Dysphagia predicts greater weight regain after Roux-en-Y gastric bypass: a longitudinal case-matched study

Highlights

• Dysphagia is a risk factor for weight regain in patients who have had Roux-en-Y gastric bypass (RYGB), a finding which could be due to conversion of regular dietary intake to relatively calorie-dense liquid and soft foods.

• Dysphagia in post-RYGB patients can be caused by primary motility disorders of the esophagus, for which high-resolution esophageal manometry (HRM) is the most accurate test.

• HRM may be underutilized in the workup of upper GI symptoms in post-RYGB patients.

• Identification of pre- or post-RYGB patients with esophageal motility disorders has the potential to improve the long-term weight loss outcomes of RYGB.

Abstract

Background

Weight regain (WR) after gastric bypass is thought to be multifactorial in etiology with behavioral, neurohormonal, and anatomic features playing a role. A significant proportion of patients complain of dysphagia after Roux-en-Y gastric bypass (RYGB) and may have difficulty tolerating solid foods. Our observations suggest that this subgroup of patients compensate for esophageal symptoms by increasing their intake of calorie-dense liquid and soft foods, which can precipitate WR.

Objectives

We hypothesize that dysphagia predisposes to greater WR than seen in individuals without swallowing symptoms.

Setting

Single tertiary care referral center.

Methods

This was a matched-cohort study analysis of prospectively collected data on RYGB patients. All individuals who underwent high-resolution manometry after RYGB were enrolled. Controls were identified via a retrospective analysis of a prospective institutional database. Patients who developed dysphagia were matched with controls, from a subset of 450 eligible controls. Each patient with dysphagia was matched with 4 control patients based on age, body mass index, and time since surgery. WR was defined as an increase of ≥15% from nadir. Χ² and t test (or Wilcoxon rank sum, if applicable) were used for bivariable analysis. Multiple logistic and linear regression were used for multivariable calculations.

Results

Forty-nine patients with dysphagia were included. After matching, there were 196 RYGB controls that did not have swallowing or esophageal symptoms. Controls had similar baseline demographic characteristics and initial weight loss compared with dysphagia cases. WR was common in both groups; however, total WR in those with dysphagia was greater than controls (15.7 versus 11.4 kg, respectively; P = .02). In addition, percent WR in those with dysphagia exceeded that seen in controls (mean 37% versus 25%, P = .003), and more individuals regained 15% of nadir weight (55% of dysphagia cases versus 38% of controls, P = .03) when adjusting for baseline body mass index, age at surgery, and race. Dietary histories suggested that, among those with dysphagia, patients with partial or complete conversion to soft or liquid calories had greater WR than those who adhered to the solid food diet.

Conclusions

Dysphagia is a risk factor for WR post-RYGB. This is likely due to increased intake of soft or liquid foods that are tolerable in these patients but lead to a positive energy balance and accelerated WR. More than half of patients with dysphagia after RYGB regain significant weight. Screening for and aggressively managing dysphagia in patients before or after RYGB may be warranted to prevent significant WR.