clinic. The patients underwent HRM before and after LSG surgery. All individuals were informed about the study, and written consent was obtained.\u003c/p\u003e \u003cp\u003ePatients were eligible for the study if they met the following inclusion criteria:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e\u0026bull; Aged between 18 and 65 years\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e\u0026bull; Body mass index (BMI)\u0026thinsp;\u0026gt;\u0026thinsp;40 kg/m\u003csup\u003e2\u003c/sup\u003e, or BMI between 35\u0026ndash;40 kg/m\u003csup\u003e2\u003c/sup\u003e with at least one comorbidity\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e\u0026bull; Undergoing primary LSG\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e\u0026bull; Undergoing upper gastrointestinal system endoscopy (UGE) at our clinic prior to surgery\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eParticipants were excluded if they met the following exclusion criteria:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e\u0026bull; Presence of hiatal hernia or findings suggestive of hiatal insufficiency during preoperative evaluation\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e\u0026bull; History of previous bariatric procedures\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e\u0026bull; Undergoing bariatric surgery other than LSG (such as mini gastric bypass)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e\u0026bull; Undergoing revisional bariatric surgery after LSG\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e\u0026bull; Diagnosis of hypertension (HT) requiring treatment with calcium channel blockers\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eDuring the study period, HRM was performed on 50 patients. A total of 22 patients were excluded (4 had achalasia or hiatal hernia, 6 had an external center or clinic request, and 12 patients did not accept to be included in the study postoperatively).\u003c/p\u003e \u003cp\u003eAll patients included in the study underwent preoperative gastroscopy at the Endoscopy Unit of our hospital, under the supervision of three gastroenterologists and three general surgeons. All patients were sedated with 0.03 mg/kg midazolam and 0.5 mg/kg propofol before the procedure. Additional doses of 0.3 mg/kg propofol were administered as needed to maintain adequate sedation. During gastroscopy, the esophagus, stomach, and duodenum (up to the second part) were examined. Hill's classification was performed on patients with hiatus hernia. These patients were not included in the study.\u003c/p\u003e \u003cp\u003eHRM assessments were conducted using the MMS SolarGI system, which operates with a catheter containing 20 pressure points. All procedures were performed by one general surgeon. The following parameters were recorded during the HRM assessment: IRP, DL, DCI, and LES resting pressure. During the study period, HRM was performed on 50 patients, 40 of whom underwent LSG. Of these, 12 did not want to undergo HRM again in the postoperative period. As a result, HRM measurements were repeated postoperatively in the remaining 28 patients.\u003c/p\u003e \u003cp\u003eAll patients' surgeries were performed by one general surgeon with extensive experience in LSG. For LSG anesthesia, patients were administered 0.03 mg/kg midazolam, 1 mcg/kg fentanyl, 2-2.5 mg/kg propofol, and 0.6 mg/kg rocuronium. Anesthesia was maintained with 2% sevoflurane and a remifentanil infusion at a rate of 0.05\u0026ndash;0.5 mcg/kg/min. When skin sutures were started, analgesia was provided with 1,000 mg paracetamol and 1.5 mg/kg tramadol.\u003c/p\u003e \u003cp\u003ePatients were positioned on the operating table in the \u0026ldquo;obesity position,\u0026rdquo; with both legs separated. For antibiotic prophylaxis, 2 g cefazolin was administered. After decompression of the stomach with a nasogastric tube, the tube was removed. A 12 mm trocar was inserted approximately 15 cm below the xiphoid and 1\u0026ndash;2 cm to the left of the midline using the direct trocar method. Pneumoperitoneum was provided via CO\u003csub\u003e2\u003c/sub\u003e insufflation through the camera trocar.\u003c/p\u003e \u003cp\u003eThe liver retractor was placed with a 5 mm trocar through an incision made 1 cm below the xiphoid under telescopic guidance. Under camera visualization, 5 and 10 mm working trocars were inserted at the midclavicular line in the right and left upper quadrants, respectively. Additionally, a 5 mm trocar was inserted at the level of the left anterior axillary line to be used by the first assistant.\u003c/p\u003e \u003cp\u003eFollowing trocar placement, the patient was placed in the reverse Trendelenburg position. The surgeon stood between the patient's legs, while the first assistant was positioned on the patient's left side. The gastrocolic ligament was gently stretched to the left and inferior side by the first assistant, while the surgeon released the greater curvature down to the level of the left crus using an energy device.\u003c/p\u003e \u003cp\u003eAn orogastric bougie was inserted by the anesthesia team and advanced to the pylorus. The camera was passed to the 10 mm trocar in the left midclavicular line as a trocar. The first stapler firing was performed approximately 4\u0026ndash;6 cm proximal to the pylorus, initiating gastric resection around the bougie. Then, the resection was completed along the greater curvature using five or six stapler cartridges.\u003c/p\u003e \u003cp\u003eBleeding foci seen in the staple line were controlled with metallic clips. In some patients, the staple line was reinforced with a continuous 2/0 V-Loc suture. The bougie was pulled to the esophagogastric junction and approximately 100 cc of methylene blue and SF were injected into the stomach to check for leakage in the staple line.\u003c/p\u003e \u003cp\u003eThe stomach sample was removed from the abdomen through the 12 mm trocar site. All trocars were removed and bleeding control was performed. The incision sites were generally closed with the mattress suture technique using 3/0 prolene sutures and the operation was concluded.\u003c/p\u003e \u003cp\u003eIn the postoperative period, patients with good general condition and stable vitals were given a clear diet approximately six hours after surgery. Patients with adequate fluid intake on the first postoperative day were discharged.\u003c/p\u003e \u003cp\u003ePatients were scheduled for follow-up visits on postoperative day 7, at one month, and every three months during the first year. HRM procedures were performed on patients who attended their follow-up visits, and BMI was recorded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSTATISTICAL ANALYSIS\u003c/h2\u003e \u003cp\u003eAll data were analyzed using IBM SPSS Statistics version 22 (IBM SPSS, Turkey). The normality of the parameters was assessed using the Shapiro-Wilk test. Descriptive statistics, including mean, standard deviation, median, and frequency, were calculated. One-way ANOVA was used to compare quantitative data. The Pearson Chi-Square test was employed to compare qualitative data. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eBetween May 5, 2023, and November 15, 2023, a total of 28 patients who met the inclusion criteria were included in the study. The mean age of the patients was 33.8 years (range: 23\u0026ndash;51 years; standard deviation: 7.57). Of the participants, 10 were male (35.7%) and 18 were female (64.3%). The mean age of female patients was 32.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.27 years, while the mean age of male patients was 31.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3 years, with no statistically significant difference between the sexes (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eThe mean BMI values were 45.82 kg/m\u0026sup2; in the preoperative period and 30.87 kg/m\u0026sup2; in the postoperative period. The reduction in BMI in the postoperative period was statistically significant (p\u0026thinsp;=\u0026thinsp;0.018). (Table\u0026nbsp;1)\u003c/p\u003e \u003cp\u003ePreoperative HRM was performed 7\u0026ndash;18 days (standard deviation: 9.73) before surgery. LES resting pressure ranged from 7.1 mmHg to 175.2 mmHg, with a mean value of 21.45 mmHg and a standard deviation of 37.2 mmHg.\u003c/p\u003e \u003cp\u003ePostoperative HRM measurements were performed between 33\u0026ndash;212 days after surgery. LES resting pressure ranged from 6.7 mmHg to 37.2 mmHg, with a mean value of 21.35 mmHg and a standard deviation of 36.6 mmHg.\u003c/p\u003e \u003cp\u003eAmong the 28 patients evaluated, LES pressure decreased postoperatively in 22 patients, while it remained the same or increased in 6 patients. This change was statistically significant (p\u0026thinsp;=\u0026thinsp;0.048), indicating a postoperative reduction in LES resting pressure compared to the preoperative period. (Table\u0026nbsp;2)\u003c/p\u003e \u003cp\u003eWhen the relationship between BMI and LES pressure was examined, a postoperative decrease in both parameters was observed in all 28 patients (100%). Then, a statistical comparison was made between the change in LES pressure and the reduction in BMI. Patients with a higher percentage decrease in BMI also demonstrated a statistically significant decrease in LES pressure (p\u0026thinsp;=\u0026thinsp;0.026).\u003c/p\u003e \u003cp\u003eWhen examining the relationship between sex and LES pressure, no statistically significant difference was observed. Among the 18 female patients, the mean preoperative LES pressure was 21.85 mmHg (standard deviation: 37.7), while the postoperative pressure was 21.75 mmHg (standard deviation: 36.3). For the 10 male patients, the mean preoperative LES pressure was 21.05 mmHg (standard deviation: 36.8), and the postoperative pressure was 20.95 mmHg (standard deviation: 36). In conclusion, no statistically significant differences were found in the changes of preoperative and postoperative LES pressure between female and male patients (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Graph 1).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn this study, the effect of LSG on the development of GERD and hiatal insufficiency in patients with morbid obesity was investigated. While investigating this, quantitative results were tried to be revealed with HRM. It was in the form of investigating the reflux symptoms shown in the studies conducted so far after LSG.\u003c/p\u003e \u003cp\u003eMany studies have investigated the prevalence of GERD after LSG. Although there are conflicting results, most studies show that GERD tends to increase.\u003c/p\u003e \u003cp\u003eStudies investigating the development of postoperative reflux identified two primary causes: the decrease in LES pressure and the deterioration of the sensory angle. In addition, Coupaye et al. reported that increased intragastric pressure due to decreased gastric compliance may also cause reflux. \u003csup\u003e9\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn the study conducted by Viscido et al. in 2017, it was found that the prevalence of GERD increased from 33% in the preoperative period to 44% in the postoperative period and the development of de novo GERD reached 36.9%. \u003csup\u003e10\u003c/sup\u003e In a study conducted in 2010, in which patients with pathological findings or GERD symptoms were excluded from preoperative endoscopy, the development of de novo reflux was found to be 27%. \u003csup\u003e11\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eWhile there are studies that have found that LSG increases GERD, there are also studies that show that it improves it. In a study conducted by Daes et al. in 2014, a preoperative GERD rate of 44.5% decreased to 2.6% in the postoperative period. \u003csup\u003e12\u003c/sup\u003e Pallati et al., who investigated the changes in GERD after different bariatric surgical interventions, showed that GERD symptoms improved in 41% of patients after LSG, while the rate of de novo GERD development was 9.2%. \u003csup\u003e13\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAs the number of studies exploring the relationship between LSG and GERD has increased, systematic reviews and meta-analyses have been published on this topic.\u003c/p\u003e \u003cp\u003eIn a systematic review and meta-analysis by Oor et al., which analyzed 24 studies investigating LSG and GERD, the rate of newly developed reflux following LSG was reported to be 34.9%, with an overall average incidence of 20%. \u003csup\u003e14\u003c/sup\u003e A 2020 systematic review and meta-analysis by Yeung et al. reported an incidence of new-onset GERD after LSG of 23%. \u003csup\u003e15\u003c/sup\u003e However, these meta-analyses lack consistent standardization due to differing diagnostic criteria for reflux, making it difficult to draw firm conclusions regarding the impact of LSG on GERD.\u003c/p\u003e \u003cp\u003eIn this study, evaluations were made using HRM measurements. In addition to assessing the patients' active complaints about reflux, HRM testing was performed on all patients in order to ensure standardization. The results demonstrated that LES pressure significantly decreased postoperatively compared to the preoperative period.\u003c/p\u003e \u003cp\u003eThe necessity of preoperative upper gastrointestinal endoscopy (UGE) before bariatric surgery has been discussed for many years. However, recent guidelines have established that all patients undergoing LSG should undergo preoperative UGE.\u003c/p\u003e \u003cp\u003e Although there are still disagreements about the need for routine postoperative endoscopic surveillance in patients who underwent bariatric surgery, the 2020 guidelines published by the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) recommend routine postoperative endoscopy specifically for LSG patients..\u003c/p\u003e \u003cp\u003eIn a 2020 systematic review and meta-analysis, Yeung et al. reported that, following gastrectomy, 36% of patients required PPI, 28% developed esophagitis, and 8% developed Barrett's esophagus. Based on these results, the authors stated that GERD, esophagitis, and Barrett's esophagus are inevitable after LSG. Therefore, they emphasized the need for routine surveillance, nothing that complication rates may be even higher if all patients are screened. \u003csup\u003e16\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe aim of this study was to investigate the development of hiatal hernia and reflux due to the decrease in LES pressure after disruption of the angle of His during LSG. It is important to recognize that esophagitis and Barrett's esophagus may occur due to chronic reflux.\u003c/p\u003e \u003cp\u003eResearch on the incidence of newly developed hiatal hernia following LSG remains limited. In a 2020 study by Saba et al., de novo HH was observed in 60% of patients with follow-up periods shorter than 18 months, and in 84.6% of those with longer follow-up periods. Similarly, a 2017 study by Viscido et al. reported a 16.4% incidence of de novo HH after LSG. \u003csup\u003e10\u003c/sup\u003e A systematic review and meta-analysis by Yeung et al., published in 2020, reported that 41% of patients developed hiatal hernia following sleeve gastrectomy. \u003csup\u003e16\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn the study conducted by Genco et al. in 2016, UGE was applied to all patients regardless of GERD symptoms before and after LSG. At the end of the average follow-up period of 58 months, the prevalence of esophagitis increased in postoperative PPI, but Barrett's esophagus was not observed in any patient in the preoperative period, while 17.2% developed Barrett's esophagus in the postoperative period. No correlation was found between the degree and frequency of reflux and esophageal lesions and Barrett's esophagus. \u003csup\u003e17,18\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn our study, HRM demonstrated that LES pressure decreased following LSG. This suggests that the risk of developing Barrett's esophagus due to reflux may increase postoperatively.\u003c/p\u003e \u003cp\u003eThe most important risk factor for esophageal adenocarcinoma is Barrett's esophagus. There are very few cases of esophageal adenocarcinoma developing after LSG in the literature. Genco et al. presented a case series of three patients on this topic. All patients were subjected to endoscopic control in the preoperative period and no pathology was detected in any patient. Importantly, all the patients stopped being followed up 3.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4 months after LSG. The patients were diagnosed with esophageal adenocarcinoma an average of 27.3\u0026thinsp;\u0026plusmn;\u0026thinsp;7.6 months after LSG. They also found four more cases in their literature review. Preoperative endoscopic examination was not performed in two of these cases, normal endoscopy was performed in one patient and short-segment Barrett's esophagus was detected in one patient. The authors reported that the patients were diagnosed with esophageal adenocarcinoma an average of 32.5\u0026thinsp;\u0026plusmn;\u0026thinsp;23 months after LSG. In light of these data, it is very important to follow up the patients in the postoperative period. \u003csup\u003e18\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn a systematic review and meta-analysis conducted by Qumseya et al. in 2020 on the prevalence of Barrett's esophagus in LSG patients, the prevalence was found to be 11.4%, and none of the Barrett's esophagus cases had dysplastic pathology. There was no correlation between the development of Barrett's esophagus and postoperative GERD. Additionally, no association was observed between the prevalence of Barrett's esophagus and the length of the follow-up period. The study also concluded that all detected cases of microscopic Barrett's were non-dysplastic, and, like in other studies, no link was found between GERD symptoms, esophagitis, and Barrett's esophagus. \u003csup\u003e19\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eOur study has some limitations. Manometry, which is recommended as the gold standard in the diagnosis of GERD, was performed, but the other gold standard procedures, pH impedance and postoperative UGE, were not performed. In addition, the number of patients included in the study was insufficient.\u003c/p\u003e \u003cp\u003eConversely, unlike in other studies, we systematically assessed reflux and used HRM.\u003c/p\u003e \u003cp\u003eWe were able to detect a decrease in LES pressure with HRM, regardless of the patients' active reflux complaints. However, no relationship was found between the severity of reflux and the development of esophagitis and Barrett's esophagus. In the vast majority of studies, Barrett's esophagus examination after LSG was performed after long follow-up periods. This study shows that increased reflux symptoms and the development of Barrett's esophagus can be expected due to the decrease in LES pressure after LSG. Therefore, screening of patients for esophagitis and Barrett's esophagus should be considered in the early period after LSG.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eIn this study, we investigated whether LSG had an effect on LES pressure by performing preoperative and postoperative HRM. We observed that LES pressure decreased in the postoperative period in patients who underwent LSG.\u003c/p\u003e \u003cp\u003eIt is obvious that some reflux complications will also occur with the decrease in LES pressure. As LSG popularity continues to increase every year worldwide, complications related to LSG should also be monitored carefully.\u003c/p\u003e \u003cp\u003eIt is very important to follow patients closely to prevent the development of esophageal adenocarcinoma due to Barrett's esophagus or to make an early diagnosis. The fact that some patients with Barrett's esophagus are asymptomatic suggests that routine endoscopic control should be performed in all patients regardless of symptoms after LSG. In order to increase patient compliance with follow-up, the importance of postoperative endoscopic follow-up should be emphasized to all patients in the preoperative period.\u003c/p\u003e \u003cp\u003eUntil IFSO obtains sufficient and accurate data on post-LSG cancer incidence, it may be advisable to recommend routine control endoscopy for all patients in the first postoperative year and every 2\u0026ndash;3 years thereafter, to facilitate the early detection of Barrett's esophagus or upper gastrointestinal system cancers.\u003c/p\u003e \u003cp\u003eFurther studies are needed to determine the pathophysiology of Barrett's esophagus after LSG and to recommend endoscopic follow-up in the postoperative period. The addition of pH impedance studies to HRM will further elucidate these post-LSG complications.\u003c/p\u003e \u003cp\u003eThe authors declare no conflict of interest.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics Statement: This study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval was obtained from the D\u0026uuml;zce University Clinical Research Ethics Committee (Approval No: 2023/58, Date: 02.05.2023). Written informed consent was obtained from all participants prior to their inclusion in the study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eM.E.G. was responsible for study conception, conducted the experimental work, overall supervision, and critical revision of the manuscript.M.F.\u0026Ccedil;. data acquisition and analysis, and prepared the initial draft.E.Y. contributed to methodological design, result interpretation, and figure preparation.M.P. supported the literature review, data validation, and manuscript proofreading.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization, Obesity (2024) and overweight. Mar 1. 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Obes Surg 30(10):3730\u0026ndash;3734. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11695-020-04742-7\u003c/span\u003e\u003cspan address=\"10.1007/s11695-020-04742-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGenco A, Soricelli E, Casella G, Maselli R, Castagneto-Gissey L, Di Lorenzo N, Basso N (2017) Gastroesophageal reflux disease and Barrett's esophagus after laparoscopic sleeve gastrectomy: a possible underestimated long-term complication. Surg Obes Relat Dis 13(4):568\u0026ndash;574. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.soard.2016.11.029\u003c/span\u003e\u003cspan address=\"10.1016/j.soard.2016.11.029\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQumseya B, Gendy S, Wallace A, Yang D, Estores D, Ayzengart A, Draganov PV (2020) Prevalence of Barrett's esophagus in obese patients undergoing pre-bariatric surgery evaluation: a systematic review and meta-analysis. Endoscopy 52(7):537\u0026ndash;547. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1055/a-1145-3500\u003c/span\u003e\u003cspan address=\"10.1055/a-1145-3500\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"langenbecks-archives-of-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"laos","sideBox":"Learn more about [Langenbeck's Archives of Surgery](http://link.springer.com/journal/423)","snPcode":"423","submissionUrl":"https://submission.nature.com/new-submission/423/3","title":"Langenbeck's Archives of Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Laparoscopic Sleeve Gastrectomy, High-Resolution Manometry, Lower Esophageal Sphincter Pressure, Reflux","lastPublishedDoi":"10.21203/rs.3.rs-8569141/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8569141/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eLaparoscopic sleeve gastrectomy (LSG) is one of the most commonly preferred surgical treatments for obesity; however, disruption of the angle of His and gastric fundus during the procedure may increase the risk of gastroesophageal reflux. This study aimed to evaluate the effect of LSG on lower esophageal sphincter (LES) resting pressure and its potential relationship with reflux development.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eLower esophageal sphincter resting pressure was assessed using high-resolution manometry in 28 patients who underwent LSG. Preoperative and postoperative LES pressure values were compared. Additionally, the relationship between changes in LES pressure, sex, and body mass index (BMI) reduction was analyzed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003ePostoperative evaluation demonstrated a significant decrease in LES resting pressure compared to preoperative values (p\u0026thinsp;=\u0026thinsp;0.048). No statistically significant difference was observed between sexes (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The reduction in LES pressure was significantly more pronounced than the decrease in BMI (p\u0026thinsp;=\u0026thinsp;0.026).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eLSG is associated with a significant postoperative reduction in LES resting pressure, which may increase the risk of gastroesophageal reflux. Therefore, patients undergoing LSG should be carefully monitored for reflux and reflux-related complications, including esophagitis and Barrett\u0026rsquo;s esophagus.\u003c/p\u003e","manuscriptTitle":"Evaluation of the Lower Esophagus Sphincter Using High-resulation Manometry (Hrm) Before and After Sleeve Gastrectomy Operation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-16 08:51:16","doi":"10.21203/rs.3.rs-8569141/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-12T21:38:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"116042088573711246764425155446414600889","date":"2026-04-26T19:47:14+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-01T16:31:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-20T19:44:37+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-20T02:13:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"Langenbeck's Archives of Surgery","date":"2026-01-10T14:58:51+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"langenbecks-archives-of-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"laos","sideBox":"Learn more about [Langenbeck's Archives of Surgery](http://link.springer.com/journal/423)","snPcode":"423","submissionUrl":"https://submission.nature.com/new-submission/423/3","title":"Langenbeck's Archives of Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"b96caaa3-88de-4ef6-a3b3-1f15a7454830","owner":[],"postedDate":"January 16th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-12T21:38:42+00:00","index":15,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-01T16:38:31+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-16 08:51:16","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8569141","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8569141","identity":"rs-8569141","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}