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Monrabal Lezama M, Bras Harriott C, Herbella FAM, Schlottmann F. Gastroesophageal Reflux Disease After Roux-en-Y Gastric Bypass: Pathophysiology and Management. J Laparoendosc Adv Surg Tech A 2024; 34:167-172. [PMID: 38153398 DOI: 10.1089/lap.2023.0289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023] Open
Abstract
Introduction: Patients with obesity are often affected by gastroesophageal reflux disease (GERD). Roux-en-Y gastric bypass (RYGB) is considered the ideal operation for patients with severe obesity and GERD. Although the majority of patients improve their reflux with the operation, some might persist symptomatic and others can even develop de novo GERD. The aim of this study was to determine pathophysiologic factors involved in the development of GERD after RYGB surgery and define potential treatments for this condition. Materials and Methods: Studies including patients with GERD before and after RYGB and/or analyzing possible GERD therapies were analyzed by the authors. Searches were conducted in PubMed, Cochrane Library, and Embase databases. Results: GERD can persist, worsen, or develop after RYGB. There are certain technical elements of the operation identified as potential risk factors for GERD. Medical therapy is effective in the majority of patients. Both endoscopic and surgical procedures can also help resolving GERD after RYGB. Conclusions: Although the majority of patients with GERD after RYGB can be effectively managed with medical therapy, some may require endoscopic or surgical treatment. Critical technical elements of RYGB should be considered to reduce the risk of postoperative GERD.
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Affiliation(s)
| | | | - Fernando A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Francisco Schlottmann
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
- Department of Surgery, University of Illinois, Chicago, Illinois, USA
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2
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MacVicar S, Mocanu V, Jogiat U, Verhoeff K, Dang J, Birch D, Karmali S, Switzer N. Revisional bariatric surgery for gastroesophageal reflux disease: characterizing patient and procedural factors and 30-day outcomes for a retrospective cohort of 4412 patients. Surg Endosc 2024; 38:75-84. [PMID: 37907658 DOI: 10.1007/s00464-023-10500-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 09/24/2023] [Indexed: 11/02/2023]
Abstract
INTRODUCTION Gastroesophageal reflux disease (GERD) is a well-established potential consequence of bariatric surgery and can require revisional surgery. Our understanding of the population requiring revision is limited. In this study, we aim to characterize patients requiring revisional surgery for GERD to understand their perioperative risks and identify strategies to improve their outcomes. METHODS Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) registry, a retrospective cohort of patients who required revisional surgery for GERD in 2020 was identified. Multivariable logistic regression modelling was used to assess correlations between baseline characteristics and morbidity. RESULTS 4412 patients required revisional surgery for GERD, encompassing 24% of all conversion procedures. In most cases, patients underwent sleeve gastrectomy (SG) as their original surgery (n = 3535, 80.1%). The revisional surgery for most patients was a Roux-en-Y gastric bypass (RYGB) (n = 3722, 84.4%). Major complications occurred in 527 patients (11.9%) and 10 patients (0.23%) died within 30 days of revisional surgery. Major complications included anastomotic leak in 31 patients (0.70%) and gastrointestinal bleeding in 38 patients (0.86%). Multivariable analyses revealed that operative length, pre-operative antacid use, and RYGB were predictors of major complications. CONCLUSION GERD is the second most common indication for revisional surgery in patients who have undergone bariatric surgery. Patients who underwent SG as their initial procedure were the primary group who required revisional surgery for GERD; most underwent revision via RYGB. Further inquiry is needed to tailor operative approaches and pre-operative optimization for revisional surgery patients.
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Affiliation(s)
- Sarah MacVicar
- Department of Surgery, University of Alberta Hospital, 8440 112 Street NW, Edmonton, AB, T6G 2B7, USA.
| | - Valentin Mocanu
- Department of Surgery, University of Alberta Hospital, 8440 112 Street NW, Edmonton, AB, T6G 2B7, USA
| | - Uzair Jogiat
- Department of Surgery, University of Alberta Hospital, 8440 112 Street NW, Edmonton, AB, T6G 2B7, USA
| | - Kevin Verhoeff
- Department of Surgery, University of Alberta Hospital, 8440 112 Street NW, Edmonton, AB, T6G 2B7, USA
| | - Jerry Dang
- Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel Birch
- Department of Surgery, University of Alberta Hospital, 8440 112 Street NW, Edmonton, AB, T6G 2B7, USA
| | - Shahzeer Karmali
- Department of Surgery, University of Alberta Hospital, 8440 112 Street NW, Edmonton, AB, T6G 2B7, USA
| | - Noah Switzer
- Department of Surgery, University of Alberta Hospital, 8440 112 Street NW, Edmonton, AB, T6G 2B7, USA
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Parkitna J, Jaworski P, Binda A, Barski K, Tarnowski W. Effect of SASI procedure (Single Anastomosis Sleeve Ileal) on the symptoms of gastroesophageal reflux disease in bariatric patients - a review of the literature. POLISH JOURNAL OF SURGERY 2023; 96:60-64. [PMID: 38348987 DOI: 10.5604/01.3001.0053.3998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
The problem of gastroesophageal reflux disease among bariatric patients is constantly growing. While bariatric surgery is the most effective method of treating obesity and related diseases, not all surgical procedures lead to improvement or resolution of gastroesophageal reflux disease. The search for the "ideal" surgical procedure for this group of patients is ongoing. The relatively recently introduced SASI procedure seems to have a beneficial effect on GERD symptoms and may be an alternative anti-reflux procedure in obese patients. The presented paper is a review of the latest literature on the impact of SASI procedure on the symptoms of gastroesophageal reflux disease.
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Affiliation(s)
- Joanna Parkitna
- Clinical Department of General, Oncological and Bariatric Surgery CMKP, Warsaw, Poland
| | - Paweł Jaworski
- Clinical Department of General, Oncological and Bariatric Surgery CMKP, Warsaw, Poland
| | - Artur Binda
- Clinical Department of General, Oncological and Bariatric Surgery CMKP, Warsaw, Poland
| | - Krzysztof Barski
- Clinical Department of General, Oncological and Bariatric Surgery CMKP, Warsaw, Poland
| | - Wiesław Tarnowski
- Clinical Department of General, Oncological and Bariatric Surgery CMKP, Warsaw, Poland
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4
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Sánchez-Pernaute A, Pérez-Aguirre E. Gastroesophageal reflux after Roux-en-Y gastric bypass: Is it just related to technical details? Cir Esp 2023; 101 Suppl 4:S58-S62. [PMID: 37952721 DOI: 10.1016/j.cireng.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 05/28/2023] [Indexed: 11/14/2023]
Abstract
Although it is uncommon, gastroesophageal reflux disease can present after Roux-en-Y gastric bypass, and it is usually related to technical errors. Hiatal hernia, a narrow calibrated gastrojejunostomy and a long gastric pouch are all factors associated with the development of pathologic gastroesophageal reflux. Techniques are available to treat this condition, such as fundoplications with the gastric remnant, gastropexy to the arcuate ligament, teres ligament repair, or sphincter augmentation with the LINX device. Despite the growing number of reports of gastroesophageal reflux after Roux-en-Y gastric bypass, it should be still considered the best surgical option for patients with obesity and a large hiatal hernia or complications secondary to gastroesophageal reflux disease.
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Triadafilopoulos G, Mashimo H, Tatum R, O'Clarke J, Hawn M. Mixed Esophageal Disease (MED): A New Concept. Dig Dis Sci 2023; 68:3542-3554. [PMID: 37470896 DOI: 10.1007/s10620-023-08008-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 06/15/2023] [Indexed: 07/21/2023]
Abstract
We define mixed esophageal disease (MED) as a disorder of esophageal structure and/or function that produces variable signs or symptoms, simulating-fully or in part other well-defined esophageal conditions, such as gastroesophageal reflux disease, esophageal motility disorders, or even neoplasia. The central premise of the MED concept is that of an overlap syndrome that incorporates selected clinical, endoscopic, imaging, and functional features that alter the patient's quality of life and affect natural history, prognosis, and management. In this article, we highlight MED scenarios frequently encountered in medico-surgical practices worldwide, posing new diagnostic and therapeutic challenges. These, in turn, emphasize the need for better understanding and management, aiming towards improved outcomes and prognosis. Since MED has variable and sometimes time-evolving clinical phenotypes, it deserves proper recognition, definition, and collaborative, multidisciplinary approach, be it pharmacologic, endoscopic, or surgical, to optimize therapeutic outcomes, while minimizing iatrogenic complications. In this regard, it is best to define MED early in the process, preferably by teams of clinicians with expertise in managing esophageal diseases. MED is complex enough that is increasingly becoming the subject of virtual, multi-disciplinary, multi-institutional meetings.
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Affiliation(s)
- George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, 94305, USA.
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway Street 3rd floor, MC6341, Redwood City, CA, 94063, USA.
| | - Hiroshi Mashimo
- Section of Gastroenterology, Harvard Medical School, VA Boston Healthcare - Roxbury, 1400 VFW Pkwy, West Roxbury, MA, 02132, USA
| | - Roger Tatum
- Department of General Surgery, University of Washington, 1660 S. Columbian Way, Seattle, WA, 98108, USA
| | - John O'Clarke
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Mary Hawn
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, 94305, USA
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Castagneto-Gissey L, Gualtieri L, Diddoro A, Lauro A, Genco A, Casella G. Y Not Roux-en-Y?: Resolution of Barrett's Esophagus After Surgical Conversion of Gastric Sleeve in Two Patients. Dig Dis Sci 2023; 68:1698-1704. [PMID: 36853549 DOI: 10.1007/s10620-023-07874-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/30/2023] [Indexed: 03/01/2023]
Abstract
Esophageal lesions ranging from erosive esophagitis to Barrett's esophagus (BE) eventually develop months-years after sleeve gastrectomy (SG), representing a significant post-surgical issue in GI practice. Roux-en-Y gastric bypass (RYGB) conversion is a widespread and effective method of managing reflux and esophageal complications following SG. Although some studies using a limited sample size have demonstrated that RYGB performed as a primary procedure may regress BE presumably by reducing reflux, whether the same may apply to RYGB performed as revision surgery after SG has scarcely been addressed in the literature. Though histological regression of BE following primary RYGB occurs in 51.9% of patients, with regression of Barrett's dysplasia in 50% of cases, revisional RYGB yields a remission rate as high as 81.8% for Barrett's metaplasia and 100% for dysplastic lesions, although the number of subjects in the published studies are very small. We report two patients who developed GERD and BE following SG with complete regression 12 months after conversion to RYGB in both subjects, confirming the substantially greater proportion of BE resolution in patients undergoing RYGB as revision surgery following SG.
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Affiliation(s)
- Lidia Castagneto-Gissey
- Department of Surgery, Sapienza University of Rome, Viale Regina Elena, 324, 00161, Rome, Italy
| | - Loredana Gualtieri
- Department of Surgery, Sapienza University of Rome, Viale Regina Elena, 324, 00161, Rome, Italy
| | - Annalisa Diddoro
- Department of Surgery, Sapienza University of Rome, Viale Regina Elena, 324, 00161, Rome, Italy
| | - Augusto Lauro
- Department of Surgery, Sapienza University of Rome, Viale Regina Elena, 324, 00161, Rome, Italy
| | - Alfredo Genco
- Department of Surgery, Sapienza University of Rome, Viale Regina Elena, 324, 00161, Rome, Italy
| | - Giovanni Casella
- Department of Surgery, Sapienza University of Rome, Viale Regina Elena, 324, 00161, Rome, Italy.
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Santonicola A, Ruggiero L, Palma R, Angrisani L, Iovino P. Gerd symptoms after laparoscopic Roux-en-Y gastric bypass: an emerging scenario. Int J Obes (Lond) 2022; 46:1076-1078. [PMID: 35066564 DOI: 10.1038/s41366-022-01072-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 01/05/2022] [Accepted: 01/12/2022] [Indexed: 02/07/2023]
Abstract
Laparoscopic Roux-en-Y gastric bypass (RYGB) is the second most performed bariatric procedure and it is considered the procedure of choice to treat patients with severe obesity and gastroesophageal reflux disease (GERD). However, some authors described the new onset or the recurrence of GERD symptoms after RYGB, and data at follow-up were scanty. In our center, we evaluated trend in weight, GERD symptoms and obesity-related comorbidities in 45 patients undergone RYGB at least 60 months before (mean follow-up 99.9 ± 22.9 months). At RYGB 51.1% patients referred preoperative GERD symptoms; among them, 47.8% showed an intraoperative hiatal hernia (HH). At medium-term follow-up mean BMI was significantly lower compared to baseline (p < 0.001). Among patients with preoperative GERD, 69.6% had GERD resolution and 30.4% reported postoperative GERD symptoms. Furthermore, 18.2% without preoperative GERD referred postoperative GERD new onset. We confirmed that RYGB as primary intervention provides satisfactory weight loss and a high percentage of GERD symptoms resolution. However, about 24.4% of patients complained of GERD symptoms at medium-term follow-up. The pathophysiology of GERD after RYGB, de novo or persistence, is not completely understood and several hypotheses could be drawn; however, further studies focusing the pathophysiology of these symptoms are needed.
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Affiliation(s)
- Antonella Santonicola
- University of Salerno, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", Baronissi, SA, Italy
| | - Luigi Ruggiero
- University of Salerno, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", Baronissi, SA, Italy
| | - Rossella Palma
- Department of Surgical Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Luigi Angrisani
- Department of Public Health, "Federico II" University of Naples, Naples, Italy
| | - Paola Iovino
- University of Salerno, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", Baronissi, SA, Italy.
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8
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Assessment and management of gastroesophageal reflux disease following bariatric surgery. Surg Obes Relat Dis 2021; 17:1919-1925. [PMID: 34620566 DOI: 10.1016/j.soard.2021.07.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 07/31/2021] [Indexed: 12/12/2022]
Abstract
Gastroesophageal reflux disease (GERD) is a common disease in patients with obesity. The incidence of de novo GERD and the effect of bariatric surgery on patients with pre-existing GERD remain controversial. Management of GERD following bariatric surgery is complicated and can range from medical therapy to non-invasive endoscopic options to invasive surgical options. To address these issues, we performed a systematic review of the literature on the incidence of GERD and the various modalities of managing GERD in patients following bariatric surgery. Given the increased number of laparoscopic sleeve gastrectomy (LSG) procedures being performed and the high incidence of GERD following LSG, bariatric surgeons should be familiar with the options available to manage GERD following LSG as well as other bariatric procedures.
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9
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Jung HY. In Which Situation is Endoscopic Radiofrequency Anti-Reflux Therapy (Stretta) Effective for Controlling Gastroesophageal Reflux Symptoms? Clin Endosc 2021; 54:451-452. [PMID: 34261209 PMCID: PMC8357594 DOI: 10.5946/ce.2021.190] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 06/20/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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10
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Curell A, Beisani M, García Ruiz de Gordejuela A, Vilallonga R, Verdaguer Tremolosa M, González López Ó, Caubet Busquet E, Fort López-Barajas JM. Outcomes of Conversion from Sleeve Gastrectomy to Roux-en-Y Gastric Bypass Due to GERD-a Retrospective Analysis of 35 Patients. Obes Surg 2021; 31:4100-4106. [PMID: 34227017 DOI: 10.1007/s11695-021-05541-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 06/14/2021] [Accepted: 06/17/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Sleeve gastrectomy (SG) has become one of the most performed bariatric procedures worldwide. Its main weaknesses are weight regain and gastroesophageal reflux disease (GERD). Conversion to Roux-en-Y gastric bypass (RYGB) is considered the gold standard to manage GERD and related symptoms. METHODS Retrospective evaluation from a prospective bariatric surgery database of all our institution's patients converted from SG to RYGB due to GERD between January 2010 and December 2018. Clinical characteristics and workups before SG and before and after RYGB were analyzed. RESULTS During the study period, 35 patients needed a conversion to RYGB, due to GERD or GERD-related symptoms. Mean age was 48.6 years, 85.7% were women, and mean BMI was 31.4 kg/m2. The interval between SG and RYGB was in a range 7 to 70 months (mean 33 months). All conversions were completed laparoscopically, associating a hiatoplasty in 45.7% of cases. A complete remission of symptoms was observed in 74% of patients, some improvement in 20%, and no relief in 6%. There were 3 cases of hiatal hernia persistence and 2 of recidivism. Only 1 patient presented pathological pHmetry, while moderate esophagitis was demonstrated in 2 patients. CONCLUSIONS Conversion to RYGB was effective in almost all patients. Pathological acid exposure and hiatal hernias seem to be the main findings prior to conversion, justifying an exhaustive examination and aggressive approach to the hiatus. Due to the insufficient correlation between symptoms and findings on morphological and functional tests, actively searching for signs of GERD is advisable.
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Affiliation(s)
- Anna Curell
- General and Digestive Surgery Department, Vall d'Hebron Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain.,Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - Marc Beisani
- Bariatric Surgery Unit, General and Digestive Surgery Department, Moises Broggi Hospital, CSI, Sant Joan Despi, Barcelona, Spain
| | - Amador García Ruiz de Gordejuela
- Endocrine, Metabolic and Bariatric Unit, General Surgery Department, Vall d'Hebron Hospital Campus, Universitat Autònoma de Barcelona, Center of Excellence for the EAC-BC, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Ramon Vilallonga
- Endocrine, Metabolic and Bariatric Unit, General Surgery Department, Vall d'Hebron Hospital Campus, Universitat Autònoma de Barcelona, Center of Excellence for the EAC-BC, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Mireia Verdaguer Tremolosa
- General and Digestive Surgery Department, Vall d'Hebron Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Óscar González López
- Endocrine, Metabolic and Bariatric Unit, General Surgery Department, Vall d'Hebron Hospital Campus, Universitat Autònoma de Barcelona, Center of Excellence for the EAC-BC, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain.
| | - Enric Caubet Busquet
- Endocrine, Metabolic and Bariatric Unit, General Surgery Department, Vall d'Hebron Hospital Campus, Universitat Autònoma de Barcelona, Center of Excellence for the EAC-BC, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - José Manuel Fort López-Barajas
- Endocrine, Metabolic and Bariatric Unit, General Surgery Department, Vall d'Hebron Hospital Campus, Universitat Autònoma de Barcelona, Center of Excellence for the EAC-BC, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
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11
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Nevins EJ, Dixon JE, Viswanath YKS. The Outcome of Endoscopic Radiofrequency Anti-Reflux Therapy (STRETTA) for Gastroesophageal Reflux Disease in Patients with Previous Gastric Surgery: A Prospective Cohort Study. Clin Endosc 2021; 54:542-547. [PMID: 33761229 PMCID: PMC8357598 DOI: 10.5946/ce.2020.243] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 11/30/2020] [Indexed: 12/13/2022] Open
Abstract
Background/Aims STRETTA improves the quality of life and reduces the need for anti-reflux medication in select patients, especially those with uncomplicated gastroesophageal reflux disease (GERD). We aimed to review the outcomes of STRETTA in patients with medically refractory GERD, who had undergone previous gastric surgery.
Methods This was a review of a prospective database in a British center. Since 2016, all GERD patients who underwent STRETTA and had a history of previous gastric surgery were studied (n=11). Anti-reflux medication pre- and post-STRETTA was evaluated. The outcomes were assessed objectively by the change in anti-reflux medication and subjectively through a pre- and post-procedure GERD-health-related quality of life (HRQL) questionnaire.
Results The median length of follow-up was 23 months. Nine patients demonstrated improved GERD-HRQL scores following STRETTA (82%). Of the 7 patients who underwent fundoplication, all reported improved symptoms, with 3 patients discontinuing the medication and 3 patients on a reduced dose of proton pump inhibitor. Four patients underwent surgery other than fundoplication, of which 2 reported improvement and discontinued the proton pump inhibitor. Two patients reported no improvement.
Conclusions This study demonstrates that STRETTA is successful in reducing refractory GERD in patients with previous gastric surgery. The outcomes were comparable to published outcomes in patients with uncomplicated GERD with no previous history of gastric surgery.
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Affiliation(s)
- Edward John Nevins
- Department of Upper GI surgery, James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - James Edward Dixon
- Department of Upper GI surgery, James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
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12
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Guzman-Pruneda FA, Brethauer SA. Gastroesophageal Reflux After Sleeve Gastrectomy. J Gastrointest Surg 2021; 25:542-550. [PMID: 32935271 DOI: 10.1007/s11605-020-04786-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 09/03/2020] [Indexed: 01/31/2023]
Abstract
Sleeve gastrectomy continues to be the most commonly performed bariatric operation worldwide. Development or worsening of pre-existing GERD has been recognized as a significant issue postoperatively. There is a paucity of information concerning the most appropriate preoperative workup and the technical and anatomical factors that may or may not contribute to the occurrence of reflux symptoms. Contemporary data quality is deficient given the predominantly retrospective nature, limited follow-up time, and heterogeneous outcome measures across studies. This has produced mixed results regarding the postoperative incidence and severity of GERD. Ultimately, better-constructed investigations are needed in order to offer evidence-based recommendations that may guide preoperative workup and improved patient selection criteria.
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Affiliation(s)
- Francisco A Guzman-Pruneda
- Department of Surgery, Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Stacy A Brethauer
- Department of Surgery, Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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13
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Kushner BS, Awad MM, Mikami DJ, Chand BB, Wai CJ, Murayama KM. Endoscopic treatments for GERD. Ann N Y Acad Sci 2020; 1482:121-129. [PMID: 33063344 DOI: 10.1111/nyas.14511] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 09/18/2020] [Accepted: 09/22/2020] [Indexed: 12/11/2022]
Abstract
Gastroesophageal reflux disease (GERD) is a condition with increasing prevalence and morbidity in the United States and worldwide. Despite advances in medical and surgical therapy over the last 30 years, gaps remain in the therapeutic profile of options. Flexible upper endoscopy offers the promise of filling in these gaps in a potentially minimally invasive approach. In this concise review, we focus on the plethora of endoluminal therapies available for the treatment of GERD. Therapies discussed include injectable agents, electrical stimulation of the lower esophageal sphincter, antireflux mucosectomy, radiofrequency ablation, and endoscopic suturing devices designed to create a fundoplication. As new endoscopic treatments become available, we come closer to the promise of the incisionless treatment of GERD. The known data surrounding the indications, benefits, and risks of these historical, current, and emerging approaches are reviewed in detail.
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Affiliation(s)
- Bradley S Kushner
- Department of Surgery, Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Michael M Awad
- Department of Surgery, Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Dean J Mikami
- Department of Surgery, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii
| | - Bipan B Chand
- Department of Surgery, Stritch School of Medicine, Loyola University Chicago, Chicago, Illinois
| | - Christina J Wai
- Department of Surgery, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii
| | - Kenric M Murayama
- Department of Surgery, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii
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14
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Fanous M, Jaehne A, Simbob J. The Benefits of Nonablative Radiofrequency Treatment of the Lower Esophageal Sphincter After Transoral Incisionless Fundoplication. Am Surg 2020; 86:1525-1527. [PMID: 32683926 DOI: 10.1177/0003134820933586] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Non-ablative radiofrequency treatment to the lower esophageal sphincter (Stretta) has been shown to be beneficial after failed Nissen fundoplication. To our knowledge, this is the first report of Stretta after transoral incisionless fundoplication (TIF). This patient is a 17-year-old female who had gastroesophageal reflux disease (GERD) symptoms for 9 years. She presented with heartburn, regurgitation, and epigastric discomfort. She used omeprazole for 9 years. Esophagogastroduodenoscopy (EGD) showed a 2 cm sliding hiatal hernia and DeMeester score of 25. The GERD Health-Related Quality of Life (GERD-HRQL) score on omeprazole was 14. Patient underwent a TIF procedure, which was uneventful. Her symptoms resolved, and she discontinued omeprazole. Six months later, she had episodes of repeated violent vomiting followed by recurrence of regurgitation, nausea, bloating, and dysphagia. She resumed omeprazole. Diagnostic workup included gastric emptying scan, which was normal. EGD showed no hiatal hernia and partial disruption of the TIF valve. DeMeester score was 36.3. Esophageal manometry with impedance showed intact peristalsis and normal relaxation of the lower esophageal sphincter. The patient underwent Stretta, which was uneventful. The previous TIF did not increase the complexity of the procedure. There were no immediate or postoperative complications. The patient reported gradual improvement of her symptoms with complete resolution 2 months postoperatively. She discontinued omeprazole. The GERD-HRQL score 17 months post-Stretta was 0. This case highlights the feasibility, safety, and efficacy of performing Stretta following TIF. It provides an endoluminal alternative to complex revisional antireflux surgery. Prospective studies with longer follow-up are required to validate this concept.
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Affiliation(s)
- Medhat Fanous
- Department of Surgery, Aspirus Iron River Hospital & Clinics, Iron River, MI, USA
| | - Anja Jaehne
- Department of Quality Assurance, Aspirus Iron River Hospital & Clinics, Iron River, MI, USA
| | - Jenna Simbob
- Surgical Services, Aspirus Iron River Hospital & Clinics, Iron River, MI, USA
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Suter M. Gastroesophageal Reflux Disease, Obesity, and Roux-en-Y Gastric Bypass: Complex Relationship—a Narrative Review. Obes Surg 2020; 30:3178-3187. [DOI: 10.1007/s11695-020-04690-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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16
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Butti F, Tobler O, Allemann P, Fournier P. Gastroesophageal Reflux Disease Following Roux-en-Y Gastric Bypass. J Laparoendosc Adv Surg Tech A 2020; 30:875-878. [PMID: 32208959 DOI: 10.1089/lap.2020.0094] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Gastroesophageal reflux disease (GERD) is one of the most important obesity-related comorbidity, with prevalence >50% in obese population. Roux-en-Y gastric bypass (RYGB) is considered the gold standard for metabolic surgery in obese patients with GERD, but in a subgroup of patients this pathological GERD may be not really controlled after this technique. Aims of this article are to discuss surgical and endoscopic options to manage refractory GERD after RYGB. Materials and Methods: We realized a literature review using the PubMed database and searching articles published before December 2019 about GERD after RYGB. Results: We found six studies, four case reports, and two retrospective studies about surgical and endoscopic options to treat this subgroup of patients. Discussion: Pharmacological therapy and life style optimization are the first line of treatment. For resistant GERD, new surgical and endoscopic strategies are proposed in the past years to manage this subgroup of patients related to anatomic limitation of RYGB. Conclusion: More studies are needed to compare surgical and endoscopic solutions. The choice of treatment depends on local resources and skills, and if necessary refer the patient to a specialist center.
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Affiliation(s)
- Fabio Butti
- Service de Chirurgie Générale, Groupement Hospitalier de l'Ouest Lémanique, Hôpital de Nyon, Chemin de Monastier, Nyon, Switzerland.,Service de Chirurgie Viscérale, Centre Hospitalier Universitaire Vaudois, Lausanne, Rue du Bugnon, Lausanne, Switzerland
| | - Olivier Tobler
- Service de Chirurgie Générale, Groupement Hospitalier de l'Ouest Lémanique, Hôpital de Nyon, Chemin de Monastier, Nyon, Switzerland
| | - Pierre Allemann
- Clinique de La Source, Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Pierre Fournier
- Service de Chirurgie Générale, Groupement Hospitalier de l'Ouest Lémanique, Hôpital de Nyon, Chemin de Monastier, Nyon, Switzerland.,Service de Chirurgie Viscérale, Centre Hospitalier Universitaire Vaudois, Lausanne, Rue du Bugnon, Lausanne, Switzerland
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Riva CG, Asti E, Lazzari V, Aquilino K, Siboni S, Bonavina L. Magnetic Sphincter Augmentation After Gastric Surgery. JSLS 2020; 23:JSLS.2019.00035. [PMID: 31624454 PMCID: PMC6785249 DOI: 10.4293/jsls.2019.00035] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background Persistent or de novo gastroesophageal reflux disease (GERD) may be a significant clinical issue after gastric/bariatric surgical procedures. We investigated the effect of magnetic sphincter augmentation (MSA) in the treatment of GERD after previous gastric/bariatric surgery. Database We conducted a systematic review according to the Preferred Reporting Items For Systematic Reviews and Meta-analyses statement. We searched multiple databases (PubMed, Cochrane, Embase, Scopus) up to May 2019. We also queried the prospectively collected database of patients who underwent MSA at our tertiary-care hospital and compared postsurgical to naïve patients operated during the same time period. Results Seven studies (3 case series and 4 case reports), for a total of 35 patients, met the inclusion criteria in the systematic review. The most common index operation was a bariatric procedure, either sleeve gastrectomy or Roux-en-Y gastric bypass. After MSA implant, the Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) score significantly improved compared to baseline (P = .005). Two patients (5.7%) required laparoscopic device removal. In the local institutional cohort series of 67 patients treated by MSA, the prevalence of preoperative grade B esophagitis, operative time, size of MSA, and length of stay were greater in patients with prior gastric surgery compared to naïve patients. Conclusions MSA is a safe, simple, and standardized antireflux procedure. It is also feasible in patients with refractory GERD following gastric/bariatric surgery. Further prospective and comparative studies are needed to validate the preliminary clinical experience in this subset of patients.
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Affiliation(s)
- Carlo Galdino Riva
- Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milano, Milano, Italy
| | - Emanuele Asti
- Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milano, Milano, Italy
| | - Veronica Lazzari
- Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milano, Milano, Italy
| | - Krizia Aquilino
- Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milano, Milano, Italy
| | - Stefano Siboni
- Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milano, Milano, Italy
| | - Luigi Bonavina
- Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milano, Milano, Italy
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Ribeiro R, Pouwels S, Parmar C, Pereira J, Manaças L, Guerra A, Borges N, Ribeiro J, Viveiros O. Outcomes of Long Pouch Gastric Bypass (LPGB): 4-Year Experience in Primary and Revision Cases. Obes Surg 2019; 29:3665-3671. [PMID: 31267476 DOI: 10.1007/s11695-019-04051-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND One of the most important complications of the one anastomosis gastric bypass (OAGB) is enterobilio acid reflux (EBAR). We report the concept of the long pouch Roux-en-Y gastric bypass (LPRYGB) meaning a Roux-en-Y with a long pouch and a 100-cm alimentary limb to avoid EBAR, with a long biliopancreatic limb to increase metabolic effects. METHODS A total of 300 LPRYGB cases in a 4-year period, with a 90% follow-up rate, were analysed. Anthropometric, technical feasibility, morbidity, weight loss and comorbidity outcomes were analysed. RESULTS The percentage total weight loss (%TWL) was 30.5% at 4 years of follow-up (32.3% in primary and 28.3% in revisions). Six intra-operative (2%) and 28 postoperative complications (9.3%) were seen. Out of this 28 complications, 11 (3.6%) were late complications. Reoperations were performed in 15 patients (5.0%). Clinically relevant EBAR was present in 3 cases only (1%) 4 years after the operation. CONCLUSIONS The LPRYGB combines the main advantages of the OAGB (light restriction and moderate malabsorption) with the anti-reflux effect from the Roux-en-Y diversion.
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Affiliation(s)
- Rui Ribeiro
- Clínica de Santo António, Metabolic Patient Multidisciplinary Centre, Reboleira, Lisbon, Portugal
| | - Sjaak Pouwels
- Department of Surgery, Haaglanden Medical Center, Lijnbaan 32, P.O. Box 432, 2501 CK, The Hague, The Netherlands.
| | | | - João Pereira
- Obesity and Endocrine Diseases Unit, Department of Surgery, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Leonor Manaças
- Obesity and Endocrine Diseases Unit, Department of Surgery, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Anabela Guerra
- Obesity and Endocrine Diseases Unit, Department of Surgery, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Nuno Borges
- Obesity and Endocrine Diseases Unit, Department of Surgery, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - João Ribeiro
- Clínica de Santo António, Metabolic Patient Multidisciplinary Centre, Reboleira, Lisbon, Portugal
| | - Octávio Viveiros
- Obesity and Endocrine Diseases Unit, Department of Surgery, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
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Khidir N, Angrisani L, Al-Qahtani J, Abayazeed S, Bashah M. Initial Experience of Endoscopic Radiofrequency Waves Delivery to the Lower Esophageal Sphincter (Stretta Procedure) on Symptomatic Gastroesophageal Reflux Disease Post-Sleeve Gastrectomy. Obes Surg 2018; 28:3125-3130. [DOI: 10.1007/s11695-018-3333-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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20
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Esophageal Magnetic Sphincter Augmentation as a Novel Approach to Post-bariatric Surgery Gastroesophageal Reflux Disease. Obes Surg 2018; 28:3080-3086. [DOI: 10.1007/s11695-018-3292-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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21
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Operative Treatments for Reflux After Bariatric Surgery: Current and Emerging Management Options. J Gastrointest Surg 2017; 21:577-582. [PMID: 28091851 DOI: 10.1007/s11605-017-3361-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 01/03/2017] [Indexed: 01/31/2023]
Abstract
Gastroesophageal reflux disease (GERD) is a common disorder that has a well-established connection with obesity. To ameliorate the morbidity associated with obesity, bariatric procedures have become an established pathway to accomplish sustained weight loss. In some procedures, such as with the Roux-en-Y gastric bypass surgery, weight loss is also accompanied by the resolution of GERD symptoms. However, other popular bariatric surgeries, such as the sleeve gastrectomy, have a controversial impact on their effect on reflux. Consequently, increased attention has been given to the development of strategies for the management of de novo or recurrent reflux after bariatric surgery. This article aims to discuss medical and surgical strategies for reflux after bariatric surgery, and their outcomes.
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Triadafilopoulos G. Endoscopic Options for Gastroesophageal Reflux: Where Are We Now and What Does the Future Hold? Curr Gastroenterol Rep 2017; 18:47. [PMID: 27424219 DOI: 10.1007/s11894-016-0521-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Early in the twenty-first century, novel endoscopic techniques were introduced for the management of gastroesophageal reflux disease, providing minimally invasive ways to eliminate pharmacologic acid inhibition and avoid the need for anti-reflux surgery. These techniques do not significantly alter the anatomy of the gastroesophageal junction, minimizing short- and long-term adverse effects, such as dysphagia and bloating. After extensive clinical testing, many endoscopic therapies were abandoned due to either lack of durable efficacy or unfavorable safety profile. Today, only four such therapies remain clinically available, each with variable levels of clinical validation and market penetration. This review will provide an assessment of these endoscopic therapies, highlighting their respective strengths and weaknesses and their present and future applicability to patients with gastroesophageal reflux disease.
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Affiliation(s)
- George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, M-211, Stanford, CA, 94306, USA.
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Laparoscopic management of reflux after Roux-en-Y gastric bypass using the LINX system and repair of hiatal hernia: a case report. Surg Obes Relat Dis 2016; 12:e51-e54. [DOI: 10.1016/j.soard.2016.02.037] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 02/24/2016] [Accepted: 02/25/2016] [Indexed: 11/22/2022]
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Radiofrequency energy delivery to the lower esophageal sphincter reduces esophageal acid exposure and improves GERD symptoms: a systematic review and meta-analysis. Surg Laparosc Endosc Percutan Tech 2012; 22:283-8. [PMID: 22874675 DOI: 10.1097/sle.0b013e3182582e92] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE Studies of endoscopic application of radiofrequency energy to the lower esophageal sphincter for gastroesophageal reflux control have produced conflicting reports of its effectiveness. This study aimed to conduct a meta-analysis of randomized controlled trials and cohort studies to assess the impact of this treatment. METHODS Twenty studies were included. Outcomes analyzed included gastroesophageal reflux disease (GERD) symptom assessment, quality of life, esophageal pH, and esophageal manometry. RESULTS A total of 1441 patients from 18 studies were included. Radiofrequency treatment improved heartburn scores (P=0.001), and produced improvements in quality of life as measured by GERD-health-related quality-of-life scale (P=0.001) and quality of life in reflux and dyspepsia score (P=0.001). Esophageal acid exposure decreased from a preprocedure Johnson-DeMeester score of 44.4 to 28.5 (P=0.007). CONCLUSIONS Radiofrequency ablation of the lower esophageal sphincter produces significant improvement in reflux symptoms and may represent an alternative to medical treatment and surgical fundoplication in select patients.
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25
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Abstract
Obesity and gastroesophageal reflux disease (GERD) are common chronic illnesses. They often coexist and need to be treated concomitantly. Fundoplication may be effective for the short-term control of GERD in the obese patient; however, this procedure does not induce weight loss or treat the comorbid conditions related to obesity. Roux-en-Y gastric bypass is a highly effective treatment of GERD, obesity, and the associated comorbidities. Surgeons who are not comfortable with a bariatric surgical procedure in these patients should either complete appropriate advanced training in bariatric surgery or refer those patients to a qualified surgeon who can offer these options.
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Affiliation(s)
- Kevin M Reavis
- Division of Gastrointestinal Surgery, Department of Surgery, University of California, Irvine Medical Center, 333 City Boulevard West, Suite 850, Orange, CA 92868, USA.
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Louis H, Devière J. Ensocopic-endoluminal therapies. A critical appraisal. Best Pract Res Clin Gastroenterol 2010; 24:969-79. [PMID: 21126708 DOI: 10.1016/j.bpg.2010.10.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2010] [Accepted: 10/07/2010] [Indexed: 02/06/2023]
Abstract
Due to its large prevalence, gastro-oesophageal reflux disease is an ideal target for companies developing medical devices designed to cure reflux. Indeed, because medications leave part of the patients unsatisfied, there is a potential place for alternative therapies, capable of restoring an efficacious anti-reflux barrier, but without the drawbacks of surgery. For more than a decade, several novel endoluminal therapies were developed, clinically evaluated, put on the market and, for many of them, withdrawn due to economic considerations, lack of efficacy or complications. These therapies were designed to act on the gastro-oesophageal junction and reinforce mechanically the anti-reflux barrier by three different ways: suturing, radiofrequency energy application, or implantation of foreign materials. Most of the published data come from open uncontrolled studies with short-term enthusiastic results. There are a few randomized control trials assessing the true efficacy of these modalities, showing often less impressive results than the open studies did, due to a high placebo effect in mild gastro-oesophageal reflux disease. Although endoscopic treatment of gastro-oesophageal disease is still an interesting topic of investigation, one can draw some lessons from the recent experiences and foresee which place these techniques could find in the management of patients suffering from reflux.
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Affiliation(s)
- Hubert Louis
- Department of Gastroenterology and Hepatopancreatology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.
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Use of endoluminal antireflux therapies for obese patients with GERD. Obes Surg 2008; 19:783-7. [PMID: 18839080 DOI: 10.1007/s11695-008-9715-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2008] [Accepted: 09/16/2008] [Indexed: 12/12/2022]
Abstract
BACKGROUND Obese patients with gastroesophageal reflux disease (GERD) refractory to medical therapy are a challenging patient population as obesity is a preoperative predictor of failure after antireflux surgery. We therefore sought to evaluate outcomes using one of two commercially available endoluminal therapies in this population. METHODS Consecutive obese patients (body mass index (BMI)>30) with GERD (DeMeester>14.5) undergoing either Plicator (NDO) or Stretta (Curon) were identified in our single-institution prospective database. Outcomes assessed were: (1) failure rate (absolutely no symptomatic improvement after procedure and/or need for subsequent antireflux surgery), (2) postoperative vs. preoperative symptom (heartburn, chest pain, regurgitation, dysphagia, cough, hoarseness, and asthma) scores, and (3) proton-pump inhibitor (PPI) medication use. RESULTS Twenty-two patients each underwent an endoluminal therapy (ten Plicator patients and 12 Stretta patients) with mean follow-up of 1.5 years. There were no treatment-associated complications. Mean BMI was not different between Plicator and Stretta groups (39.6 vs. 38.6, respectively, p=0.33). The failure rate for the entire cohort was 28% (10% Plicator vs. 42% Stretta, p=0.11). The proportion of patients reporting moderate/severe symptoms postop was significantly less than preop: chest pain 9% vs. 13% (p=0.04), cough 22% vs. 36% preop (p=0.025), voice changes 9% vs. 36% preop (p=0.012), and dysphagia 9% vs. 32% preop (p=0.04). The proportion of patients on PPI medications postop was also less than preop (45% vs. 81%, p=0.1) CONCLUSION Endoluminal treatment can provide a safe means of improving GERD symptoms for some obese patients, though many will continue to require medication therapy also. Further work aimed at understanding optimal candidates for endoluminal therapy in this patient population is warranted.
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Surgical management of gastroesophageal reflux disease in obesity. Dig Dis Sci 2008; 53:2318-29. [PMID: 18663575 DOI: 10.1007/s10620-008-0415-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2008] [Accepted: 06/18/2008] [Indexed: 01/08/2023]
Abstract
Bariatric surgery is ubiquitous today. In the obese patient with comorbid gastroesophageal reflux disease (GERD), it is increasingly being used as an alternative to fundoplication because it not only has an effect on GERD but also on other comorbid illnesses. Traditional GERD surgery is designed to augment the mechanical barriers against reflux, decrease acid production in the stomach, improve gastric emptying, or divert bile from the stomach. Roux-en-Y gastric bypass addresses these issues in addition to resulting in profound weight loss in patients. Banding may have a positive influence in patients' GERD, though to a lesser extent. The duodenal switch provides excellent control for patients with alkaline reflux. A revision of the 1991 National Institutes of Health guidelines for determining bariatric surgical candidates is overdue, and it may be feasible to consider expanding the body mass index and comorbidity requirements to reflect the benefits offered by these techniques for GERD patients.
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Reavis KM, Melvin WS. Advanced endoscopic technologies. Surg Endosc 2008; 22:1533-46. [PMID: 18401657 DOI: 10.1007/s00464-008-9831-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2007] [Accepted: 02/04/2008] [Indexed: 12/20/2022]
Abstract
The use of endoscopy for diagnosing and treating ailments of the alimentary tract has evolved steadily over the past few decades, with tremendous growth and innovation in the past few years. Initially, endoscopy relied on rigid telescopes, direct visualization, and dangerously exothermic sources of illumination. The introduction of fiber optics, charge-coupled-device cameras, and increasingly efficient light sources has enabled researchers to investigate areas of the human gastrointestinal tract through flexible endoscopy not previously thought to be reachable without formal surgical exploration. The more recent advances in scope platforms, devices, and techniques have allowed researchers to push the envelope of endoscopic diagnostics and therapeutics to greater heights. Specific new platforms include ColonoSight and mother-daughter endoscopes such as the ShapeLock TransPort and the SpyGlass direct visualization system. Specific devices include the EndoCinch suturing system, the full-thickness Plicator procedure, Esophyx, the Stretta system, and the HALO(360) system. Specific new techniques include small-caliber endoscopy, endoscopic mucosal and submucosal resection, and natural orifice translumenal endoscopic surgery (NOTES). This article describes the most relevant recent advances in endoscopic innovation with regard to platform design, devices, and techniques anticipated to serve as the foundation for further research and design for developing generations of endoscopic technologies to come.
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Affiliation(s)
- Kevin M Reavis
- Division of General Surgery, The Ohio State University, RM N 729 Doan Hall, 410 W. Tenth Avenue, Columbus, OH 43210, USA.
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Abstract
Morbid obesity continues to grow at an alarming rate. As of 2004, 35% of Americans were considered to have a body mass index (BMI) over 30. As the number of patients undergoing weight loss surgery increases, the patient population presenting to primary care physicians with previous gastric bypass will also increase. Accordingly, it will become imperative for primary care physicians to be familiar and comfortable with the care of these patients. This review focuses on the management of gastrointestinal disorders in postoperative gastric bypass patients.
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Affiliation(s)
- Troy A Markel
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, EH202, Indianapolis, IN 46202, USA
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