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Ibrahim MA, Mowoh DP, Al Khadem M, Abbas M, Khaitan L. Long-term outcomes of magnetic sphincter augmentation in sleeve gastrectomy and Roux-en-Y gastric bypass patients: a comprehensive analysis. Surg Endosc 2024; 38:5343-5349. [PMID: 39030413 PMCID: PMC11362508 DOI: 10.1007/s00464-024-11059-4] [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: 04/29/2024] [Accepted: 07/06/2024] [Indexed: 07/21/2024]
Abstract
INTRODUCTION Management of gastroesophageal reflux disease after bariatric procedures can be challenging. There are very few long-term studies in this arena. This study aims to evaluate the long-term outcomes of the magnetic sphincter augmentation (MSA) reflux management system in a cohort of bariatric patients who had previously undergone sleeve gastrectomy and Roux-en-Y gastric bypass, with a focus on assessing gastroesophageal reflux disease (GERD) scores, medication use, and patient-reported symptoms. METHODS We conducted a retrospective chart review of 16 consecutive bariatric patients who received MSA implants following sleeve gastrectomy (n = 14) or gastric bypass (n = 2) surgeries. Data were collected regarding BMI, GERD quality of life assessments (GERD-HRQL), reflux symptoms, and use of PPIs in the sleeve/RGB patients through an extended period with a mean follow-up of 48 months. RESULTS Patients were followed up for a range of .5-84 months. Preoperative assessments included upper gastrointestinal imaging (UGI), high-resolution manometry, Bravo pH studies, and esophagogastroduodenoscopy (EGD). Three patients exhibited reflux on UGI, and 13/13 patients had positive Bravo studies preoperatively. Sixteen patients had a lower esophageal sphincter (LES) pressure under 18 mmHg, and eight patients had biopsy-proven esophagitis. Long-term outcomes are as follows. Daily PPI use fell from 88 to 25% at greater than three years. GERD-HRQL scores fell from 50.6 at baseline (range 27-70) and normalized at long-term follow-up. GERD symptom of regurgitation completely resolved. At long term, two patients had dysphagia and two patients had ongoing reflux. No adverse events were noted. CONCLUSION This is the first long-term outcomes study of magnetic sphincter augmentation placement after bariatric surgery. Our study showed the majority of patients had long-term improvement in GERD-HRQL scores and resolution/ relief of their reflux symptoms, with decreased use of PPIs. MSA is a safe, effective and durable management tool for reflux after bariatric surgery in carefully selected patients.
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Affiliation(s)
- Mina A Ibrahim
- Department of Surgery, Cleveland Medical Center, Case Western Reserve University School of Medicine, University Hospitals, 11100 Euclid Avenue, Cleveland, OH, 44121, USA.
| | - Daniel P Mowoh
- Department of Surgery, Cleveland Medical Center, Case Western Reserve University School of Medicine, University Hospitals, 11100 Euclid Avenue, Cleveland, OH, 44121, USA
| | - Mai Al Khadem
- Department of Surgery, Cleveland Medical Center, Case Western Reserve University School of Medicine, University Hospitals, 11100 Euclid Avenue, Cleveland, OH, 44121, USA
| | - Mujjahid Abbas
- Department of Surgery, Cleveland Medical Center, Case Western Reserve University School of Medicine, University Hospitals, 11100 Euclid Avenue, Cleveland, OH, 44121, USA
| | - Leena Khaitan
- Department of Surgery, Cleveland Medical Center, Case Western Reserve University School of Medicine, University Hospitals, 11100 Euclid Avenue, Cleveland, OH, 44121, USA
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Rapolti DI, Monrabal Lezama M, Manueli Laos EG, Schlottmann F, Masrur MA. Management of Gastroesophageal Reflux Disease after Sleeve Gastrectomy: Effectiveness of Medical, Endoscopic, and Surgical Therapies. J Laparoendosc Adv Surg Tech A 2024; 34:581-602. [PMID: 38568115 DOI: 10.1089/lap.2024.0111] [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: 07/26/2024] Open
Abstract
Introduction: Sleeve gastrectomy (SG) has become the most frequently performed bariatric operation in the United States. One of the main disadvantages of this procedure is the risk of developing gastroesophageal reflux disease (GERD) after the operation. We aimed to analyze different approaches for the treatment of GERD after SG. Methods: A literature review was performed to identify all possible treatment options for post-SG GERD. All the studies were assessed for full eligibility by manual assessment of their aims, methodology, results, and conclusions. Records were individually reviewed by the authors comparing outcomes and complications between procedures. Results: Although some studies have shown improvement or even resolution of GERD symptoms after SG, most patients develop or worsen symptoms. Lifestyle modifications along with medical therapy should be started on patients with GERD after SG. For those who are refractory to medication, endoscopic and surgical therapies can be offered. Conversion to Roux-en-Y gastric bypass (RYGB) is consistently effective in treatment of GERD and is the ideal therapy in patients with associated insufficient weight loss. Endoscopic and alternative surgical procedures are also available and have shown acceptable short-term outcomes. Conclusions: Several treatment options exist for the treatment of GERD after SG. Although conversion to RYGB remains the most effective therapy, other emerging endoscopic and surgical procedures could avoid the potential morbidity of this procedure and should be further evaluated. An evidence-based algorithm for the management of GERD after SG is proposed to guide decision making.
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Affiliation(s)
- Diana I Rapolti
- Department of Surgery, University of Illinois, Chicago, Illinois, USA
| | | | | | - Francisco Schlottmann
- Department of Surgery, University of Illinois, Chicago, Illinois, USA
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | - Mario A Masrur
- Department of Surgery, University of Illinois, Chicago, Illinois, USA
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Evans LA, Castillo-Larios R, Cornejo J, Elli EF. Challenges of Revisional Metabolic and Bariatric Surgery: A Comprehensive Guide to Unraveling the Complexities and Solutions of Revisional Bariatric Procedures. J Clin Med 2024; 13:3104. [PMID: 38892813 PMCID: PMC11172990 DOI: 10.3390/jcm13113104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/15/2024] [Accepted: 05/23/2024] [Indexed: 06/21/2024] Open
Abstract
Revisional metabolic and bariatric surgery (RMBS) presents unique challenges in addressing weight loss failure or complications arising from initial bariatric procedures. This review aims to explore the complexities and solutions associated with revisional bariatric procedures comprehensively, offering insights into the evolving terrain of metabolic and bariatric surgery. A literature review is conducted to identify pertinent studies and expert opinions regarding RMBS. Methodological approaches, patient selection criteria, surgical techniques, preoperative assessments, and postoperative management strategies are synthesized to provide a comprehensive overview of current practices and advancements in the field, including institutional protocols. This review synthesizes key findings regarding the challenges encountered in RMBS, including the underlying causes of primary procedure failure, anatomical complexities, technical considerations, and assessments of surgical outcomes. Additionally, patient outcomes, complication rates, and long-term success are presented, along with institutional approaches to patient assessment and procedure selection. This review provides valuable insights for clinicians grappling with the complexities of RMBS. A comprehensive understanding of patient selection, surgical techniques, preoperative management, and postoperative care is crucial for enhancing outcomes and ensuring patient satisfaction in the field of metabolic bariatric surgery.
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Affiliation(s)
| | | | | | - Enrique F. Elli
- Department of Surgery, Mayo Clinic Florida, 4500 San Pablo Rd., Jacksonville, FL 32224, USA
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Pletch A, Lidor A. GERD after Bariatric Surgery: A Review of the Underlying Causes and Recommendations for Management. Curr Gastroenterol Rep 2024; 26:99-106. [PMID: 38353898 DOI: 10.1007/s11894-024-00919-7] [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] [Accepted: 01/19/2024] [Indexed: 03/24/2024]
Abstract
PURPOSE OF REVIEW GERD after bariatric surgery is an ongoing concern for bariatric surgeons and their patients. This paper reviews the association of persistent or de novo GERD after multiple types of bariatric surgery, and focuses on the work up and management of GERD after SG. RECENT FINDINGS Two recent large, multicenter randomized clinical trials have shown stronger associations between SG and GERD compared to RYGB. A large group of internationally recognized bariatric surgeons collaborated on 72 consensus statements to help guide the bariatric community on the subject of redo surgeries after SG, including as it pertains to GERD. We present an algorithm that consolidates the best-practices recommendations of the work-up and management of GERD after sleeve gastrectomy, and mention areas of persistent controversy where future research is warranted.
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Affiliation(s)
- Alison Pletch
- Department of Surgery, University at Buffalo, 100 High Street, Buffalo, NY, D35014203, USA.
| | - Anne Lidor
- Division of Minimally Invasive Surgery, Department of Surgery, University of Wisconsin, School of Medicine and Public Health, 600 Highland Avenue, Madison, WI, 53726, USA
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Liu R, Guo Y, Yin G, Tuo H, Zhu Y, Yang W, Wang Y. Magnetic anchoring device assisted-laparoscopic sleeve gastrectomy versus conventional laparoscopic sleeve gastrectomy: A retrospective cohort study. Heliyon 2024; 10:e26875. [PMID: 38434329 PMCID: PMC10907795 DOI: 10.1016/j.heliyon.2024.e26875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 02/17/2024] [Accepted: 02/21/2024] [Indexed: 03/05/2024] Open
Abstract
Background Bariatric surgeries, including the sleeve gastrectomy, have been recognized as the most effectively treatment strategy for severe obesity. Magnetic devices have been successfully used in bariatric surgeries. Here, we intended to evaluate the safety and efficiency of magnetic anchoring device assisted-laparoscopic sleeve gastrectomy (MLSG), and to make a comparison of the short-term results between conventional laparoscopic sleeve gastrectomy (CLSG) and MLSG. Methods The retrospective cohort study was carried out by analyzing and summarizing the data from a database of routinely collected data. The cohort included the patients who underwent either CLSG (n = 120) or MLSG (n = 115) at a single center between January 2018 and December 2020 with a two-year follow-up. The effects of these two surgeries on the weight loss, resolution of comorbidities and quality of life (QOL) were analyzed. Results The two groups were similar in gender, age, body mass index, abdominal girth, as well as the type and proportion of comorbidities. And the cases in MLSG group had a markedly shorter time of operation (MLSG, 72.59 min vs. CLSG, 76.67 min; P = 0.003). Length of stay in hospital was significantly shorter in the MLSG group than that in the CLSG group (MLSG, 5.59 days vs. CLSG, 5.96 days; P = 0.016). Neither fatal event nor conversion to open surgery happened among all cases. There were no differences in terms of the postoperative complications between the two groups. Magnetic device-related mild hepatic lacerations occurred and were handled by hemostatic treatments in 3 cases. The QOL of patients in MLSG was better at 6-month after surgery, but there was no significant difference between the two groups at 1-year or 2-year after surgery. Conclusion Both MLSG and CLSG prove safe and effective, and the patients underwent MLSG have a shorter length of stay in hospital, and a better QOL during 6 months after surgery.
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Affiliation(s)
- Runkun Liu
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Yixian Guo
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Guozhi Yin
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Hang Tuo
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Yifeng Zhu
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Wei Yang
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Yufeng Wang
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
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Masood M, Low DE, Deal SB, Kozarek RA. Current Management and Treatment Paradigms of Gastroesophageal Reflux Disease following Sleeve Gastrectomy. J Clin Med 2024; 13:1246. [PMID: 38592683 PMCID: PMC10932325 DOI: 10.3390/jcm13051246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 02/16/2024] [Accepted: 02/19/2024] [Indexed: 04/10/2024] Open
Abstract
Obesity is associated with serious comorbidities and economic implications. Bariatric surgery, most commonly Roux-en-Y gastric bypass and sleeve gastrectomy, are effective options for weight loss and the improvement of obesity-related comorbidities. With the growing obesity epidemic, there has been a concomitant rise in bariatric surgeries, particularly in sleeve gastrectomy, which has been the most widely performed bariatric surgery since 2013. Gastroesophageal reflux disease (GERD) is highly prevalent in obese individuals, can significantly impact quality of life and may lead to serious complications. Obesity and GERD both improve with weight loss. However, as the incidence of sleeve gastrectomy rises, recent data have revealed a risk of exacerbation of pre-existing GERD or the development of de novo GERD following sleeve gastrectomy. We performed a detailed review of GERD post-sleeve gastrectomy, including its overall incidence, pathophysiology and current treatment paradigms.
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Affiliation(s)
- Muaaz Masood
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA 98101, USA;
| | - Donald E. Low
- Division of Thoracic Surgery, Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA 98101, USA;
| | - Shanley B. Deal
- Division of General and Bariatric Surgery, Center for Weight Management, Virginia Mason Franciscan Health, Seattle, WA 98101, USA;
| | - Richard A. Kozarek
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA 98101, USA;
- Center for Interventional Immunology, Benaroya Research Institute, Virginia Mason Franciscan Health, Seattle, WA 98101, USA
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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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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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Masood M, Low D, Deal SB, Kozarek RA. Gastroesophageal Reflux Disease in Obesity: Bariatric Surgery as Both the Cause and the Cure in the Morbidly Obese Population. J Clin Med 2023; 12:5543. [PMID: 37685616 PMCID: PMC10488124 DOI: 10.3390/jcm12175543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 08/11/2023] [Accepted: 08/18/2023] [Indexed: 09/10/2023] Open
Abstract
Gastrointestinal reflux disease (GERD) is a chronic, highly prevalent condition in the United States. GERD can significantly impact quality of life and lead to complications including aspiration pneumonia, esophageal stricture, Barrett's esophagus (BE) and esophageal cancer. Obesity is a risk factor for GERD, which often improves with weight loss and bariatric surgery. Though the incidence of bariatric surgery, in particular, minimally invasive sleeve gastrectomy, has risen in recent years, emerging data has revealed that the severity or new onset of GERD may follow bariatric surgery. We performed a literature review to provide a detailed analysis of GERD with an emphasis on bariatric surgery as both the cure and the cause for GERD in the morbidly obese population. We also describe the pathophysiological mechanisms, management approach and treatment strategies of GERD following bariatric surgery.
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Affiliation(s)
- Muaaz Masood
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA 98101, USA
| | - Donald Low
- Division of Thoracic Surgery, Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA 98101, USA
| | - Shanley B. Deal
- Division of General Surgery, Center for Weight Management, Virginia Mason Franciscan Health, Seattle, WA 98101, USA
| | - Richard A. Kozarek
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA 98101, USA
- Center for Interventional Immunology, Benaroya Research Institute, Virginia Mason Franciscan Health, Seattle, WA 98101, USA
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10
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Grover K, Khaitan L. Magnetic sphincter augmentation as treatment of gastroesophageal reflux disease after sleeve gastrectomy. Dis Esophagus 2023; 36:doad030. [PMID: 37317934 DOI: 10.1093/dote/doad030] [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: 03/21/2023] [Indexed: 06/16/2023]
Abstract
The sleeve gastrectomy's efficacy for the reduction of excess weight- and obesity-related comorbidities has been consistently demonstrated though the improvement of postoperative reflux symptoms has been questionable. The purpose of this article is to offer a diagnostic and treatment algorithm for patients suffering from GERD after the sleeve gastrectomy. This article is comprised of recommendations of from a single expert bariatric and foregut surgeon. While previously thought to be a relative contraindication, evidence suggests that select patients with a history of sleeve gastrectomy can safely and effectively undergo magnetic sphincter augmentation (MSA) and achieve improved control of reflux and discontinuation of PPIs. Concomitant hiatal hernia repair with MSA is recommended. MSA is a fantastic strategy for managing GERD after sleeve gastrectomy with careful patient selection.
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Affiliation(s)
- Karan Grover
- Department of Surgery, University Hospitals, Cleveland Medical Center, Cleveland, OH, USA
| | - Leena Khaitan
- Department of Surgery, University Hospitals, Cleveland Medical Center, Cleveland, OH, USA
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Al Trabulsi H, Muassess T, Guraya SY. Single-stage transoral incisionless fundoplication and laparoscopic sleeve gastrectomy for the management of GERD and obesity. Int J Surg Case Rep 2023; 105:108059. [PMID: 36996706 PMCID: PMC10070620 DOI: 10.1016/j.ijscr.2023.108059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 03/21/2023] [Accepted: 03/22/2023] [Indexed: 03/30/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Gastro-esophageal reflux disease (GERD) is frequently associated with obesity. Excess body weight, particularly central adiposity, with a concomitantly raised intra-abdominal pressure, leads to a reduced lower esophageal sphincter (LES) pressure and GERD. The lax LES essentially causes acid reflux in the lower esophagus. CASE PRESENTATION We report a 44-year-old woman who presented to our surgical clinic with heartburn and acid reflux, associated with difficulty in weight management. The patient had a BMI of 35 kg/m2. The upper GI endoscopy showed a small hiatal hernia, with lax LES and grade A esophagitis. She was initially started on daily proton pump inhibitors (PPIs). All available management plans were discussed with the patient, and she did not prefer to continue with life-long PPIs. At the same time, the patient was also concerned about her weight and requested for a plausible weight management solution. CLINICAL DISCUSSION The patient was planned for a single-stage Transoral Incisionless Fundoplication (TIF) and laparoscopic sleeve gastrectomy for her GERD and obesity, respectively. TIF was performed by two experienced endoscopists, one controlling the EsophyX device and the other ensuring continuous direct visualization of the field of work with the endoscope. Following the procedure, laparoscopic sleeve gastrectomy was performed during the same session. The patient had an uneventful recovery. CONCLUSION Eight months after surgery, the patient reported resolution of her GERD symptoms and a weight loss of 20 kg.
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12
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Best practice approach for redo-surgeries after sleeve gastrectomy, an expert's modified Delphi consensus. Surg Endosc 2023; 37:1617-1628. [PMID: 36693918 DOI: 10.1007/s00464-023-09879-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 01/08/2023] [Indexed: 01/26/2023]
Abstract
BACKGROUND Sleeve gastrectomy (SG) is the most common metabolic and bariatric surgical (MBS) procedure worldwide. Despite the desired effect of SG on weight loss and remission of obesity-associated medical problems, there are some concerns regarding the need to do revisional/conversional surgeries after SG. This study aims to make an algorithmic clinical approach based on an expert-modified Delphi consensus regarding redo-surgeries after SG, to give bariatric and metabolic surgeons a guideline that might help for the best clinical decision. METHODS Forty-six recognized bariatric and metabolic surgeons from 25 different countries participated in this Delphi consensus study in two rounds to develop a consensus on redo-surgeries after SG. An agreement/disagreement ≥ 70.0% on statements was considered to indicate a consensus. RESULTS Consensus was reached for 62 of 72 statements and experts did not achieve consensus on 10 statements after two rounds of online voting. Most of the experts believed that multi-disciplinary team evaluation should be done in all redo-procedures after SG and there should be at least 12 months of medical and supportive management before performing redo-surgeries after SG for insufficient weight loss, weight regain, and gastroesophageal reflux disease (GERD). Also, experts agreed that in case of symptomatic GERD in the presence of adequate weight loss, medical treatment for at least 1 to 2 years is an acceptable option and agreed that Roux-en Y gastric bypass is an appropriate option in this situation. There was disagreement consensus on efficacy of omentopexy in rotation and efficacy of fundoplication in the presence of a dilated fundus and GERD. CONCLUSION Redo-surgeries after SG is still an important issue among bariatric and metabolic surgeons. The proper time and procedure selection for redo-surgery need careful considerations. Although multi-disciplinary team evaluation plays a key role to evaluate best options in these situations, an algorithmic clinical approach based on the expert's consensus as a guideline can help for the best clinical decision-making.
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13
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Furay E, Doggett S, Buckley Iii FP. Criteria of patient selection for magnetic sphincter augmentation. Dis Esophagus 2023:6987661. [PMID: 36644894 DOI: 10.1093/dote/doac115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 11/14/2022] [Indexed: 01/17/2023]
Abstract
This article is an expert review of published literature with the goal of defining the ideal patient selection for Magnetic Sphincter Augmentation (MSA) in Anti-reflux Surgery (ARS). The authors performed a literature search of outcomes after MSA for different patient populations. Although MSA utilization has expanded to include patients with advanced gastroesophageal reflux disease (GERD), obese patients, and patients with a history of bariatric surgery there is still a paucity of data to support its definitive use in these cohorts. We concluded that younger patients with mild/moderate GERD as evidenced by objective studies in conjunction with normal motility on manometry have the most favorable outcomes after MSA. MSA should be avoided in patients with allergies to nickel, titanium, stainless steel, or ferrous materials. As the utilization of MSA in ARS continues to expand and as more robust data emerges the ideal patient for this device will likely expand as well.
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Affiliation(s)
- E Furay
- University of Texas at Austin, Department of Surgery and Perioperative Care, Austin, TX, USA
| | - S Doggett
- University of Texas at Austin, Department of Surgery and Perioperative Care, Austin, TX, USA
| | - F P Buckley Iii
- University of Texas at Austin, Department of Surgery and Perioperative Care, Austin, TX, USA
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14
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Feasibility and Efficacy of Magnetic Sphincter Augmentation for the Management of Gastroesophageal Reflux Disease Post-Sleeve Gastrectomy for Obesity. Obes Surg 2023; 33:387-396. [PMID: 36471179 PMCID: PMC9834340 DOI: 10.1007/s11695-022-06381-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 11/18/2022] [Accepted: 11/27/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Patients with medically intractable GERD after laparoscopic sleeve gastrectomy (LSG) have limited surgical options. Fundoplication is difficult post-LSG. Roux-en-Y gastric bypass may be used as a conversion procedure but is more invasive with potential for serious complications. Magnetic sphincter augmentation (MSA) is a less invasive GERD treatment alternative. The objective of this study was to assess safety and efficacy outcomes of MSA after LSG. METHODS The primary outcome of this observational, multicenter, single-arm prospective study was the rate of serious device and/or procedure-related adverse events (AEs). The efficacy of the LINX device was measured comparing baseline to 12-month post-implant reductions in distal acid exposure, GERD-HRQL score, and average daily PPI usage. RESULTS Thirty subjects who underwent MSA implantation were followed 12 months post-implant. No unanticipated adverse device effects were observed. There were two adverse events deemed serious (dysphagia, pain, 6.7%) which resolved without sequelae. GERD-HRQL scores showed significant improvement (80.8%, P < 0.001), and reduction in daily PPI usage was seen (95.8%, P < 0.001). Forty-four percent of subjects demonstrated normalization or > = 50% reduction of total distal acid exposure time (baseline 16.2%, 12 months 11%; P = 0.038). CONCLUSIONS Post-LSG, MSA showed an overall improvement of GERD symptoms, and reduction in PPI use with explants within anticipated range along with improvement in distal esophageal acid exposure time.
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Patel SH, Smith B, Polak R, Pomeranz M, Patel PV, Englehardt R. Laparoscopic magnetic sphincter augmentation device placement for patients with medically-refractory gastroesophageal reflux after sleeve gastrectomy. Surg Endosc 2022; 36:8255-8260. [PMID: 35474390 DOI: 10.1007/s00464-022-09261-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 04/10/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND The use of the magnetic sphincter augmentation (MSA) in patients with de novo or persistent gastroesophageal reflux disease (GERD) after sleeve gastrectomy has not been thoroughly investigated. OBJECTIVE The aim of this study is to evaluate the efficacy of MSA device placement in improving GERD symptoms and reducing anti-reflux medication usage in patients with persistent or de novo GERD after sleeve gastrectomy. METHODS This is a retrospective analysis of patients who underwent laparoscopic MSA device placement between January 2018 and July 2020 after sleeve gastrectomy. RESULTS A total of twenty-two patients met inclusion criteria. Twenty patients were female (91%) and two patients were male (9%). All patients were taking anti-reflux medications daily to control GERD symptoms prior to MSA device placement. There was a significant improvement in the mean GERD-HRQL survey scores when comparing scores prior to (43.8) and after (16.7) MSA device placement (p < 0.0001). Majority of the patients did well without any post-operative complications (77%). Nearly 82% of patients were no longer taking any anti-acid medications after MSA device placement (p < 0.0485). There were no patients that required MSA device removals. There were no adverse events such as MSA device erosions or device-related mortalities. CONCLUSIONS MSA device placement in patients with medically refractory GERD after sleeve gastrectomy is a safe and viable alternative to Roux-en-Y gastric bypass without conferring additional risks. We show an improvement in reflux symptoms after MSA device placement as evidenced by decreased post-operative GERD-HRQL scores, decreased anti-acid medication usage, and overall patient satisfaction with the procedure. Further prospective and comparative studies with longer term follow-up are needed to validate the use of MSA in patients who have undergone sleeve gastrectomy.
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Affiliation(s)
- Samik H Patel
- Bariatric Medical Institute of Texas, 335 E Sonterra Blvd STE. 200, San Antonio, TX, 78258, USA.
| | - Barry Smith
- Bariatric Medical Institute of Texas, 335 E Sonterra Blvd STE. 200, San Antonio, TX, 78258, USA
| | - Robert Polak
- Bariatric Medical Institute of Texas, 335 E Sonterra Blvd STE. 200, San Antonio, TX, 78258, USA
| | - Morgan Pomeranz
- Bariatric Medical Institute of Texas, 335 E Sonterra Blvd STE. 200, San Antonio, TX, 78258, USA
| | - Punam V Patel
- Bariatric Medical Institute of Texas, 335 E Sonterra Blvd STE. 200, San Antonio, TX, 78258, USA
| | - Richard Englehardt
- Bariatric Medical Institute of Texas, 335 E Sonterra Blvd STE. 200, San Antonio, TX, 78258, USA
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16
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Reddy NC, Sujka J, DuCoin C. Magnetic Sphincter Augmentation Algorithm for Post-bariatric Surgery Gastroesophageal Reflux Disease Patients. Obes Surg 2022; 32:3185-3187. [PMID: 35809197 DOI: 10.1007/s11695-022-06168-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 06/12/2022] [Accepted: 06/15/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Nikhil C Reddy
- University of South Florida Morsani College of Medicine, 5 Tampa General Cir, Tampa, FL, 33606, USA.
| | - Joseph Sujka
- Department of Surgery, University of South Florida, Tampa, FL, USA
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17
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Laparoscopic management of pathologic gastroesophageal reflux after sleeve gastrectomy using the magnetic sphincter augmentation (MSA) device-a Video Vignette. Obes Surg 2022; 32:1791-1793. [PMID: 35290612 PMCID: PMC8986733 DOI: 10.1007/s11695-022-06007-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 02/27/2022] [Accepted: 03/08/2022] [Indexed: 11/08/2022]
Abstract
Purpose The development of gastroesophageal reflux disease (GERD) has been shown to be not infrequent after laparoscopic sleeve gastrectomy (LSG). Management may vary from medical therapy to Roux-en-Y gastric bypass (RYGB) conversion. Magnetic sphincter augmentation (MSA) device has been shown to be a promising option with excellent results. The purpose of this video was to demonstrate the laparoscopic management of post-LSG GERD with MSA device implant. Materials and Methods An intraoperative video has been edited to demonstrate the MSA device placement after LSG for the treatment of pathologic GERD. Results The procedure started with the lysis of the perigastric adhesions to free the distal esophagus circumferentially. The posterior vagus nerve was identified, and a small window was created between the posterior esophageal wall anteriorly and the vagus nerve posteriorly. A hiatoplasty was performed using two non-resorbable interrupted 2.0 Prolene® sutures. The system’s sizer was placed to measure the junctional circumference. A 15-mm MSA device was implanted. Conclusion MSA device placement seems technically feasible and safe with promising results in term of improved LES resting pressure and esophageal acid exposure. While future studies are necessary to corroborate these preliminary indications, MSA device may possibly become a valid option in surgeon armamentarium. Supplementary Information The online version contains supplementary material available at 10.1007/s11695-022-06007-x.
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18
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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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19
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Tian P, Fu J, Liu Y, Bian S, Li M, Zhang M, Liu J, Jin L, Zhang Z, Zhang P. Current status of gastroesophageal reflux disease after sleeve gastrectomy: Still a long way to go. Biosci Trends 2021; 15:305-312. [PMID: 34373428 DOI: 10.5582/bst.2021.01288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Obesity is a public health concern that is becoming increasingly more serious around the world. Bariatric surgery has become more prevalent due to the obesity epidemic worldwide. Sleeve gastrectomy (SG) is one of the most popular procedures which is safe and efficient. Despite all its favorable features, however, there is an increasing evidence from the literature that the long-term incidence of gastroesophageal reflux disease (GERD) is likely to represent the Achilles' heel of this procedure. Management of severe reflux after SG usually requires revisional surgery. The relationship between SG and GERD needs to be better ascertained in order to prevent related complications, such as esophageal adenocarcinoma. This review attempts to elucidate the effect of SG on GERD and the postoperative management of reflux disease according to recent literature in the hope of drawing the attention of clinicians to postoperative gastroesophageal reflux and guiding the optimal management strategy associated with this "troublesome complication".
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Affiliation(s)
- Peirong Tian
- Division of Metabolic and Bariatric Surgery, Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Jing Fu
- Department of Endocrinology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yang Liu
- Division of Metabolic and Bariatric Surgery, Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Shibo Bian
- Division of Metabolic and Bariatric Surgery, Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Mengyi Li
- Division of Metabolic and Bariatric Surgery, Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Meng Zhang
- Division of Metabolic and Bariatric Surgery, Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Jia Liu
- Division of Metabolic and Bariatric Surgery, Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Lan Jin
- Division of Metabolic and Bariatric Surgery, Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Zhongtao Zhang
- Division of Metabolic and Bariatric Surgery, Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Peng Zhang
- Division of Metabolic and Bariatric Surgery, Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing, China
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Abstract
PURPOSE OF REVIEW Obesity is rapidly increasing in prevalence, and bariatric surgery has become a popular treatment option that can improve all-cause mortality in obese individuals. Gastroesophageal reflux disease (GERD) and esophageal motility disorders are common in the obese population, and the effects of bariatric surgery on these conditions differ depending on the type of bariatric surgery performed. RECENT FINDINGS Laparoscopic adjustable gastric banding has declined in popularity due to its contributions to worsening GERD symptoms and the development of esophageal dysmotility. Although laparoscopic sleeve gastrectomy (LSG) is the most popular type of bariatric surgery, a comprehensive assessment for acid reflux should be performed as LSG has been linked with worsening GERD. Novel methods to address GERD due to LSG include magnetic sphincter augmentation and concomitant fundoplication. Due to the decreased incidence of postoperative GERD and dysmotility compared to other types of bariatric surgeries, Roux-en-Y gastric bypass should be considered for obese patients with GERD and esophageal dysmotility. SUMMARY Bariatric surgery can affect esophageal motility and contribute to worsening or development of GERD. A thorough workup of gastrointestinal symptoms before bariatric surgery should be performed with consideration for formal testing with high-resolution manometry and pH testing. Based on these results, the choice of bariatric surgery technique should be tailored accordingly to improve clinical outcomes.
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Ghanem OM, Badaoui JN. Comment on: Conversion of laparoscopic sleeve gastrectomy to Roux-en-Y gastric bypass: patterns predicting persistent symptoms after revision. Surg Obes Relat Dis 2021; 17:1690-1691. [PMID: 34275762 DOI: 10.1016/j.soard.2021.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 06/19/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Omar M Ghanem
- Department of General Surgery, Mayo Clinic, Rochester, Minnesota
| | - Joseph N Badaoui
- Division of Breast, Endocrine, Metabolic, and GI Surgery, Mayo Clinic, Rochester, Minnesota
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22
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Gagner M. Comment on: Sleeve gastrectomy with tailored 360° fundoplication according to Rossetti in patients affected by obesity and gastroesophageal reflux: a prospective observational study. Surg Obes Relat Dis 2021; 17:1067-1068. [PMID: 33810999 DOI: 10.1016/j.soard.2021.02.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 02/20/2021] [Indexed: 12/12/2022]
Affiliation(s)
- Michel Gagner
- Hôpital du Sacre Coeur, Montreal, Quebec, Canada; Westmount Square Surgical Center, Westmount, Quebec, Canada
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24
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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: 14] [Impact Index Per Article: 4.7] [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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25
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Fass OZ, Mashimo H. The Effect of Bariatric Surgery and Endoscopic Procedures on Gastroesophageal Reflux Disease. J Neurogastroenterol Motil 2021; 27:35-45. [PMID: 33380553 PMCID: PMC7786084 DOI: 10.5056/jnm20169] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Obesity is a global epidemic posing a significant burden on patients and healthcare systems. Gastroesophageal reflux disease is associated with obesity and its prevalence is also growing worldwide. Numerous bariatric surgeries and endoscopic procedures have arisen to assist with weight loss and management of obesity-related conditions. However, the effect of these interventions on reflux is variable and the evidence is often conflicting. To date, Roux-en-Y gastric bypass remains the gold-standard for attaining both reflux and weight loss management, however novel endoscopic techniques are quickly becoming more prevalent as an alternative to surgery. This review aims to summarize currently available endoscopic and surgical weight loss procedures and their impact on reflux symptoms while emphasizing areas requiring additional investigation.
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Affiliation(s)
- Ofer Z Fass
- Department of Medicine, New York University Langone Health, New York, NY, USA
| | - Hiroshi Mashimo
- epartment of Medicine, VA Boston Healthcare System, Harvard Medical School, Boston, MA, USA
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Rausa E, Manfredi R, Kelly ME, Bianco F, Aiolfi A, Bonitta G, Lucianetti A, Zappa MA. Magnetic Sphincter Augmentation Placement for Recalcitrant Gastroesophageal Reflux Disease Following Bariatric Procedures: A Systematic Review and Bayesian Meta-Analysis. J Laparoendosc Adv Surg Tech A 2020; 31:1034-1039. [PMID: 33347784 DOI: 10.1089/lap.2020.0763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background: This study aims to consolidate all available articles on this topic and evaluate MSA effectiveness in the management of gastroesophageal reflux disease (GERD). Matherials and Methods: We conducted an electronic systematic search using MEDLINE databases (PubMed), EMBASE, and Web of Science. An electronic systematic search of articles comparing preoperative and postoperative health-related quality of life (GERD-HRQL) scores in patients who underwent MSA placement for management of GERD following bariatric surgery was performed. Three retrospective studies totaling 33 patients met the inclusion criteria and were included in this meta-analysis. Results: The pooled mean difference in change from preoperative GERD-HRQL score was 17.5 (95% CrI; -22.88 to -12.20) and it was statistically significant. The between-study variability is 3.621 (95% HPD; 1.39 4.99) with low heterogeneity (I2 = 15%; 95% HPD; 2.1 26.2%). Conclusions: MSA for refractory GERD following bariatric surgery appears feasible. Prospective randomized controlled with standardized surgical technique and objective follow-up evaluation is needed to better assess short- and long-term efficacy.
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Affiliation(s)
- Emanuele Rausa
- General Surgery I, Ospedale Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Roberto Manfredi
- General Surgery I, Ospedale Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Michael Eamon Kelly
- Department of Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Federica Bianco
- General Surgery I, Ospedale Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Alberto Aiolfi
- General Surgery, Istituto Clinico Sant'Ambrogio, Milano, Italy
| | - Gianluca Bonitta
- General Surgery I, Ospedale Papa Giovanni XXIII Hospital, Bergamo, Italy
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Huynh P, Konda V, Sanguansataya S, Ward MA, Leeds SG. Mind the Gap: Current Treatment Alternatives for GERD Patients Failing Medical Treatment and Not Ready for a Fundoplication. Surg Laparosc Endosc Percutan Tech 2020; 31:264-276. [PMID: 33347088 PMCID: PMC8154178 DOI: 10.1097/sle.0000000000000888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 10/05/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Gastroesophageal reflux disease is associated with Barrett esophagus, esophageal adenocarcinoma, and significantly impacts quality of life. Medical management is the first line therapy with surgical fundoplication as an alternative therapy. However, a small portion of patients who fail medical therapy are referred for surgical consultation. This creates a "gap" in therapy for those patients dissatisfied with medical therapy but are not getting referred for surgical consultation. Three procedures have been designed to address these patients. These include radiofrequency ablation (RFA) of the lower esophageal sphincter, transoral incisionless fundoplication (TIF), and magnetic sphincter augmentation. MATERIALS AND METHODS A Pubmed literature review was conducted of all publications for RFA, TIF, and MSA. Four most common endpoints for the 3 procedures were compared at different intervals of follow-up. These include percent of patients off proton pump inhibitors (PPIs), GERD-HRQL score, DeMeester score, and percent of time with pH <4. A second query was performed for patients treated with PPI and fundoplications to match the same 4 endpoints as a control. RESULTS Variable freedom from PPI was reported at 1 year for RFA with a weighted mean of 62%, TIF with a weighted mean of 61%, MSA with a weighted mean of 85%, and fundoplications with a weighted mean of 84%. All procedures including PPIs improved quality-of-life scores but were not equal. Fundoplication had the best improvement followed by MSA, TIF, RFA, and PPI, respectively. DeMeester scores are variable after all procedures and PPIs. All MSA studies showed normalization of pH, whereas only 4 of 17 RFA studies and 3 of 11 TIF studies reported normalization of pH. CONCLUSIONS Our literature review compares 3 rival procedures to treat "gap" patients for gastroesophageal reflux disease with 4 common endpoints. Magnetic sphincter augmentation appears to have the most reproducible and linear outcomes but is the most invasive of the 3 procedures. MSA outcomes most closely mirrors that of fundoplication.
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Affiliation(s)
- Phuong Huynh
- Division of Minimally Invasive Surgery, Baylor University Medical Center
- Center for Advanced Surgery, Baylor Scott & White Health
| | - Vani Konda
- Center for Esophageal Diseases, Baylor University Medical Center, Dallas
| | | | - Marc A. Ward
- Division of Minimally Invasive Surgery, Baylor University Medical Center
- Center for Advanced Surgery, Baylor Scott & White Health
- Texas A&M College of Medicine, Bryan, TX
| | - Steven G. Leeds
- Division of Minimally Invasive Surgery, Baylor University Medical Center
- Center for Advanced Surgery, Baylor Scott & White Health
- Texas A&M College of Medicine, Bryan, TX
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28
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Comment on: Magnetic sphincter augmentation at the time of bariatric surgery: an analysis of the MBSAQIP. Surg Obes Relat Dis 2020; 17:561-562. [PMID: 33384258 DOI: 10.1016/j.soard.2020.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 11/22/2020] [Indexed: 11/24/2022]
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Clapp B, Dodoo C, Harper B, Kim J, Castro C, Hamdan M, Grasso S, Davis B. Magnetic sphincter augmentation at the time of bariatric surgery: an analysis of the MBSAQIP. Surg Obes Relat Dis 2020; 17:555-561. [PMID: 33272856 DOI: 10.1016/j.soard.2020.10.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 10/14/2020] [Accepted: 10/17/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Magnetic sphincter augmentation (MSA) has gained popularity as a treatment for gastroesophageal reflux disease (GERD). The role of MSA in treating GERD in metabolic and bariatric surgery (MBS) patients at the time of primary MBS is unknown. OBJECTIVE To determine the short-term outcomes of MSA placed at the time of MBS. SETTING National database, United States. METHODS We queried the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database for MSA performed at time of the sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) for the years 2017-2018. A propensity adjusted analysis was performed to assess 30-day outcomes of patients who had MSA placed versus those who did not. RESULTS There were 319,580 patients who underwent MBS in the study period. Twenty-four patients had MSA at time of surgery. These patients did not have a higher reported rate of preoperative GERD (P = .93). Six patients (25%) with MSA had a RYGB; the other 18 patients (75%) patients had SG (P < .001). Operative times were similar between the groups and there was no difference in length of stay. After propensity matched analysis (with 24 patients in each arm), patients who underwent an MSA had shorter discharge times (1.4 days [.8] versus 2.0 [.9], P = .012). CONCLUSION MSA is safe in the short term in MBS. There is no difference in major morbidity or mortality and operative times are similar in MSA patients. The long-term efficacy of this practice is unknown.
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Affiliation(s)
- Benjamin Clapp
- Department of Surgery, Texas Tech Paul Foster School of Medicine, El Paso, Texas.
| | - Christopher Dodoo
- Department of Surgery, Texas Tech Paul Foster School of Medicine, El Paso, Texas
| | - Brittany Harper
- Department of Surgery, Texas Tech Paul Foster School of Medicine, El Paso, Texas
| | - Jisoo Kim
- Department of Surgery, Texas Tech Paul Foster School of Medicine, El Paso, Texas
| | - Christian Castro
- Department of Surgery, Texas Tech Paul Foster School of Medicine, El Paso, Texas
| | - Marah Hamdan
- Department of Surgery, Texas Tech Paul Foster School of Medicine, El Paso, Texas
| | - Samuel Grasso
- Department of Surgery, William Beaumont Army Medical Center, El Paso, Texas
| | - Brian Davis
- Department of Surgery, Texas Tech Paul Foster School of Medicine, El Paso, Texas
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30
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Safety of magnetic sphincter augmentation in patients with prior bariatric and anti-reflux surgery. Surg Endosc 2020; 35:5322-5327. [DOI: 10.1007/s00464-020-08025-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 09/16/2020] [Indexed: 12/15/2022]
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31
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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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32
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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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Schizas D, Mastoraki A, Papoutsi E, Giannakoulis VG, Kanavidis P, Tsilimigras D, Ntourakis D, Lyros O, Liakakos T, Moris D. LINX ® reflux management system to bridge the “treatment gap” in gastroesophageal reflux disease: A systematic review of 35 studies. World J Clin Cases 2020; 8:294-305. [PMID: 32047777 PMCID: PMC7000944 DOI: 10.12998/wjcc.v8.i2.294] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 12/06/2019] [Accepted: 12/14/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) occurs when the reflux of stomach contents causes troublesome symptoms and/or complications. When medical therapy is insufficient, surgical therapy is indicated and, until now, Laparoscopic fundoplication (LF) constitutes the gold-standard method. However, magnetic sphincter augmentation (MSA) using the LINX® Reflux Management System has recently emerged and disputes the standard therapeutic approach.
AIM To investigate the device’s safety and efficacy in resolving GERD symptoms.
METHODS This is a systematic review conducted in accordance to the PRISMA guidelines. We searched MEDLINE, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials CENTRAL databases from inception until September 2019.
RESULTS Overall, 35 studies with a total number of 2511 MSA patients were included and analyzed. Post-operative proton-pump inhibitor (PPI) cessation rates reached 100%, with less bloating symptoms and a better ability to belch or vomit in comparison to LF. Special patient groups (e.g., bariatric or large hiatal-hernias) had promising results too. The most common postoperative complication was dysphagia ranging between 6% and 83%. Dilation due to dysphagia occurred in 8% of patients with typical inclusion criteria. Esophageal erosion may occur in up to 0.03% of patients. Furthermore, a recent trial indicated MSA as an efficient alternative to double-dose PPIs in moderate-to-severe GERD.
CONCLUSION The findings of our review suggest that MSA has the potential to bridge the treatment gap between maxed-out medical treatment and LF. However, further studies with longer follow-up are needed for a better elucidation of these results.
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Affiliation(s)
- Dimitrios Schizas
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laikon Hospital, Athens 11527, Greece
| | - Aikaterini Mastoraki
- 4th Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Chaidari, Athens 11527, Greece
| | - Eleni Papoutsi
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laikon Hospital, Athens 11527, Greece
| | - Vassilis G Giannakoulis
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laikon Hospital, Athens 11527, Greece
| | - Prodromos Kanavidis
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laikon Hospital, Athens 11527, Greece
| | - Diamantis Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH 45830, United States
| | - Dimitrios Ntourakis
- Department of Surgery, School of Medicine, European University Cyprus, Nicosia 2404, Cyprus
| | - Orestis Lyros
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital Leipzig, Leipzig 04103, Germany
| | - Theodore Liakakos
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laikon Hospital, Athens 11527, Greece
| | - Dimitrios Moris
- Department of Surgery, Duke University Medical Center, Duke University, Durham, NC 27705, United States
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