Lap-Band Impact on the Function of the Esophagus

Conversion of one-anastomosis gastric bypass (OAGB) to Roux-en-Y gastric bypass (RYGB) for gastroesophageal reflux disease (GERD): who is more at risk? A multicenter study

BACKGROUND

Although gastroesophageal reflux disease (GERD) affects 0.6% to 10% of patients operated on for one-anastomosis gastric bypass (OAGB), only about 1% require surgery to convert to Roux-en-Y gastric bypass (RYGB) [3-5]. The aim of the present study was to analyze the characteristics of OAGB patients converted to RYGB for GERD not responding to medical treatment.

METHODS

This retrospective multicenter study included patients who underwent conversion from OAGB to RYGB for severe GERD. The conversion was performed with resection of the previous gastro-jejunal anastomosis and the use of the afferent loop as a new biliary loop.

RESULTS

A total of 126 patients were included in the study. Of these patients, 66 (52.6%) had a past medical history of bariatric restrictive surgery (gastric banding, sleeve gastrectomy). A hiatal hernia (HH) was present in 56 patients (44.7%). The association between previous restrictive surgery and HH was recorded in 33 (26.2%) patients. Three-dimensional gastric computed tomography showed an average gastric pouch volume of 242.4 ± 55.1 cm3. Conversion to RYGB was performed on average 60 ± 35.6 months after OAGB. Seven patients (5.5%) experienced an early postoperative complication (4 patients grade IIIb and 3 grade IIb), and 3 (2.4%) a late complication. Patients showed further weight loss after RYGB conversion and an average of 24.8 ± 21.7 months after surgery, with a mean % of total weight loss (%TWL) of 6.9 ± 13.6 kg. From a clinical point of view, the problem of GERD was definitively solved in more than 90% of patients.

CONCLUSIONS

Situations that weaken the esogastric junction appear to be highly frequent in patients operated on for OAGB and converted to RYGB for severe reflux. Similarly, the correct creation of the gastric pouch could play an important role in reducing the risk of conversion to RYGB for GERD.

Septic Aspiration Pneumonia After Laparoscopic Adjustable Gastric Banding for Morbid Obesity

The laparoscopic adjustable gastric banding (LAGB) surgery is a minimally invasive procedure performed to help with weight loss in patients with advanced obesity with a body mass index (BMI) of >40 kg/m² or above 35 kg/m² with comorbid obesity-related health conditions (hypertension, type two diabetes mellitus, obstructive sleep apnea, etc). Although this surgery is effective for weight loss, it is imperative that close follow-up and aftercare are conducted in order to circumvent severe and rare esophageal and pulmonary complications. We report a case of systemic pulmonary and esophageal complications associated with LAGB that required immediate medical and surgical intervention in a female patient. She underwent her surgery in Mexico, and she did not receive any follow-up care for 12 years, which seemingly led to this preventable situation.

Assessment and management of gastroesophageal reflux disease following bariatric surgery

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.

Impact of bariatric surgery on gastroesophageal reflux disease and esophageal motility

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.

Upper Gastrointestinal Function in Morbidly Obese Adolescents Before and 6 Months After Gastric Banding

BACKGROUND

The effects of laparoscopic adjustable gastric band (LAGB) placement on upper gastrointestinal tract function in obese adolescents are unknown. Therefore, our aim was to determine the short-term effects of LAGB on esophageal motility, gastroesophageal reflux, gastric emptying, appetite-regulatory hormones, and perceptions of post-prandial hunger and fullness.

METHODS

This study was part of a prospective cohort study (March 2009-December 2015) in one tertiary referral hospital. The study included obese adolescents (14-18 years) with a body mass index (BMI) > 40 (or ≥ 35 with comorbidities). Gastric emptying was assessed by ¹³C-octanoic acid breath test, pharyngeal, and esophageal motor function by high-resolution manometry with impedance (HRIM), and appetite and other perceptions using 100-mm visual analogue scales. Dysphagia symptoms were scored using a Dakkak questionnaire. Data were compared pre- and post-LAGB placement and at a 6-month follow-up.

RESULTS

Based upon analysis of 15 adolescents, at the 6-month follow-up, LAGB placement: (i) led to a significant reduction in weight and BMI; (ii) increased fullness and decreased hunger post-meal; (iii) increased symptoms of dysphagia after solid food; and, despite these effects, (iv) caused little or no changes to appetite hormones, while (v) effects on gastric emptying, esophageal motility, esophageal bolus transport, and esophageal emptying were not significant.

CONCLUSION

In adolescents, LAGB improved BMI and altered the sensitivity to nutrients without significant effects on upper gastrointestinal tract physiology at the 6-month follow-up.

Outcomes of routine upper gastrointestinal series screening and surveillance after laparoscopic adjustable gastric banding

BACKGROUND

Esophageal dilatation and dysmotility are known complications of the laparoscopic adjustable gastric band (LAGB), but their incidence varies widely in the literature. There are no formal recommendations guiding surveillance for these potentially underdiagnosed pathologies. This study demonstrates the utility and outcomes of a yearly upper gastrointestinal series screening protocol to detect and manage esophageal dysfunction after LAGB.

METHODS

We reviewed charts for all patients presenting for an outpatient surgical encounter related to LAGB between January 1, 2015 and December 31, 2017. Exclusion criteria included failure to undergo UGIS 6 months or more after band placement, or having undergone band placement in combination with another bariatric procedure. Descriptive statistics were used to characterize demographics, imaging findings and surgical outcomes. All imaging classifications were based on final radiologist report. Means were compared using a Student's t test.

RESULTS

A total of 322 records were reviewed with 39 patients excluded; 31 without UGIS and 8 with concomitant gastric bypass. 85% were female with an average age of 50 years. 66.8% identified as white or Caucasian with 24.7% black/African-American. Greater than 75% of the cohort had at least 5-year follow-up interval. UGIS was performed for symptoms in 66.1% and for routine screening in 33.9%. Of asymptomatic patients, 47.9% demonstrated esophageal dilatation or dysmotility on UGIS, similar to 51.3% of symptomatic patients. 96.8% of all patients went on to band removal. Sixty-four patients had repeat UGIS an average of 8 months following band removal, of which 40.6% were persistently abnormal.

CONCLUSIONS

The incidence of esophageal pathology was significantly higher than most reported series, as was the number of patients with persistently abnormal UGIS despite band removal. The data supports our policy of yearly UGIS for all post-LAGB patients, with strong recommendation for band removal if esophageal dilatation or dysmotility is found.

Complications of Bariatric Surgery: What You Can Expect to See in Your GI Practice

Obesity is one of the most significant health problems worldwide. Bariatric surgery has become one of the fastest growing operative procedures and has gained acceptance as the leading option for weight-loss. Despite improvement in the performance of bariatric surgical procedures, complications are not uncommon. There are a number of unique complications that arise in this patient population and require specific knowledge for proper management. Furthermore, conditions unrelated to the altered anatomy typically require a different management strategy. As such, a basic understanding of surgical anatomy, potential complications, and endoscopic tools and techniques for optimal management is essential for the practicing gastroenterologist. Gastroenterologists should be familiar with these procedures and complication management strategies. This review will cover these topics and focus on major complications that gastroenterologists will be most likely to see in their practice.

What is the role of radiological testing of lower esophageal sphincter function?

Radiological fluoroscopic evaluation remains the primary imaging modality of choice to evaluate patients with swallowing disorders, despite the increasing availability and technical advantages of nonradiological techniques and the current radiological focus on cross-sectional imaging studies, such as computed tomography and magnetic resonance imaging. The radiological swallowing evaluation should be tailored to assess the entire upper gastrointestinal tract, including the lower esophageal sphincter. Fluoroscopy enables the simultaneous assessment of esophageal motility disorders, as well as structural pathologies, including strictures, webs, rings, diverticula, and tumors. Mono- and double-contrast esophagrams and solid bolus tests together allow assessment of lower esophageal sphincter function and complement other methods, such as endoscopy, manometry, or impedance planimetry. Here we review the role of radiological studies for correct assessment of structural and functional pathologies at the level of the lower esophageal sphincter.

Consequences of bariatric surgery on oesophageal function in health and disease

Obesity is a continuing epidemic with substantial associated morbidity and mortality. Owing to the limitations of lifestyle modifications and pharmacological options, bariatric surgery has come to the forefront as an efficient method of achieving sustained weight loss and decreasing overall mortality in comparison with nonsurgical interventions. The most frequently performed bariatric operations are either purely restrictive, such as laparoscopic adjustable gastric band (LAGB) and laparoscopic sleeve gastrectomy (LSG), or restrictive-malabsorptive, such as the Roux-en-Y gastric bypass (RYGB). Each operation results in weight loss, but can also have unintended effects on the health of the oesophagus. Specifically, operations might lead to oesophageal dilation or the development of GERD. LAGB is the best-studied procedure with notable evidence for postoperative worsening of GERD and pseudo-achalasia, which increases lower oesophageal pressure and causes aperistalsis. In some studies, LSG initiates not only a worsening of GERD, but also the formation of de novo GERD in patients without preoperative GERD symptoms. RYGB demonstrates the most profound evidence for improvement of GERD symptoms and preservation of oesophageal motility. Future high-quality studies will be required to better understand the interaction between bariatric surgery and oesophageal disease.

Variation in utilization of acid-reducing medication at 1 year following bariatric surgery: results from the Michigan Bariatric Surgery Collaborative

BACKGROUND

Morbidly obese patients undergoing bariatric surgery have high rates of gastroesophageal reflux and are often treated with acid-reducing medications (ARM) such as proton pump inhibitors or H2-blockers. The objective of this study was to evaluate the effect of bariatric procedures on the utilization of ARM. We analyzed data from the clinical registry of the Michigan Bariatric Surgery Collaborative on 35,477 patients undergoing bariatric surgery between January 2006 and October 2012 who completed both baseline and 1-year follow-up surveys. Procedures included laparoscopic adjustable gastric banding (LAGB, n=2,627), Roux-en-Y gastric bypass (RYGB, n=6,410), sleeve gastrectomy (SG, n=1,567), and biliopancreatic diversion with duodenal switch (BPD/DS, n=162).

METHODS

Rates of ARM at 1 year by procedure type were compared using logistic regression analysis. Models were adjusted for patient characteristics, baseline co-morbidities, weight loss, and hiatal hernia repair.

RESULTS

Overall ARM use at baseline was 37.7% and declined to 29.6% at 1 year after bariatric surgery. The proportion of patients starting an ARM at 1 year when they were not using one at baseline by procedure was LAGB (13.9%), RYGB (19.2%), SG (21.6%), and BPD/DS (26.7%). The proportion of patients discontinuing an ARM at 1 year when they were using one at baseline by procedure was LAGB (55.6%), RYGB (56.2%), SG (37.3%), and BPD/DS (42.1%). Compared with LAGB on multivariable analysis, the likelihood of ARM use at 1 year was higher for SG (OR 1.70, 95% CI 1.45-1.99) and BDP/DS (OR 1.53, CI .97-2.40) but not different for RYGB (OR 1.02, CI .90-1.16).

CONCLUSION

Overall ARM use decreases after bariatric surgery; however, it is not uniform and depends on procedure type. SG is a significant predictor for ARM use at 1 year.

The post-adjustable gastric band abdominoplasty

Serious complications associated with post-laparoscopic adjustable gastric band (LAGB) abdominoplasty have been reported in the medical literature. Furthermore, others have noted aesthetic problems with closure of the umbilicus due to apparatus port proximity. Currently, no clinical protocol or formal industry guidance for LAGB apparatus management during abdominoplasty is available in the medical literature. In this article, the authors describe their procedure for safe LAGB apparatus management during abdominoplasty and illustrate key surgical principles by presenting unique cases from their series of 20 patients treated with this technique.

Laparoscopic gastric bypass for failure of adjustable gastric banding: a review of 85 cases

Laparoscopic adjustable gastric banding (LAGB) is the first bariatric procedure in Europe and is becoming more and more popular in North America. However, the failure rate at 5 years can reach 50%. Although there is still no consensus on revisional surgery, the trend seems to be in favor of conversion to gastric bypass (GBP) with encouraging results. The aim of this study was to assess the results, the risks of conversion into GBP after failure of gastric banding. From January 2003 to July 2010, 85 patients had a revisional GBP after failure of LAGB, performed by two experienced surgeons. Post-operative morbidity, functional results, and weight loss were analyzed. The conversion rate was 2.3%. The mean operative time was 166 min. The mean length of stay was 5.2 days. The early morbidity rate was 7% and the mortality rate was nil. The mean body mass index (BMI) at the time of LAGB was 47.2 kg/m(2) with the lowest BMI reached at 35. The mean BMI at conversion into GBP was 42.9 and the final BMI after a mean follow-up of 22 months was 34.8. Of the patients, 57.7% had a final BMI inferior to 35 and 15.3% had a final BMI superior to 40 and these were super obese and older patients. Super-obesity and advanced age appear to be factors of failure of LAGB and revisional GBP. However, conversion into GBP currently remains the choice procedure in case of gastric banding failure with satisfactory results and acceptable morbidity.

Review article: the impact of bariatric surgery on gastrointestinal motility

BACKGROUND

Obesity is a major medical problem worldwide. Different treatment modalities have emerged to treat obese patients, but the best long-term results are achieved with bariatric surgery. Currently, the interventions most commonly performed are laparoscopic adjustable gastric banding (LAGB), Roux-en-Y- gastric bypass (RYGB) and sleeve gastrectomy.

AIM

To review the gastrointestinal motor complications associated with each of these types of bariatric interventions and the clinical implications of such complications.

METHODS

Search of medical database (PubMed) on English-language articles from January 1996 to March 2011. The search terms used were laparoscopic adjustable gastric banding (LAGB), sleeve gastrectomy (LSG), roux-en-Y-gastric bypass (RYGB), using the AND operator with the terms: complications, motility, GERD, reflux, gastric emptying, esophagitis, dysphagia.

RESULTS

Of the three bariatric interventions reviewed, LAGB was the most studied. Most studies reported short follow-up, of ≤ 1 year. Oesophageal motor dysfunction is the most common motility complication following the bariatric interventions that were reviewed and is mainly observed after LAGB. Some data suggest that oesophageal motor function testing predicts development of post-operative symptoms and oesophageal dilation. RYGB offers protection from gastro-oesophageal reflux. Sleeve gastrectomy was the least studied and was associated with an acceleration of gastric emptying.

CONCLUSIONS

The effects of these interventions on GI motility should be considered when selecting patients for bariatric surgery. There is scant information regarding the overall effect of sleeve gastrectomy on gastro-oesophageal reflux patterns and oesophageal motility.

Outcomes, satiety, and adverse upper gastrointestinal symptoms following laparoscopic adjustable gastric banding

BACKGROUND

Follow-up is critical to the success of laparoscopic adjustable gastric banding (LAGB). Few data guide this and expected norms of satiety, adverse symptoms, and outcomes have not been defined.

METHODS

Consecutive patients, who underwent LAGB, were evaluated using a newly developed instrument that assessed satiety, adverse upper gastrointestinal (dysphagia, reflux, and epigastric pain), and outcomes (overall satisfaction, weight loss, and quality of life (SF-36)).

RESULTS

Three hundred twenty-three of 408 patients responded (80%; mean age 44.4 ± 11.8 years, 56 males). Excess weight loss was 52%. Satiety was greater at breakfast compared to lunch (5.3 ± 1.9 vs. 4.1 ± 1.7, p < 0.005) or dinner (3.8 ± 1.8, p < 0.005). The satisfaction score was 8.3 ± 2.1 out of 10, and 91% would have the surgery again. Quality of life was less than community norms, except in physical functioning (83.4 ± 20.5 vs. 84.7 ± 22.0, p = 0.25) and bodily pain (78.4 ± 15.2 vs. 75.9 ± 25.3, p = 0.004). Inability to consume certain foods was cited as the biggest problem by 66% of respondents. The dysphagia score was 19.9 ± 8.7; softer foods were tolerated, although difficulty was noted with firmer foods. The reflux score was 8.7 ± 9.8 and regurgitation occurred a mean of once per week. Weight loss and the mental component score were the only predictors of overall satisfaction (r² = 0.46, p = 0.01).

CONCLUSIONS

Patients are highly satisfied with the outcome of LAGB and achieve substantial weight after 3 years. Expected ranges of satiety, adverse symptoms, and outcomes have been defined. The most troublesome symptom is the inability to consume certain foods. Weight loss predicted overall satisfaction, regardless of adverse symptoms.