Secondary Peristalsis Is More Affected Than Primary Peristalsis by Increased Intragastric Pressure After Metabolic Bariatric Surgery: Findings From Functional Lumen Imaging Probe and High‐Resolution Esophageal Manometry

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INTRODUCTION: Esophageal dysmotility following metabolic bariatric surgery (MBS) may relate to decreased gastric compliance. We investigated high-resolution esophageal manometry (HRM) and secondary peristalsis assessed by functional lumen imaging probe (FLIP) and their association with intragastric pressure after MBS. METHODS: Patients undergoing HRM, FLIP, and barium esophagram (BE) after MBS were included. HRM metrics and proximal intragastric pressure at baseline (IGP baseline), during wet swallow-induced esophagogastric junction relaxation (IGP EGJ opening), and following wet swallow-induced esophagogastric junction opening with subsequent closure (IGP post EGJ closure) were measured. Contractile response was assessed during FLIP. RESULTS: Forty patients (26 Roux en Y gastric bypass, 14 sleeve gastrectomy) with FLIP a median of 4 years after MBS, were identified. HRM was normal or consistent with ineffective esophageal motility (IEM) in 33 (82.5%) patients, while the contractile response on FLIP was abnormal (disordered/impaired, absent, or spastic reactive) in 28 (70%). Delayed emptying on BE was numerically more frequent with abnormal FLIP (6% vs. 0%, p = 0.08). IGP post-EGJ closure (median 21.8 vs. 15 mmHg, p = 0.03) and ∆ IGP post-EGJ closure-IGP baseline (median 4 vs. 0 mmHg, p = 0.02) were greater and predictive of abnormal contractility on FLIP (OR 1.11, 95% CI 1.00-1.2, p = 0.03 and OR 1.6, 95% CI 1.07-2.39, p = 0.003, respectively). DISCUSSION: Abnormal contractility on FLIP, reflecting disordered secondary peristalsis, frequently occurs despite normal HRM findings after MBS. Secondary peristalsis may be associated with reduced gastric compliance, reflected by elevated proximal intragastric pressure. FLIP contractility could serve as an early marker for post-MBS esophageal dysfunction.

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