Treatment of morbid obesity with laparoscopic adjustable gastric banding affects esophageal motility

Normative high resolution esophageal manometry values in asymptomatic patients with obesity

BACKGROUND

Surgical bariatric interventions, while highly effective, can be associated with post-operative esophageal symptoms, gastroesophageal reflux disease and esophageal dysmotility. Whether pre-operative physiology impacts this risk is unknown, in part because expected values on esophageal manometry in patients with obesity are not well understood. This study seeks to establish normative values on esophageal high resolution manometry (HRM) and the prevalence of esophageal dysmotility in the asymptomatic patient with obesity.

METHODS

This retrospective study included adult patients with body mass index (BMI) ≥35 kg m-2 without esophageal symptoms undergoing preoperative bariatric surgical evaluation, including HRM, at a single tertiary care center between February, 2019 and February, 2020.

RESULTS

Of 104 asymptomatic patients with obesity, HRM identified normal esophageal motility in 94 (90.4%) with the remaining 10 having ineffective esophageal motility (3.8%), manometric esophagogastric junction outflow obstruction (3.8%), distal esophageal spasm (1.0%), and hypercontractile esophagus (1.0%). Mean of median lower esophageal sphincter integrated relaxation pressure (LES IRP) was 10.6 mmHg supine (95th percentile 21.5 mmHg) and 8.5 mmHg upright (95th percentile 21.3 mmHg). 86% of patients had intragastric pressure above 8 mmHg. Mean of mean distal contractile integral (DCI) was 2261.6 mmHg cm s-1 (95th percentile 5889.5 mmHg cm s-1).

CONCLUSION

The vast majority of asymptomatic patients with obesity had normal manometry. LES IRP and DCI were higher than that observed in non-obese cohorts. Additionally, BMI correlated to increased intragastric pressure. These data suggest that normative values in patients with obesity should be adjusted to prevent overdiagnosis of EGJOO or hypercontractile esophagus.

Foregut Malignancy After Metabolic Surgery: a Literature Review

Obesity is known to be epidemiologically associated with malignancy. Although there is an increasing global number of bariatric surgeries, the relationship between bariatric surgery and esophagogastric cancers is not well understood. Diagnosis of esophagogastric cancers following bariatric surgery is challenging because the presentation tends to be nonspecific and may be perceived as usual postoperative symptoms in bariatric patients. Therefore, the early diagnosis requires a high index of suspicion. In addition, endoscopic investigation of the excluded stomach after a Roux-en-Y gastric bypass or a one-anastomosis gastric bypass is technically challenging, which further complicates the diagnosis. The aim of this study is to review the current evidence in the literature on esophagogastric cancers following bariatric surgery.

The Effects of Bariatric Surgery and Endoscopic Bariatric Therapies on GERD: An Update

PURPOSE OF REVIEW

Bariatric surgery and endoluminal bariatric therapies (EBTs) form an increasingly utilized therapeutic approach to treat obese patients but may worsen gastroesophageal reflux disease (GERD). In this updated article, we review the evidence on the effects of bariatric procedures on GERD.

FINDINGS

Recent evidence implicates sleeve gastrectomy with the highest rates of de novo GERD and Barrett's esophagus (BE), whereas malabsorptive-restrictive procedures such as Roux-en-Y gastric bypass (RYGB) and one anastomosis gastric bypass (OAGB) were shown to have significantly lower reported rates. The intragastric balloon (IGB) has been associated with increased likelihood of GERD, whereas insufficient evidence exists linking endoscopic sleeve gastroplasty (ESG) to GERD.

SUMMARY

Gastroesophageal reflux disease may be treated with some bariatric procedures but is often developed de novo as a result of the change in anatomy. Patients set to undergo bariatric surgery may benefit from pre-procedural endoscopy to choose the more suitable therapy. Further studies with objective measurements of GERD post procedure may provide more insight into the effects of bariatric therapies on reflux, especially more novel ones such as ESG.

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.

Effects of bariatric surgery on the esophagus

PURPOSE OF REVIEW

Bariatric surgery is the best therapeutic approach to patients with morbid obesity, but there is mounting evidence that it is associated with esophageal dysfunctions, including gastroesophageal reflux disease (GERD) and motor disorders. In the present review, we summarize the existing information on the complex link between bariatric surgery and esophageal disorders.

RECENT FINDINGS

Although high-quality studies on these effects are lacking, because of evident methodological flaws and retrospective nature, the review of published investigations show that pure restrictive procedures, such as laparoscopic adjustable gastric banding (LAPG) and laparoscopic sleeve gastrectomy (LSG), are associated with de novo development or worsening of GERD. Moreover, LAGB is the procedure with the greatest frequency of esophageal motor disorders, including impairment of LES relaxation and ineffective esophageal peristalsis associated with esophageal dilation. LSG seems to be less associated with esophageal dysmotility, although evidence derived from studies with objective measurements of esophageal dysfunction is limited. Finally, RYGB seems to be the best procedure for improvement of GERD symptoms and preservation of esophageal function.

SUMMARY

Overall, the restrictive-malabsorptive approach represented by RYGB must be preferred to pure restrictive operations in order to avoid the negative consequences of bariatric surgery on esophageal functions.

Achalasia After Bariatric Surgery

BACKGROUND

Obesity is an epidemic on the rise. Increasing body mass index (BMI) has been associated with a number of comorbid diseases, including rarely reported motility disorders such as achalasia. Motility disorders are prevalent in obese patients, possibly more prevalent when compared to the nonobese population. Identification of motility disorders is important before bariatric surgery and may alter the planned type of procedure performed. Limited data exist regarding the development or existence of esophageal motility disorders after bariatric surgery. This study aims to characterize patients who have undergone bariatric surgery and subsequently developed or were diagnosed with achalasia.

METHODS

Patients with a diagnosis of achalasia who previously underwent bariatric surgery were identified. Data collected included baseline demographics, perioperative parameters, and postoperative outcomes. Descriptive statistics were computed for all variables.

RESULTS

Ten patients met the inclusion criteria. All patients had endoscopy and manometry confirming diagnosis of achalasia after previous bariatric surgery. Eight patients had undergone Roux-en-Y gastric bypass (RYGB), and two patients had vertical banded gastroplasty (VBG). Median length of time from bariatric surgery to diagnosis was 6 years. Two patients had undergone Botox(®) treatment, and five had gone through the scope esophageal dilations. All patients had a surgical intervention for achalasia, specifically Heller myotomy (HM) (n = 4 open, n = 4 laparoscopic) was performed in the eight RYGB patients, whereas near total gastrectomy and esophagectomy (n = 1), and transhiatal esophagectomy with a partial gastrectomy (n = 1), were performed in each of the patients who previously underwent VBG. These patients were considered to have end-stage achalasia. All patients showed significant decrease in BMI after bariatric surgery (11.1 ± 1.5 kg/m(2)). Six of the eight patients who underwent HM achieved resolution of achalasia symptoms at a mean time of 1.6 months and remained asymptomatic for the total follow-up of 36 months. One patient developed recurrent achalasia 2 years after HM and subsequently underwent a peroral endoscopic myotomy. One HM patient was lost to follow-up. The two patients who underwent esophagectomies were symptom free at 36 months.

CONCLUSION

Although the incidence of achalasia in the bariatric population is unknown, it does coexist and should be treated when identified. Dysmotility is not uncommon and rarely is the workup completed to identify achalasia before bariatric surgery. Increasing our attention to identify motility diseases preoperatively and specifically raising awareness that achalasia can occur after bariatric surgery will result in better care for patients. Our results suggest achalasia can be effectively treated with surgical therapy after previous bariatric surgery.

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.

Gastroesophageal reflux disease after bariatric procedures

GERD is a significant comorbidity in bariatric patients preoperatively and postoperatively. Surgeons should be aware of appropriate evaluation, procedures choices, and management options. Revision surgery for reflux symptoms is common and appropriate anatomy and outcomes should be considered when offering these interventions to our patients. Patient selection is important to ensure avoiding postoperative development or worsening of GERD.

The effects of sleeve gastectomy on gastro-esophageal reflux and gastro-esophageal motility

Sleeve gastrectomy is an increasingly performed bariatric procedure associated with low morbidity and good short to medium term effects on weight loss and comorbid conditions. Studies assessing the prevalence of post-operative gastro-esophageal reflux disease (GERD), show sleeve gastrectomy may provoke de novo GERD symptoms or worsening of pre-existing GERD. Pathophysiological mechanisms of GERD after sleeve gastrectomy include a hypotensive lower esophageal sphincter, increased gastro-esophageal pressure gradient and intra-thoracic migration of the remnant stomach. A reduction in the compliance of the gastric remnant may provoke an increase in transient lower esophageal sphincter relaxations. Time-resolved MRI suggests relative gastric stasis in the proximal remnant and increased emptying from the antrum. A lack of standardisation of technique, along with heterogeneity of studies assessing GERD may explain the wide variability in reported results. Simultaneous and careful repair of an associated hiatus hernia may result in a reduction in the prevalence of post-operative GERD.

Upper gastrointestinal symptoms in obese patients and their outcomes after bariatric surgery

Obesity is considered an important risk factor for the development of gastrointestinal (GI) disorders, likely through alterations of GI motility. Even though gastroesophageal reflux disease is the condition mainly studied at present, the prevalence of other upper GI symptoms is also augmented in obese patients. Owing to their chronic trend, these disorders have a bearing on public spending and their correct diagnosis would avoid unnecessary cost-consuming investigations. Furthermore, bariatric surgery dramatically changes GI anatomy and physiology, influencing GI symptom outcomes. The aim of this review is to categorize the available results in a pathophysiological framework in an attempt to set up the correct clinical GI management of obese patients before and after bariatric surgery. This would be helpful in tentatively reducing their considerable economic burden on public health services.

The risk of regurgitation and pulmonary aspiration in a patient after gastric banding

Laparoscopic gastric banding is a popular surgical treatment performed to control morbid obesity all over the world. Regurgitation of food material from stomach is very common in these patients. Remnants of food material may risk the airway for pulmonary aspiration. This case experience shows that despite the extended fasting period, airway is not protected from the risk of aspiration. Delayed gastric emptying and altered gastroesophageal motility keep the food materials in the stomach and precipitate regurgitation. So any such patient should be considered as full stomach. Airway manipulation in these patients should be under direct laryngoscopic vision and rapid sequence induction with endotracheal intubation should be considered as mandatory for general anesthesia.

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.

High resolution esophageal manometry evaluation in symptomatic patients after gastric banding for morbid obesity

BACKGROUND

Dysphagia and vomiting are frequent after laparoscopic gastric banding (LAGB). These symptoms could be secondary to esophageal motility disorders. Our aim was to assess esophageal motility and clearance in symptomatic LAGB patients using high resolution manometry (HRM).

METHODS

Twenty-two LAGB patients with esophageal symptoms (dysphagia, vomiting, and regurgitations) were included. Esophageal motility was studied using HRM (ManoScan®, Sierra Systems) and classified according to the Chicago classification.

RESULTS

The median delay between surgery and manometry evaluation was 6.3 years (range 1-10). Manometric data were considered as normal in only 2 patients. Achalasia was diagnosed in 3 cases, functional EGJ obstruction in 15, hypotensive peristalsis in 2. During swallowing pan-esophageal pressurization was observed in 6 patients, hiatal hernia pressurization in 7 and gastric pouch pressurization in 2. The intra-bolus pressure was elevated in 18 patients. LAGB was deflated in 6 patients and removed in 12. In 2 patients with unchanged symptoms after LAGB removal motility disorders persisted (1 achalasia, 1 functional EGJ obstruction).

CONCLUSION

In symptomatic LAGB patients, esophageal dysmotility is frequent. High resolution manometry allows the assessment of esophageal clearance and provides guidance for the choice of treatment.

Environmental - lifestyle related factors

The prevalence of gastro-oesophageal reflux disease (GORD) has been increasing worldwide. This increase is likely associated with the increased prevalence of obesity, the ageing of the population and the decreased prevalence of Helicobacter pylori (Hp) infection. These different environmental factors interact with GORD pathogenesis in a potentially negative way. Oesophago-gastric junction (OGJ) competence, oesophageal clearance mechanisms and reflux causticity are involved in GORD pathophysiology. Obesity alters GORD pathogenesis by disrupting the OGJ and increasing intragastric pressure. Additionally, the number of transient lower oesophageal sphincter relaxations is potentially increased in obese patients. The potential effect of obesity on oesophageal peristalsis and the implication of impaired oesophageal clearance in GORD pathogenesis are still to establish. Ageing also plays an important role in GORD pathogenesis by decreasing lower oesophageal sphincter pressure and impairing oesophageal clearance. However a link between these abnormalities and an increased acid oesophageal exposure has not yet been demonstrated in the elderly. The role of H. pylori and its eradication remain controversial. The type of Hp gastritis may explain the controversial effect. Hp with antral predominant gastritis is responsible for an increased gastric acid secretion and thus promotes GORD. On the opposite spectrum, Hp with diffuse gastritis induces a gastric atrophy and in this particular case, the Hp eradication may restore acid secretion and lead to a more caustic refluxate in patients with predisposing conditions for GORD. The association of GORD and the type of Hp gastritis remains to be confirmed.

Effects of adjustable gastric banding on gastroesophageal reflux and esophageal motility: a systematic review

Controversial opinions exist concerning the effect of laparoscopic adjustable gastric banding on gastroesophageal reflux. MEDLINE and EMBASE databases were searched for relevant studies on patients undergoing adjustable gastric banding. Data are expressed in mean (range). Twenty studies were identified with a total of 3307 patients. The prevalence of reflux symptoms decreased postoperatively from 32.9% (16-57) to 7.7% (0-26.9) and medication use from 27.5% (16-38.5) to 9.5% (3.1-19.2). Newly developed reflux symptoms were found in 15% (6.1-20) of the patients. The percentage of esophagitis decreased postoperatively from 33.3% (19.4-61.6) to 27% (2.3-60.8). Newly developed esophagitis was observed in 22.9% (0-38.4). Pathological reflux was found in 55.8% (34.9-77.4) preoperatively and postoperatively in 29.4% (0-41.7) of the patients. Lower esophageal sphincter pressures increased from 12.9 to 16.9 mmHg (11.3-21.4). Lower esophageal sphincter relaxation decreased from 100% to 79.7% (58-86). The percentage of dysmotility increased from 3.5% (0-10) to 12.6% (0-25). Adjustable gastric banding has anti-reflux properties resulting in resolution or improvement of reflux symptoms, normalized pH monitoring results and a decrease of esophagitis on short term. However, worsening or newly developed reflux symptoms and esophagitis are found in a subset of patients during longer follow-up.

Gastroesophageal reflux disease and morbid obesity: is there a relation?

Gastroesophageal reflux disease (GERD) is highly prevalent in morbidly obese patients, and a high body mass index (BMI) is a risk factor for the development of GERD. However, the mechanism by which the BMI affects esophageal acid exposure is not completely understood. Although many advances have been made in the understanding of the pathophysiology of GERD, many aspects of the pathophysiology of this disease in morbidly obese patients remain unclear. The following review describes the current evidence linking esophageal reflux to obesity, covering the pathophysiology of the disease and the implications for treatment of GERD in the obese patient.

Systematic review: the effects of conservative and surgical treatment for obesity on gastro-oesophageal reflux disease

BACKGROUND

Incidence rates of both obesity and gastro-oesophageal reflux disease (GERD) are increasing, particularly in the Western world. It has been suggested that GERD symptoms may be improved by weight reduction.

AIM

To review the literature on the effect of various weight reducing modalities on manifestations of GERD in obese patients.

METHODS

A literature search was performed using PubMed, EMBASE and the Cochrane Library, combining the words obesity and gastro-oesophageal reflux with bariatric surgery, diet, lifestyle intervention and weight loss.

RESULTS

With regard to diet/lifestyle intervention (conservative), four of seven studies reported an improvement of GERD. For Roux-en-Y gastric bypass, a positive effect on GERD was found in all studies, although this was mainly evaluated by questionnaires. In contrast, for vertical banded gastroplasty, no change or even an increase of GERD was noted, whereas the results for laparoscopic adjustable gastric banding were conflicting.

CONCLUSIONS

Dietary and lifestyle intervention may improve GERD in obese patients; however, the most favourable effect is likely to be found after bariatric surgery, especially after Roux-en-Y gastric bypass. Future studies need to elucidate for which GERD patients laparoscopic adjustable gastric banding might have a beneficial effect and how they can be identified preoperatively.

Weight loss and quality of life after gastric band removal or deflation

BACKGROUND

The study aim was to retrospectively assess whether patients were able to maintain their weight after gastric band removal or deflation and how they felt about gastric banding.

METHODS

A total of 41 patients (93% female, mean age 34.1 (SD 10.5) years) were included in this study: patients who had their band removed/deflated without further surgical intervention (group 1, n = 26) and those who later underwent a second bariatric operation (group 2, n = 15). We evaluated weight gain after band removal/during the time between band removal and second bariatric operation.

RESULTS

Of our patients, 31 (76%) suffered a complication (18 late pouch dilatations, six band infections, five band migrations, and two band leaks) requiring band removal. Ten patients wanted their band removed (six) or emptied (four). Mean time after band removal, when patients had neither a band nor a second bariatric operation, was 2.84 (SD 2.3) years. Five (12.2%) patients maintained their weight, four of whom experienced a learning effect; all others gained weight. Mean body mass index for both groups after the period without a band was 36.7 (SD 8.0) kg/m(2) (vs 29.4 (SD 7.0) at removal), and excess weight loss was 33.2% (SD 39.2; vs 69.8% (SD 32.9) at removal). Of our patients, 73% would not agree to gastric banding again. According to the bariatric analysis and reporting outcome system, long-term outcome of patients following band removal was a "failure" in 66% of patients.

CONCLUSIONS

Long-term outcome following band removal is unsatisfactory in many patients. Nevertheless, a minority of patients was able to maintain its weight loss.

Clinical application of laparoscopic bariatric surgery: an evidence-based review

BACKGROUND

Approximately one-third of U.S. adults are obese. Current evidence suggests that surgical therapies offer the morbidly obese the best hope for substantial and sustainable weight loss, with a resultant reduction in morbidity and mortality. Minimally invasive methods have altered the demand for bariatric procedures. However, no evidence-based clinical reviews yet exist to guide patients and surgeons in selecting the bariatric operation most applicable to a given situation.

METHODS

This evidenced-based review is presented in conjunction with a clinical practice guideline developed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). References were reviewed by the authors and graded as to the level of evidence. Recommendations were developed and qualified by the level of supporting evidence available at the time of the associated SAGES guideline publication. The guideline also was reviewed and co-endorsed by the American Society for Metabolic and Bariatric Surgery.

RESULTS

Bariatric surgery is the most effective treatment for severe obesity, producing durable weight loss, improvement of comorbid conditions, and longer life. Patient selection algorithms should favor individual risk-benefit considerations over traditional anthropometric and demographic limits. Bariatric care should be delivered within credentialed multidisciplinary systems. Roux-en-Y gastric bypass (RGB), adjustable gastric banding (AGB), and biliopancreatic diversion with duodenal switch (BPD + DS) are validated procedures that may be performed laparoscopically. Laparoscopic sleeve gastrectomy (LSG) also is a promising procedure. Comparative data find that procedures with more dramatic clinical benefits carry greater risks, and those offering greater safety and flexibility are associated with less reliable efficacy.

CONCLUSIONS

Laparoscopic RGB, AGB, BPD + DS, and primary LSG have been proved effective. Currently, the choice of operation should be driven by patient and surgeon preferences, as well as by considerations regarding the relative importance placed on discrete outcomes.

Diagnosis and treatment of megaesophagus after adjustable gastric banding for morbid obesity

BACKGROUND

Laparoscopic adjustable gastric banding (LAGB) can impair esophageal peristalsis and can also cause a lack of relaxation of the lower esophageal sphincter, possibly leading to esophageal dilation. The aim of the present study was to determine the incidence of megaesophagus, the role of preoperative manometry in predicting its occurrence, and the management of megaesophagus after gastric banding in the setting of a research clinic.

METHODS

We performed a retrospective review of a prospectively collected database. A total of 257 patients underwent LAGB from January 2002 to December 2006. The incidence of megaesophagus, its relationship to the preoperative esophageal manometry and upper gastrointestinal series findings, and the treatment of patients with this complication were analyzed.

RESULTS

Of the 257 patients, 5 (1.9%) presented with megaesophagus after gastric banding. The mean interval to development was 32 months (range 24-36). The diagnosis was made using the symptoms, signs, and upper gastrointestinal series findings. The preoperative esophageal manometry findings were normal in 4 (80%) of these 5 patients, and 1 patient (20%) had a nonspecific motility disorder. The mean age was 54.5 years (range 30-76). The mean preoperative weight was 127.1 kg (range 112.7-145.9), and the body mass index was 43.2 kg/m2 (range 41-49). In all cases, the management of megaesophagus was gastric band removal. All the patients improved partially after band deflation but required band removal because of continued symptoms.

CONCLUSION

Megaesophagus is a possible late complication after LAGB. The preoperative manometry results cannot predict for its occurrence. The management of megaesophagus caused by LAGB requires, in most cases, band removal.

Improvement in comorbid illness after placement of the Swedish Adjustable Gastric Band

BACKGROUND

Obesity and its related comorbid illnesses have become a national health priority. We report comorbidity and quality of life (QoL) data after weight loss with gastric banding using the Swedish Adjustable Gastric Band (SAGB).

METHODS

Data were collected prospectively for 838 consecutive morbidly obese patients who underwent laparoscopic adjustable gastric banding (LAGB) between January 2001 and July 2007. Patients were followed-up by a multidisciplinary team consisting of a surgeon, physician, dietician, and exercise consultant, all of whom were involved in the evaluation of clinical outcomes. Continuous data were reported as mean +/- SD; categorical data were reported as number and percentage. Patients served as their own controls.

RESULTS

Respective preoperative mean age, weight, and body mass index (BMI) were 44 years (range 16-76), 122 kg (range 86-240), and 44 kg/m2 (range 35-86), respectively. SAGB implantation was accomplished by the pars flaccida technique with no conversion to an open procedure. Mature follow-up data were available for 35% of patients at 24 months and 21% at 36 months. In the total cohort of 838 patients, BMI (mean +/- SD) decreased to 32 +/- 5 kg/m2 and 32 +/- 7 kg/m2 at 24 months and 36 months, respectively. Percentage excess weight loss (%EWL) (mean +/- SD) was 32% +/- 14% (n = 506), 47% +/- 15% (n = 461), 52% +/- 16% (n = 291), and 54% +/- 23% (n = 175) at 6, 12, 24, and 36 months, respectively (P < .001). There were 545 patients identified with comorbid illness at >6-month follow-up. After a median follow-up of 13 months (range 6-36 months), resolution and/or improvement of comorbidities was as follows: type 2 diabetes mellitus, 79%; metabolic syndrome, 78%; hypertension, 67%; dyslipidemia, 66%; gastroesophageal reflux, 66%; asthma, 57%; arthritis/joint pain, 70%; polycystic ovarian syndrome, 48%; and depression, 57%. There was a significant improvement in QoL (as measured by the Short Form-36 Health Survey [SF-36]), bringing patients' QoL to a level consistent with that of community norms in all 8 domain scores. Of 342 patients surveyed with the Beck Depression Inventory (BDI-II), a statistically significant improvement in depressive mood was also observed (P < .001).

CONCLUSION

Weight loss achieved by use of the SAGB provides a dramatic reduction in many serious comorbid illnesses as well as improvement in the psychosocial wellbeing of morbidly obese patients.

Crural repair permits morbidly obese patients with not large hiatal hernia to choose laparoscopic adjustable banding as a bariatric surgical treatment

BACKGROUND

Hiatal hernia, present radiologically in about 50% of patients desiring bariatric surgery, has been thought a contraindication to laparoscopic adjustable gastric banding (LAGB). Posited was the notion that adding crural repair to LAGB would enable this procedure to be offered to patients desiring bariatric surgery who had hiatal hernias.

METHODS

After obtaining IRB approval, charts of all patients who underwent simultaneous crural repair and LAGB from June 2003 to January 2006 were reviewed. All patients were evaluated with the DeMeester score and the GERD-HQRL score pre- and postoperatively. Statistical analyses included the Mann-Whitney U test and the Chi-squared test.

RESULTS

Twenty-one patients underwent laparoscopic procedure with crural repair; none required conversion to an open procedure. There were no mortalities. Two complications, a wound infection at the level of the port, and a case postoperative dysphagia resolved with therapy. Eighty-six percent of the patients ceased regular intake of heartburn medicines, P<.01. Median percent excess weight loss was 45% at 1 year and 55% at 2 years. The modified DeMeester score fell to 0-2 postoperatively (P<.01). Two years after the procedure, symptoms were less, as assessed by GERD-HQRL scores (P<.01).

CONCLUSION

Crural repair permits LAGB to be safely and effectively performed in patients with hiatal hernia.

Preoperative upper gastrointestinal testing can help predicting long-term outcome after gastric banding for morbid obesity

BACKGROUND

Gastric banding (GB) is one of the most popular bariatric procedures for morbid obesity. Apart from causing weight loss by alimentary restriction, it can interfere with functions of the esophagus and upper stomach. The aim of this study was to evaluate if the results of extensive preoperative upper GI testing were correlated with long-term outcome and complications after GB.

METHODS

Using a prospectively maintained computerized database including all the patients undergoing bariatric operations in both our hospitals, we performed a retrospective analysis of the patients who underwent complete upper gastrointestinal (GI) testing (endoscopy, pH monitoring, and manometry) before GB.

RESULTS

One hundred thirty-four patients underwent complete testing before GB. Abnormal pH monitoring (increased total reflux time, increased diurnal reflux time, increased number of reflux episodes) predicted the development of complications and especially pouch dilatation and food intolerance. The mean De Meester score was higher among patients who developed complications than in the remaining ones (25.4 vs 17.7, P=0.03). High lower esophageal sphincter pressure also predicted progressive long-term food intolerance. Endoscopic findings were not predictive of the long-term outcome.

CONCLUSIONS

There is some association between the function of the upper digestive tract and long-term complications after gastric banding. Abnormal pH monitoring predicts overall long-term complications, especially food intolerance with or without reflux, and pouch dilatation, and a high lower esophageal sphincter pressure predicts long-term food intolerance. Extended upper gastrointestinal testing with endoscopy, 24-h pH monitoring, and esophageal manometry is probably worthwhile in selecting patients for gastric banding.

Vagal nerve dissection during pouch formation in laparoscopic Roux-Y-gastric bypass for technical simplification: does it matter?

BACKGROUND

In Roux-Y gastric bypass surgery pouch formation is the most demanding part of the operation. The vagal nerve is usually tempted to be preserved although results reporting beneficial effects are lacking. Dividing the perigastric tissue including the anterior vagal trunk may technically alleviate gastric pouch formation. We evaluated the clinical outcome in patients with and without vagal nerve dissection in patients after Roux-Y gastric bypass (RY-BP).

METHODS

In this study 40 morbidly obese patients undergoing RY-BP have been included. Patients were divided into two groups according to vagal nerve preservation (Group 1, n = 25) or vagal nerve dissection (Group 2, n = 22). Clinical parameters (weight loss, complications, gastrointestinal symptoms), esophageal endoscopy, and motility data (manometry, pH-metry) and a satiety score were assessed. Serum values of ghrelin and gastrin were measured.

RESULTS

All procedures were performed by laparoscopy with a 0% mortality rate. One patient of each groups necessitated redo-laparoscopy (bleeding and a lost drainage). All patients significantly reduced body weight (p < 0.01 compared to preoperative) during a median follow-up of 36.1 months. Two patients of Group 2 showed acid reflux demonstrated by pathologic postoperative DeMeester scores. Esophageal body peristalsis and barium swallows did not reveal statistically significant differences between the two groups. Parameters of satiety assessment did not differ between the two groups as did serum values of gastrin and ghrelin.

CONCLUSION

Pouch formation during RY-BP may be alleviated by simply dissecting the perigastric fatty tissue. In this way the anterior vagal trunk is dissected, however, no influence on clinical, functional and laboratory results occur.

Gastroesophageal reflux disease in morbid obesity: the effect of Roux-en-Y gastric bypass

BACKGROUND

Gastroesophageal reflux disease (GERD) is a common condition in obesity. The impact of Roux-en-Y gastric bypass (RYGBP) on GERD is poorly known. We studied the effect of the RYGBP on GERD in patients with morbid obesity (MO).

METHODS

Twenty consecutive patients with MO (BMI > 40 kg/m(2)) were studied before and 6 months after RYGBP. GERD symptoms were evaluated with Carlsson-Dent questionnaire (CDQ). All the patients underwent esophageal manometry and ambulatory 24-h pH-metry. Chi-square test was used to compare categorical variables, and Wilcoxon test was used for numerical variables. A p value under 0.05 was considered significant.

RESULTS

There were 16 women (80%) and 4 men (20%) with mean age 38.9 +/- 6.9 years included in this study. BMI was 48.5 +/- 6.2 kg/m(2) and 33.2 +/- 4.5 kg/m(2) before and after RYGBP, respectively. Mean weight reduction was 42.5 +/- 9.7 kg (p < 0.001). Reflux symptoms measured by CDQ and esophageal acid exposure improved significantly after RYGBP. The percentage of time of pH < 4 was 10.7 +/- 6.7 before and 1.6 +/- 1.2 after the surgical procedure (p < 0.001). LES basal pressure before and after the RYGBP was 18 +/- 11 and 20.1 +/- 5.6 mmHg (p = 0.372), and the esophageal body amplitude was 104.2 +/- 47.2 and 75.1 +/- 36.2 mmHg, respectively (p = 0.005).

CONCLUSION

RYGBP improves GERD symptoms and reduces esophageal acid exposure in patients with MO.

Is preoperative manometry in restrictive bariatric procedures necessary?

BACKGROUND

Restrictive bariatric procedures are frequently considered for patients with morbid obesity, because the weight loss and reduction of comorbidities are good. An impact on gastroesophageal reflux disease (GERD), which is common in this population, may be anticipated. Converse results of GERD symptoms are reported for patients after adjustable gastric banding (AGB), sleeve gastrectomy (SG), and Roux-en-Y gastric bypass (RYGBP).

METHODS

A literature search was performed and, with our personal experience, are summarized.

RESULTS

Esophageal manometry is a practical tool to identify functional disorders of the esophageal body and the lower esophageal sphincter (LES). For patients with weak esophageal body motility, AGB should not be considered as a therapeutic option because esophageal dilation, esophageal stasis, and consequent esophagitis often occur during long-term follow-up, and band deflation is inevitable. Stable body weight can therefore not be achieved in these patients. Low resting pressure of the LES may be a contraindication for SG, because taking away the angle of His further impairs the antireflux mechanism at the cardia. So far, RYGBP is an option for all morbidly obese patients regardless of the results of esophageal manometry.

CONCLUSION

Preoperative esophageal manometry is advised for restrictive procedures such as AGB and SG.

Simultaneous surgical management of achalasia and morbid obesity

Achalasia presenting in the context of morbid obesity is rare. The case is presented of a woman with achalasia and morbid obesity who was treated with simultaneous laparoscopic esophageal myotomy and gastric bypass. The sparse literature addressing these rare patients is reviewed and management considerations discussed. Simultaneous laparoscopic esophageal myotomy and gastric bypass is safe, feasible and provides good results.

Is Esophageal Dysmotility after Laparoscopic Adjustable Gastric Banding Reversible?

Laparoscopic adjustable gastric banding (LAGB) has become an increasingly popular option to treat morbid obesity. Esophageal dysmotility secondary to LAGB has been described, but is usually reversible after removal of the band. Long-term esophageal dysmotility persisting after removal of the band is an unusual and not yet described complication. We report the case of a 58-year-old obese patient who developed severe dysphagia and vomiting associated with atypical esophageal dysmotility 22 months after gastric band placement. Radiological exploration revealed no acute band slippage but only a pseudoachalasia. Device deflation and then band removal were required in an attempt to treat her symptoms. Esophageal dysmotility persisted for several months after band removal and was still present after a Roux-en-Y gastric bypass performed as revisional operation. Possible mechanisms generating this complication and clinical implications are discussed.

Esophageal motility disorders after gastric banding

The long-term effects of gastric banding on esophageal function are not well described. This report describes a 28-year-old woman who developed signs and symptoms of abnormal esophageal motility and lower esophageal sphincter hypotension after gastric banding for morbid obesity. The current literature addressing the effects of gastric banding on esophageal function in light of this case report is discussed.