Surgical management of gastroesophageal reflux disease in the obese patient

Mid-term Outcomes of Nissen Fundoplication Versus Roux-en-y Gastric Bypass for Primary Management of Gastroesophageal Reflux Disease in Patients With Obesity

INTRODUCTION

The efficacy and outcomes of laparoscopic Nissen fundoplication (LNF) in patients with obesity is controversial. Specifically, concerns regarding long-term outcomes and recurrence in the setting of obesity has led to interest in laparoscopic Roux-en-Y gastric bypass (RYGB).

METHODS

In this retrospective cohort study, we studied patients with obesity who underwent either LNF or RYGB for gastroesophageal reflux disease. Baseline demographics, clinical variables, operative outcomes, and symptom severity scores were compared.

RESULTS

Baseline demographics, operative outcomes, and quality-of-life scores were similar. Proton pump inhibitor usage, quality-of-life, symptom severity scores, and satisfaction with the operation were similar between groups at mid-term follow-up.

DISCUSSION

RYGB and LNF produced similar improvements in disease-specific quality of life with similar rates of complications, side effects, and need for reoperation. This demonstrates that RYGB and LNF represent possible options for surgical management of gastroesophageal reflux disease in obese patients.

Bariatric Evaluation Through AI: a Survey of Expert Opinions Versus ChatGPT-4 (BETA-SEOV)

BACKGROUND

Recent advancements in artificial intelligence, such as OpenAI's ChatGPT-4, are revolutionizing various sectors, including healthcare. This study investigates the use of ChatGPT-4 in identifying suitable candidates for bariatric surgery and providing surgical recommendations to improve decision-making in obesity treatment amid the global obesity epidemic.

METHODS

We devised ten patient scenarios, thoughtfully encompassing a spectrum that spans from uncomplicated cases to more complex ones. Our objective was to delve into the decision-making process regarding the recommendation of bariatric surgery. From July 29th to August 10th, 2023, we conducted a voluntary online survey involving thirty prominent bariatric surgeons, ensuring that there was no predetermined bias in the selection of a specific type of bariatric surgery. This survey was designed to collect their insights on these scenarios and gain a deeper understanding of their professional experience and background in the field of bariatric surgery. Additionally, we consulted ChatGPT-4 in two separate conversations to evaluate its alignment with expert opinions on bariatric surgery options.

RESULTS

In 40% of the scenarios, disparities were identified between the two conversations with ChatGPT-4. It matched expert opinions in 30% of cases. Differences were noted in cases like gastrointestinal metaplasia and gastric adenocarcinoma, but there was alignment with conditions like endometriosis and GERD.

CONCLUSION

The evaluation of ChatGPT-4's role in determining bariatric surgery suitability uncovered both potential and shortcomings. Its alignment with experts was inconsistent, and it often overlooked key factors, emphasizing human expertise's value. Its current use requires caution, and further refinement is needed for clinical application.

Anti-reflux surgery vs. bariatric surgery as anti-GERD and hiatal hernia treatment in obese patient. New surgical proposals

The persistence of obesity favors the failure of the Fundoplication (FP) in the treatment of Gastroesophageal Reflux (GER). However, the weight loss obtained with the performance of a Gastric Bypass (GBP) allows a good resolution of symptoms, without increasing the incidence of postoperative complications. All of this leads us to consider that while FP is the indication in patients with BMI < 30, in those patients with BMI > 35, GBP appears to be the procedure of choice. But there is still no position in the case of patients with a BMI between 30 and 35, although we must take into account that an increase in GER recurrence has been described after FP in patients with a BMI > 30. Although Sleeve Gastrectomy (SG) is one of the most frequently used bariatric procedures in recent years, its association with a high rate of postoperative GER has led several authors to propose its performance associated with an anti-reflux procedure in patients with GER symptoms. Likewise, if the existence of an Hiatal Hernia is verified, it must be treated by hiatoplasty, both during the performance of a GBP and a SG. This simultaneous treatment is not associated with an increase in complications.

Surgeon experience with insurance barriers to offering gastric bypass as an evidence-based operation for pathologic GERD

INTRODUCTION

Obesity is an increasingly prevalent public health problem often associated with poorly controlled gastroesophageal reflux disease. Fundoplication has been shown to have limited long-term efficacy in patients with morbid obesity and does not address additional weight-related co-morbidities. Roux-en-Y gastric bypass (RYGB) is the gold standard operation for durable resolution of GERD in patients with obesity, and is also used as a salvage operation for GERD after prior foregut surgery. Surgeons report access to RYGB as surgical treatment for GERD is often limited by RYGB-specific benefit exclusions embedded within insurance policies, but the magnitude and scope of this problem is unknown.

METHODS

A 9-item survey evaluating surgeon practice and experience with insurance coverage for RYGB for GERD was developed and piloted by a SAGES Foregut Taskforce working group. This survey was then administered to surgeon members of the SAGES Foregut Taskforce and to surgeons participating in the SAGES Bariatrics and/or Foregut Facebook groups.

RESULTS

187 surgeons completed the survey. 89% reported using the RYGB as an anti-reflux procedure. 44% and 26% used a BMI of 35 kg/m2 and 30 kg/m2 respectively as cutoff for the RYGB. 89% viewed RYGB as the procedure of choice for GERD after bariatric surgery. 69% reported using RYGB to address recurrent reflux secondary to failed fundoplication. 74% of responders experienced trouble with insurance coverage at least half the time RYGB was offered for GERD, and 8% reported they were never able to get approval for RYGB for GERD indications in their patient populations.

CONCLUSION

For many patients, GERD and obesity are related diseases that are best addressed with RYGB. However, insurance coverage for RYGB for GERD is often limited by policies which run contrary to evidence-based medicine. Advocacy is critical to improve access to appropriate surgical care for GERD in patients with obesity.

Laparoscopic fundoplication versus laparoscopic Roux-en-Y gastric bypass for gastro-oesophageal reflux disease in obese patients: protocol for a randomized clinical trial

BACKGROUND

Laparoscopic fundoplication (LF) is the standard surgical procedure for the treatment of gastro-oesophageal reflux disease (GORD). Laparoscopic Roux-en-Y gastric bypass (LRYGB) is commonly performed to achieve weight loss in obese patients, but it also has anti-reflux properties. Hence, in the obese population suffering from GORD, LRYGB could be an alternative to LF. The aim of this trial will be to compare LF and LRYGB in an obese population presenting with GORD and being considered for surgery.

METHODS

This will be an investigator-initiated randomized clinical trial. The research population will be obese patients (BMI 30-34.9 with waist circumference more than 88 cm (women) or more than 102 cm (men), or BMI 35-40 with any waist circumference) referred to a public hospital for consideration of anti-reflux surgery. The primary aim of the study will be to determine the efficacy of LF compared with LRYGB on subjective and objective control of GORD. Secondary aims include determining early and late surgical morbidity and the side-effect profile of LF compared with LRYGB and to quantify any non-reflux benefits of LRYGB (including overall quality of life) compared with LF.

CONCLUSION

This trial will determine whether LRYGB is effective and acceptable as an alternative to LF for the surgical treatment of GORD in obese patients Registration number: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12622000636752p (https://www.anzctr.org.au/).

Comparative Outcomes of Anti-Reflux Surgery in Obese Patients with Gastroesophageal Reflux Disease1

INTRODUCTION

Roux-en-Y gastric bypass (RYGB) has been the preferred operation for obese patients with gastroesophageal reflux disease (GERD); however, some patients are hesitant to undergo bypass. Obese patients have a multifactorial predisposition to GERD, including lower esophageal sphincter (LES) dysfunction and aberrant pressure gradients across their diaphragmatic crura. Among non-obese patients, anti-reflux surgery (ARS) with hiatal hernia (HH) repair and LES augmentation has shown excellent long-term results. We aimed to determine whether patient satisfaction and GERD recurrence differed between obese and non-obese patients who underwent ARS.

METHODS

Review of patients who underwent ARS between January 2012 and June 2021 was performed. Perioperative and postoperative characteristics were compared across three BMI groups: BMI < 30 kg/m², 30 kg/m² ≤ BMI < 35 kg/m², and BMI ≥ 35 kg/m².

RESULTS

Four-hundred thirteen patients were identified, of which 294 (71.1%) had BMI < 30 kg/m², 87 (21.1%) were 30 kg/m² ≤ BMI < 35 kg/m², and 32 (7.7%) had a BMI ≥ 35 kg/m². Patients with BMI ≥ 35 kg/m² had higher preoperative manometric and EndoFLIP™ intra-balloon pressure at the LES than those with lower BMIs. This value was increased to a similar level throughout ARS across the three cohorts. Post-operative GERD-specific satisfaction was similar across the three cohorts, as were rates of postoperative reflux and hiatal hernia recurrence on barium swallow; rates of reoperation were low.

CONCLUSIONS

ARS with HH repair and LES augmentation may be appropriate for select patients across a range of BMIs, including those with a BMI ≥ 35 kg/m² who are hesitant to undergo RYGB.

Gastroesophageal Reflux Disease and the Patient with Obesity

Patients with obesity who present with gastroesophageal reflux disease (GERD) require a nuanced approach. Those with lower body mass index (BMI) (less than 33) can be counseled on weight loss, and if successful may be approached with laparoscopic fundoplication. Those who are unable to achieve weight loss or those who present with a BMI greater than or equal to 35 should proceed with laparoscopic Roux-en-Y gastric bypass (LRYGB). Conversion to LRYGB from sleeve gastrectomy is a safe and effective way to manage GERD after sleeve gastrectomy.

Excess Body Weight and Gastroesophageal Reflux Disease

Background

Gastroesophageal reflux disease (GERD) is strongly associated with excess body weight.

Summary

GERD is characterized by typical symptoms with or without mucosal damage because of retrograde flow of gastric content into the esophagus. An ineffective esophagogastric junction (EGJ) combined with anatomical abnormalities is considered to be causative. The incidence of GERD is strongly associated with excess body weight, reflecting the pathophysiological relevance of the abdominothoracic pressure gradient.

Key Message

Weight loss has been demonstrated to be an effective therapy for GERD combined with obesity. In cases in which surgical therapy is indicated, traditional antireflux surgery has led to equivocal results, advocating a proximal Roux-en-Y gastric bypass in these patients to correct both GERD and excess body weight.

De novo gastroesophageal reflux disease esophageal surgery in bariatrics: a literature review and analysis of the current treatment options

With the exponential increase of worldwide obesity, the number of bariatric surgery (BaS) procedures have equally risen. The surgical management of obesity has been widely established as the standard of care for sustained weight reduction, resolution, and improvement of associated comorbidities. However, BaS itself can have postoperative deleterious effects, including de novo gastroesophageal reflux disease (GERD) and upper gastrointestinal motility disorders. The modified anatomy resulting from BaS, due to either a restrictive or hypoabsorptive component, gives this disorder a multifactorial etiology. The overall management of de novo GERD should focus on three primordial approaches: Non-surgical, endoluminal, and surgical. Even in the absence of de novo GERD following primary or secondary BaS, said disorder should be closely monitored and therapy should be catered in a case-by-case approach. Consequently, treatment strategies have been developed on this principle as to adequately resolve de novo GERD. Despite the presence of multiple and suitable treatment modalities, the operating surgeon should perform them in the best interest of the patient. Short-, medium-, and long-term outcomes should be taken into consideration prior to proceed with any type of preferred management option. This article herein presents an update on the surgical management of de novo GERD following BaS and current practical innovations.

Does Laparoscopic Sleeve Gastrectomy lead to Barrett's esophagus, 5-year esophagogastroduodenoscopy findings: A retrospective cohort study

Introduction

Laparoscopic Sleeve Gastrectomy (LSG) is one of the most prevalent approaches to tackle obesity and its co-morbidities. The main complication following the LSG is Gastro-esophageal reflux disease (GERD), with most patients developing worsening symptoms of GERD, and a small number progressing to Barrett's esophagus. This retrospective analysis aims to assess the rate of GERD pre- and post- LSG as well as the rate of progression to Barrett's.

Methods

Data was collected from 1639 patients. 92 patients fit our inclusion criteria. Data was then analyzed and summarized against similar literature.

Results

Of 64 (69.6%) patients who had normal EGD findings pre-LSG, only 28 patients (30.4%) had the same results 5 years post-LSG (p= < 0.05). The number of patients who had Grade A GERD almost quadrupled post-LSG, increasing from 3 patients (3.3%) to 14 (15.2%). Patients with esophagitis/gastritis/duodenitis increased from 20 (21.7%) to 32 patients (34.8%). Patients with hiatal hernias increased from 4 (4.4%) to 10 patients (10.9%). The most significant result is that 2 out of 92 patients developed Barrett's Esophagus (2.2%), while 7 other patients developed further serious complications.

Conclusion

LSG is a very effective and safe bariatric procedure. However, the major downslide is that it can lead to the aggravation of GERD symptoms. This paper and the included literature demonstrate that LSG does lead to a substantial increase in the rate of GERD, however, the percentages of Barrett's Esophagus are markedly low. Performing an EGD pre- and post- LSG is an important protocol that aids in the diagnosis and management of LSG related GERD.

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The main complication post-LSG is Gastro-esophageal reflux disease (GERD), with some progressing to Barrett’s esophagus.

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We assessed Esophagogastroduodenoscopy (EGD) results pre-LSG and 5 yrs post-op to determine the development of Barrett’s.

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This paper and the included literature demonstrate that LSG does lead to the development of Barrett’s Esophagus.

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Performing an EGD pre- and post-LSG is an important protocol that aids in the diagnosis and management of LSG related GERD.