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

Outcomes of Concurrent Hiatus Hernia Repair with Different Bariatric Surgery Procedures: a Systematic Review and Meta-analysis

BACKGROUND

Hiatus hernia (HH) is prevalent among patients with obesity. Concurrent repair is often performed during metabolic and bariatric surgery (MBS), but a consensus on the safety and effectiveness of concurrent HH repair (HHR) and MBS remains unclear. We performed a systematic review of the safety and effectiveness of concurrent HHR and MBS through the measurement of multiple postoperative outcomes.

METHOD

Seventeen studies relating to concurrent MBS and HHR were identified. MBS procedures included laparoscopic sleeve gastrectomy (LSG), Roux-en-Y gastric bypass (LRYGB), and adjustable gastric banding (LAGB). Studies with pre- and postoperative measurements and outcomes were extracted.

RESULTS

For LSG, 9 of 11 studies concluded concurrent procedures to be safe and effective with no increase in mortality. Reoperation and readmission rates however were increased with HHR, whilst GORD rates were seen to improve, therefore providing a solution to the predominant issue with LSG. For LRYGB, in all 5 studies, concurrent procedures were concluded to be safe and effective, with no increase in mortality, length of stay, readmission and reoperation rates. Higher complication rates were observed compared to LSG with HHR. Among LAGB studies, all 4 studies were concluded to be safe and effective with no adverse outcomes on mortality and length of stay. GORD rates were seen to decrease, and reoperation rates from pouch dilatation and gastric prolapse were observed to significantly decrease.

CONCLUSION

Concurrent HHR with MBS appears to be safe and effective. Assessment of MBS warrants the consideration of concurrent HHR depending on specific patient case and the surgeon's preference.

Practical guideline on obesity care in patients with gastrointestinal and liver diseases - Joint ESPEN/UEG guideline

BACKGROUND

Patients with chronic gastrointestinal disease such as inflammatory bowel disease (IBD), irritable bowel syndrome (IBS), celiac disease, gastroesophageal reflux disease (GERD), pancreatitis, and chronic liver disease (CLD) often suffer from obesity because of coincidence (IBD, IBS, celiac disease) or related pathophysiology (GERD, pancreatitis and CLD). It is unclear if such patients need a particular diagnostic and treatment that differs from the needs of lean gastrointestinal patients. The present guideline addresses this question according to current knowledge and evidence.

OBJECTIVE

The present practical guideline is intended for clinicians and practitioners in general medicine, gastroenterology, surgery and other obesity management, including dietitians and focuses on obesity care in patients with chronic gastrointestinal diseases.

METHODS

The present practical guideline is the shortened version of a previously published scientific guideline developed according to the standard operating procedure for ESPEN guidelines. The content has been re-structured and transformed into flow-charts that allow a quick navigation through the text.

RESULTS

In 100 recommendations (3× A, 33× B, 24 × 0, 40× GPP, all with a consensus grade of 90% or more) care of gastrointestinal patients with obesity - including sarcopenic obesity - is addressed in a multidisciplinary way. A particular emphasis is on CLD, especially metabolic associated liver disease, since such diseases are closely related to obesity, whereas liver cirrhosis is rather associated with sarcopenic obesity. A special chapter is dedicated to obesity care in patients undergoing bariatric surgery. The guideline focuses on adults, not on children, for whom data are scarce. Whether some of the recommendations apply to children must be left to the judgment of the experienced pediatrician.

CONCLUSION

The present practical guideline offers in a condensed way evidence-based advice how to care for patients with chronic gastrointestinal diseases and concomitant obesity, an increasingly frequent constellation in clinical practice.

Dietary and Nutritional Support in Gastrointestinal Diseases of the Upper Gastrointestinal Tract (I): Esophagus

The esophagus is the centerpiece of the digestive system of individuals and plays an essential role in transporting swallowed nutrients to the stomach. Diseases of the esophagus can alter this mechanism either by causing anatomical damage that obstructs the lumen of the organ (e.g., peptic, or eosinophilic stricture) or by generating severe motility disorders that impair the progression of the alimentary bolus (e.g., severe dysphagia of neurological origin or achalasia). In all cases, nutrient assimilation may be compromised. In some cases (e.g., ingestion of corrosive agents), a hypercatabolic state is generated, which increases resting energy expenditure. This manuscript reviews current clinical guidelines on the dietary and nutritional management of esophageal disorders such as severe oropharyngeal dysphagia, achalasia, eosinophilic esophagitis, lesions by caustics, and gastroesophageal reflux disease and its complications (Barrett's esophagus and adenocarcinoma). The importance of nutritional support in improving outcomes is also highlighted.

European guideline on obesity care in patients with gastrointestinal and liver diseases - Joint ESPEN/UEG guideline

BACKGROUND

Patients with chronic gastrointestinal (GI) disease such as inflammatory bowel disease (IBD), irritable bowel syndrome (IBS), celiac disease, gastroesophageal reflux disease (GERD), pancreatitis, and chronic liver disease (CLD) often suffer from obesity because of coincidence (IBD, IBS, celiac disease) or related pathophysiology (GERD, pancreatitis and CLD). It is unclear if such patients need a particular diagnostic and treatment that differs from the needs of lean GI patients. The present guideline addresses this question according to current knowledge and evidence.

OBJECTIVE

The objective of the guideline is to give advice to all professionals working in the field of gastroenterology care including physicians, surgeons, dietitians and others how to handle patients with GI disease and obesity.

METHODS

The present guideline was developed according to the standard operating procedure for ESPEN guidelines, following the Scottish Intercollegiate Guidelines Network (SIGN) grading system (A, B, 0, and good practice point (GPP)). The procedure included an online voting (Delphi) and a final consensus conference.

RESULTS

In 100 recommendations (3x A, 33x B, 24x 0, 40x GPP, all with a consensus grade of 90% or more) care of GI patients with obesity - including sarcopenic obesity - is addressed in a multidisciplinary way. A particular emphasis is on CLD, especially fatty liver disease, since such diseases are closely related to obesity, whereas liver cirrhosis is rather associated with sarcopenic obesity. A special chapter is dedicated to obesity care in patients undergoing bariatric surgery. The guideline focuses on adults, not on children, for whom data are scarce. Whether some of the recommendations apply to children must be left to the judgment of the experienced pediatrician.

CONCLUSION

The present guideline offers for the first time evidence-based advice how to care for patients with chronic GI diseases and concomitant obesity, an increasingly frequent constellation in clinical practice.

Combined Partial Toupet Fundoplication With Laparoscopic Sleeve Gastrectomy for Patients With Morbid Obesity and Symptomatic GERD: Preliminary Results of the T-sleeve Technique

AIM

The aim of this study to reveal preliminary results of our Toupet-sleeve technique in morbid obese patients with symptomatic gastroesophageal reflux disease (GERD) and compare their outcomes with laparoscopic sleeve gastrectomy (LSG) patients' outcomes.

METHODS

The study included 103 patients who underwent primary LSG between March 2018 and October 2020 and 18 patients who underwent partial T-sleeve. Patients were stratified into 2 groups according to the surgical technique. All of the patients had preoperative symptomatic GERD. Patients were reevaluated with regard to GERD symptoms and weight loss in the postoperative period. Two groups' data were compared.

RESULTS

The mean age of the patients was 39.2±10.2 years (63% female), and the mean body mass index was 43.2±6.4 kg/m2. The median operative time was 93 minutes (75 to 110 min) in group A (primary LSG) and 110 minutes (90 to 120 min) in group B (partial T-sleeve). The mean body mass index decreased to 28±4.5 kg/m2 in group A and 25.8±3.5 kg/m2 in group B at 12 months after the surgery. At the 12th month, the patients were reevaluated for GERD symptoms. Reflux symptoms were found to be resolved in 62% of the patients (n=64) in group A, while 32% of the patients (n=39) had persistent GERD symptoms. In group B, all of the patients had discontinued proton pump inhibitors postoperatively, and GERD symptoms were completely resolved in 94% of these patients (n=17).

CONCLUSIONS

The present study showed that T-sleeve provides a very good weight loss and reflux control in patients with symptomatic GERD with morbid obesity in the short-term period. This technique can be proposed in some cases as a primary treatment modality. High numbers of patients and longer follow-up are needed.

The Effect of Laparoscopic Sleeve Gastrectomy With Concomitant Hiatal Hernia Repair on Gastroesophageal Reflux Disease

AIM

The aim of this study is to reveal incidence of gastroesophageal reflux disease (GERD) after laparoscopic sleeve gastrectomy (LSG) and to determine the effect of LSG with hiatal hernia repair on GERD.

METHODS

A total of 440 patients, 395 of them underwent primary LSG (group A) and 45 of them underwent LSG with concomitant hiatal hernia repair (group B) between March 2018 and September 2020 were included in the study. Presence of hiatal hernia was evaluated with endoscopy and confirmed intraoperatively. Patients were evaluated for GERD symptoms in the pre and postoperative period. Two groups' data were compared.

RESULTS

Mean age of the 440 patients was 38.4±11 years (56% female) and mean body mass index was 44.2±7 kg/m2. Symptomatic GERD was detected in 103 (23.4%) and hiatal hernia was detected in 45 (10.2%) patients. İn the preoperative assessment there was no difference with regard to demographics and symptomatic GERD between the 2 groups. Mean duration of follow-up was 17±5.7 (12 to 28) months in the overall study population. Mean body mass index decreased to 28.3±4.9 kg/m2at 12 months after LSG. Excess weight loss ratio was found to be 81±20.4%. The rate of symptomatic GERD after LSG in group A was found to be 20% (n=79/395). Of these patients, 46 (11.6%) had de novo GERD and 33 (38%) had persistent GERD. GERD resolved completely in 54 (62%) patients. In the group B, the rate of symptomatic GERD was detected as 33% (n=15/45) (P=0.04). The rate of de novo GERD (20%) was also higher in group B (P=0.03). The rate of persistent GERD (37%) and GERD resolution (62%) were similar in both groups.

CONCLUSION

İn our study, symptomatic and de novo GERD rates were detected to be higher in the LSG+HH group than LSG alone.

Evolution of gastroesophageal reflux disease symptoms after bariatric surgery: A dose-response meta-analysis

BACKGROUND

Obesity is associated with increased prevalence of gastroesophageal reflux disease, with recent reports suggesting improvement in gastroesophageal reflux disease symptoms and weight loss following bariatric surgical intervention. However, the exact impact of the type of bariatric surgery on the evolution of gastroesophageal reflux disease symptoms has remained unexamined.

METHODS

We systematically searched electronic databases (PubMed, EMBASE, Web of Science, and the Cochrane Library from inception to December 2018) for eligible studies that satisfy prespecified inclusion criteria. We included clinical trials of all designs that reported on gastroesophageal reflux disease outcomes following laparoscopic sleeve gastrectomy or laparoscopic Roux-en-Y gastric bypass. Two independent reviewers extracted relevant data based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Data were pooled using a random-effects model. Main outcomes were symptomatic improvement in gastroesophageal reflux disease symptoms following bariatric surgery.

RESULTS

A total of 31 studies were analyzed, and a robust-error meta-regression model was used to conduct a dose-response meta-analysis synthesizing data on 31 studies that reported gastroesophageal reflux disease outcomes after bariatric surgery. Of 5,295 patients who underwent either laparoscopic sleeve gastrectomy (n = 4,715 patients) or laparoscopic Roux-en-Y gastric bypass (n = 580 patients), 63.4% experienced improvement in gastroesophageal reflux disease symptoms (95% CI 32.46-72.18). The dose-response meta-analysis demonstrated a window period of 2 years for sustained improvement after which symptoms began to recur in those that were asymptomatic.

CONCLUSION

Bariatric surgery may improve gastroesophageal reflux disease symptoms in obese patients who underwent laparoscopic sleeve gastrectomy; however, the most favorable effect is likely to be found after Roux-en-Y gastric bypass surgery. The effects were not sustained and returned to baseline within 4 years.

The Outcomes of Laparoscopic Biliopancreatic Diversion with Duodenal Switch on Gastro-esophageal Reflux Disease: the Mayo Clinic Experience

PURPOSE

The outcomes of laparoscopic biliopancreatic diversion with duodenal switch (BPD-DS) on gastro-esophageal reflux disease (GERD) are not well elucidated.

MATERIAL/METHODS

This retrospective review included patients undergoing laparoscopic primary BPD-DS at Mayo Clinic from 2009 to 2019. GERD parameters analyzed included subjective symptom report/anti-reflux medication intake and/or endoscopic findings. GERD-HRQL questionnaire was also utilized post-operatively. Three subgroups were employed to stratify patients depending on GERD outcomes: the "No-effect" subgroup included patients where surgery did not affect either positively (GERD resolution) or negatively (de novo GERD) GERD outcome, "De novo GERD" subgroup, and "GERD-resolved" subgroup. Multinomial logistic modeling was used to examine associations with the 3-level GERD subgroup (p<0.05).

RESULTS

Seventy-six patients were included in the analysis. Thirty-four (44.7%) patients were found to be in the "GERD-resolved" subgroup, 28 (36.8%) patients in the "No-effect" subgroup, and 14 (18.4%) patients in the "De novo GERD" subgroup. Multinomial logistic modeling showed that patients with pre-surgery diabetes mellitus (DM) had lesser odds (OR= 0.248, (95% CI: 0.085-0.724, p=0.0108)) of GERD resolution than patients without pre-surgery DM. An association was also established between %TWL at 6 and 12 months following the procedure and GERD outcome (p=0.017 and 0.008, respectively). Finally, the mean (SD) post-operative GERD-HRQL score was 8.7 (8.1) points, and 69 (91%) patients were currently satisfied with their post-operative condition.

CONCLUSION

Laparoscopic BPD-DS appears to have a satisfactory GERD outcome in most patients undergoing the operation. There appears to be an association between pre-operative DM, %TWL at 6 and 12 months, and GERD prognosis in this population.

Metabolic Surgery Outcomes in U.S. Patients with Class I Obesity

Background: Although numerous studies outside the United States (U.S.) have explored weight loss and comorbidity resolution among patients with class I obesity (body mass index [BMI] 30–34.9 kg/m²) after metabolic surgery, few U.S.-based studies have been conducted.

Objective: Our aim was to compare weight loss and comorbidity resolution among U.S. patients with class I obesity, who underwent laparoscopic sleeve gastrectomy (LSG) versus Roux-en-Y gastric bypass (RYGB). Methods: Weight loss and comorbidity data among only patients with class I obesity, who underwent LSG or RYGB, were examined. Between April 2009 and April 2017, 1215 metabolic surgeries were performed with 30 patients meeting the inclusion criteria (17 LSG and 13 RYGB).

Results: Percent total weight loss (%TWL) for LSG peaked at 12 months (20.85%), while RYGB %TWL peaked at 18 months (21.65%). Percent excess weight loss (%EWL) peaked at 12 months after LSG (83.59%) and 18 months after RYGB (98.29%). Overall follow-up was 56.3%, 36.7%, and 43.3% at 12, 18, and 24 months. LSG and RYGB were both successful with regard to resolution of medical comorbidities at 12 months.

Conclusion: RYGB and LSG appear to have similar, successful outcomes among U.S. patients with class I obesity for weight loss and comorbidity resolution.

Omentopexy during laparoscopic sleeve gastrectomy: Is it effective in reducing postoperative gastrointestinal symptoms. A retrospective cohort study

Background

Postoperative gastrointestinal symptoms are common in patients undergoing sleeve gastrectomy. This study is aimed to assess the effectiveness of omentopexy during laparoscopic sleeve gastrectomy in reducing gastrointestinal symptoms.

Methods

A retrospective analysis of patients who underwent laparoscopic sleeve gastrectomy with and without omentopexy in the period between January 2016 to September 2017. All procedures were performed by three surgeons utilizing the same surgical technique. Data extracted included patient socio-demographics', preoperative body mass index (BMI), hospitalization period, treatments and post-operative gastrointestinal symptoms. It contained the GERD-Health Related Quality of Life Questionnaire (GERD-HRQL) measuring symptom severity in gastro esophageal reflux disease (GERD). Data were analyzed at 6, 12 and 18 months with reference to weight loss.

Results

A total of 140 patients were included in this study, 70 in each group arm. Age, preoperative BMI, pre-operative co-morbid conditions like hypertension, diabetes, and asthma were considered as confounding variables among the two groups. None of the previous factors were statistically significantly different among both groups. The outcomes of both groups were compared in terms of postoperative nausea, vomiting, regurgitation, intra-hospital stay, medication use, early return to work, and EWL%. None of the previous outcomes except for days of hospital stay and ondansetron use was found to be significantly different between both groups.

Conclusion

Omentopexy does not change the outcome for laparoscopic sleeve gastrectomy in terms of gastrointestinal symptoms or weight loss results.

Esophageal cancer after sleeve gastrectomy: a population-based comparative cohort study

BACKGROUND

Sleeve gastrectomy (SG) is the most common bariatric surgery; however, this approach may induce gastroesophageal reflux disease (GERD). Both obesity and GERD are independent risk factors for esophageal cancer, however the impact of SG on risk of esophageal cancer remains unknown.

OBJECTIVE

To evaluate the risk of esophageal cancer after reflux-prone bariatric surgery.

SETTING

Population-level, provincial administrative healthcare database, Quebec, Canada.

METHODS

We identified a population-based cohort of all patients with obesity who underwent reflux-prone surgery (SG and duodenal switch [DS]) or reflux-protective Roux-en-Y gastric bypass (RYGB) during 01/2006-12/2012 in Quebec, Canada. For every surgical patient, 2-3 nonsurgical controls with obesity matched for age, sex, and geography were also identified. Crude incidence rate ratios (IRRs) for esophageal cancer were calculated using person-time analysis. Hazard ratios (HRs) were obtained using multivariate cox regression.

RESULTS

A total of 4121 patients had reflux-prone procedures and 852 underwent RYGB. At a mean follow-up of 7.6 years, 8 cases of esophageal cancer were identified after bariatric surgery. Compared with RYGB, IRR for esophageal cancer in reflux-prone group was 1.45 (95%CI: .19-65.5) and HR = .83 (95%CI: .10-7.27). The crude incidence rate of esophageal cancer in the reflux-prone group was higher than that of nonsurgical controls (n = 12,159; IRR = 3.46, 95%CI: 1.00-12.5), but after adjustment the difference disappeared (HR = 2.47, 95%CI: .82-7.45).

CONCLUSIONS

Long-term incidence of esophageal cancer after reflux-prone bariatric surgery is not greater than RYGB. While crude incidence of esophageal cancer after reflux-prone surgery is higher than in nonsurgical patients with obesity, such difference disappears after accounting for confounders. Given the low incidence of esophageal cancer and slow progression of dysplastic Barrett esophagus, studies with longer follow-up are needed.

BRAZILIAN PHYSICIANS' PRACTICES ON THE MANAGEMENT OF SYMPTOMS SUGGESTING GASTROESOPHAGEAL REFLUX DISEASE: A MULTIDISCIPLINARY SURVEY

BACKGROUND

Clinical guidelines are available to steer decisions regarding diagnosis, management and treatment of gastrointestinal disorders. Despite this, variations in physician's practices regarding gastroesophageal reflux disease (GERD) symptoms are well described in the literature.

OBJECTIVE

To describe practices of physicians from different specialties on the management of patients with typical symptoms of GERD (heartburn and regurgitation) in a Brazilian sample.

METHODS

National online survey enrolling a sample of general practitioners, gastroenterologists, cardiologists and otolaryngologists. The survey was conducted from August 6th to September 12th, 2018. Subjects answered a structured questionnaire addressing variables regarding physicians' profile (age, sex, specialty, practice setting, years in practice, type of medical expense reimbursement), their patients characteristics and prescribing behaviors.

RESULTS

The final weighted sample was comprised of 400 physicians, 64% male, with an average of 15 years of experience. Physicians' estimates of gastroesophageal symptoms prevalence among their pool of patients was 37.6% for the total sample, reaching 70.3% among gastroenterologists. The medical specialty with lower average percentage of patients presenting gastroesophageal symptoms was otolaryngology (24.5%). Physicians reported that they request ancillary tests for 64.5% of patients with GERD typical symptoms. The most common diagnostic test was endoscopy (69.4%), followed by video nasolaryngoscopy (16.6%). The percentage of patient to whom endoscopy is performed was significantly higher among gastroenterologists and general practitioners as compared to otolaryngologists and cardiologists, while video nasolaryngoscopy is markedly more frequent among otolaryngologists. In terms of therapeutic options, the most frequently reported strategy was lifestyle modifications followed by proton pump inhibitors.

CONCLUSION

Overall patients' profile and patterns of GERD diagnosis and management seem different between gastroenterologists, general practitioners, otolaryngologists, and cardiologists. Clinical guidelines should address this variability and include other medical specialties besides gastroenterologists in their scope.

Sleeve gastrectomy with concomitant hiatal hernia repair in obese patients: long-term results on gastroesophageal reflux disease

BACKGROUND

Hiatal hernia repair (HHR) during Sleeve Gastrectomy (SG) is recommended when the defect is intraoperatively found; however, the long term effect on gastro-esophageal reflux disease (GERD) remains controversial.

OBJECTIVES

This study aimed to report long-term follow-up data, at least after 7 years, of SG with concomitant HHR and the outcome on GERD symptoms.

SETTING

Tertiary-care referral hospital.

METHODS

This study retrospectively analyzed 91 obese patients submitted to SG + HHR with a minimum of 7-years follow-up. The preoperative evaluation included GERD symptoms assessment by a standardized questionnaire, proton pump inhibitor usage evaluation, an upper gastrointestinal endoscopy, and a barium-swallow esophagogram to detect the presence of HH. At long-term follow-up visit, GERD assessment was performed to evaluate remission, persistence, or new onset of typical GERD symptoms; proton pump inhibitor usage was also investigated. Patients underwent barium-swallow esophagogram and/or upper gastrointestinal endoscopy.

RESULTS

At long-term evaluation, 2 of 91 patients (2.2%) were lost and 1 patient underwent Roux-en-Y gastric bypass. Of patients with preoperative GERD, 60% had GERD resolution; however, 27 of 88 (30.6%) patients reported postoperative GERD symptoms. Among these patients 15 (55.5%) showed the HH recurrence detected by barium-swallow esophagogram. All patients with HH recurrence had esophagitis and 1 case had a Barrett's esophagus. In the remaining 12 patients (44.4%) with postoperative GERD without HH recurrence, the barium-swallow esophagogram showed signs of reflux in reverse Trendelenburg.

CONCLUSIONS

At long-term follow-up HH recurrence was consistently related to the presence of GERD symptoms and to a high rate of esophagitis and Barrett's esophagus. In all patients with GERD symptoms after SG + HHR, a HH recurrence should be suspected and an upper gastrointestinal endoscopy strongly recommended to rule out esophagitis, and especially Barrett's esophagus.

Potential involvement of adiponectin in obesity-associated erosive esophagitis

A strong causal relationship between obesity and erosive esophagitis has been proposed. Obesity may affect the pathogenesis of erosive esophagitis through adipokines as well as acid reflux. We evaluated the involvement of adiponectin in obesity-associated erosive esophagitis. In total, 1,902 patients who underwent endoscopy during medical check-ups were selected for study. Variables including the body mass index (BMI) and adiponectin level were compared between subjects with erosive esophagitis and normal controls. The subjects were classified by quartiles (Qs) of adiponectin level. Q4 was the reference group. The median adiponectin level differed by gender (men, 5.3 µg/ml vs women, 9.3 µg/ml; p<0.001). As the severity of erosive esophagitis increased in men, the BMI increased (p<0.001) while the adiponectin level decreased (p = 0.026). The multivariate odds ratio for erosive esophagitis was 1.79 for Q1, 1.73 for Q2, 2.34 for obesity, and 27.40 for hiatal hernia in men. When classified by obesity, the multivariate odds ratio for erosive esophagitis was 1.94 for Q1, 2.10 for Q2, and 18.47 for hiatal hernia only in obese men. In women, there were no trends in BMI, adiponectin levels, or severity of erosive esophagitis. We demonstrated that low adiponectin levels are involved in obesity-associated erosive esophagitis in men but not women.

Surgical strategy for gastroesophageal reflux disease in patients with obesity

Gastroesophageal reflux disease (GERD) and obesity have become serious problems affecting global health. The surgical treatment strategy for GERD patients with obesity is still a difficult point. In particular, obesity exacerbates the occurrence of GERD, and simple anti-reflux surgery has limited efficacy in obese patients. Currently, bariatric surgery is a good choice for the treatment of such patients, and Roux-en-Y gastric bypass is the best choice. Revisional surgery remains to be standardized for serious complications in postoperative patients. In addition, the new anti-reflux bariatric surgery that has been emerging in recent years is expected to be an effective alternative treatment for GERD patients with obesity.

HISTORICAL PERSPECTIVE OF GASTROESOPHAGEAL REFLUX DISEASE CLINICAL TREATMENT

BACKGROUND

Gastroesophageal reflux disease (GERD) is one of the most prevalent gastrointestinal diseases. GERD generates significant impairment in patients' quality of life and it is associated to relevant medical resources utilization. A better understanding of GERD pathophysiology in the past five decades has favored the evolution of therapeutic strategies from non-drug interventions and antacids to more efficacious and safer alternatives.

OBJECTIVE

To summarize data about the historical evolution of GERD management in Brazil, focusing on medical therapy and addressing evidence on efficacy and safety of drug classes currently recommended.

METHODS

A narrative review was conducted by systematizing information about discoveries on GERD pathophysiology. We also addressed efficacy and safety of medications currently used to reduce symptoms and improve endoscopic healing of esophageal lesions. A structured search on Pubmed was performed to identify systematic reviews and meta-analysis investigating GERD outcomes positively impacted by proton pump inhibitors (PPIs), the first choice of pharmacotherapy for the disease.

RESULTS

The chronological development of therapeutic measures for GERD in Brazil evolved from lifestyle interventions with relative poor effect on symptoms related to esophageal acid exposure, particularly heartburn, to effective and safe pharmacological interventions such as histamine H2-receptor antagonists and PPIs. In the present days, some drug classes play a minor role in disease management, namely prokinetics and antacids, due to their reduced efficacy and relevant safety concerns (particularly with prokinetics). The main challenge for prescribers and researchers seems to be finding long-acting acid suppressants strategies able to ameliorate patients' symptoms and quality of life, thereafter, reducing medical resource consumption. The dual delayed-release PPI dexlansoprazole seems to respond for some of the limitations other PPIs have.

CONCLUSION

Recognizing the historical evolution of GERD management can help care providers to better understand therapeutic options for their patients, as well as focus on unmet needs that deserve further attention. PPIs are still the first choice therapy, with good evidence in favor of their efficacy, despite some safety concerns. However, as with any medical intervention, it is recommended to prescribe PPIs for patients with clear indication, using adequate dosing and monitoring for adverse events.

Gastroesophageal Reflux Disease in Obese Patients

Gastroesophageal reflux disease (GERD) and obesity coexist in many patients in the Western population. The association is not coincidental, since GERD pathophysiology is, in part, linked to obesity. Visceral adipose tissue secretes hormones, which increase the risk of GERD. Obesity increases esophageal motor disorders and higher number of transient lower esophageal sphincter relaxations. Central obesity increases abdominal-thoracic pressure gradient and disrupts the gastroesophageal junction by inducing hiatal hernia formation. Obese patients benefit from weight loss by diet to decrease GERD symptoms; however, Roux-en-Y gastric bypass surgery is associated with a higher weight loss and a decrease in GERD symptoms, and is considered the best way to treat both diseases at the same time.

A New Algorithm to Reduce the Incidence of Gastroesophageal Reflux Symptoms after Laparoscopic Sleeve Gastrectomy

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is one of the most prefered treatment option for morbid obesity. However, the effects of LSG on gastroesophageal reflux disease (GERD) are controversial. Asymptomatic GERD and hiatal hernia (HH) is common in obese patients. Therefore, it is important to identify the high risk patients prior to surgery. This study aims to evaluate efficacy of cruroplasty for HH during LSG in morbidly obese patients using ambulatory pH monitoring (APM) results, and to investigate the patients' selection criteria for this procedure.

METHODS

This retrospective study includes outcomes of 59 patients who underwent LSG and HH repair according to our patient selection algorithm. Outcomes included preoperative GERD Health-Related Quality of Life (GERD-HRQL) questionnaire, APM results, percentage of postoperative excess weight loss, and total weight loss.

RESULTS

For a total of 402 patients, APM was applied in 70 patients who had a positive score of GERD-HRQL, and 59 patients underwent LSG and concomitant HH repair who had a DeMeester score of 14.7% or above. There was no statistically significant difference in weight loss at 6 and 12-month follow-up. Two patients (3.3%) had symptoms of GERD at 12 months postoperatively, and only one (1.6%) patient required treatment of proton pump inhibitor for reflux. In the total cohort, 11 (2.7%) patients also evolved de novo GERD symptoms.

CONCLUSIONS

This study confirm that careful attention to patient selection and surgical technique can reduce the symptoms of GERD at short-term. Routine bilateral crus exploration could be a major risk factor of postoperative GERD.

Does hiatal repair affect gastroesophageal reflux symptoms in patients undergoing laparoscopic sleeve gastrectomy?

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has gained popularity as a treatment of choice for morbid obesity and associated comorbidities. There has been a concern about new onset or worsening of gastroesophageal reflux (GERD) following LSG.

OBJECTIVE

The objective of the study was to evaluate the effect of surgically treating hiatal weakness on GERD symptoms in patients undergoing LSG.

SETTING

Single tertiary referral institution, Sydney, Australia.

METHODS

A prospective observational cohort study was conducted with consecutive patients undergoing LSG. Hiatal findings, patient demographics, medications and reflux score were recorded prospectively. Patients were followed up post-operatively for a minimum of 12 months and assessed using GERD-HRQL score to quantify reflux symptoms.

RESULTS

Data from 100 patients with a minimum of 1-year follow-up were analysed. Mean follow-up was 18.9 months. Overall, GERD-HRQL improved from mean 4.5 ± 5.8 pre-operatively to 0.76 ± 1.5 after 18.9 months (p = 0.0001). For those with pre-operative reflux, GERD-HRQL improved from mean (SD) 8.43 ± 6.26 pre-operatively to 0.94 ± 1.55 (p = 0.0001). All the nine patients with troublesome daily reflux significantly improved. For those without pre-operative reflux, GERD-HRQL improved from 0.88 ± 1.37 to 0.47 ± 1.25 (p-ns) post-operatively. On multivariate analysis, higher pre-operative reflux and dysphagia/bloat scores, younger age and lower percentage excess weight loss after 18.9 months were associated with GERD-HRQL improvement.

CONCLUSION

In the medium term, GERD-HRQL improves following sleeve gastrectomy with meticulous hiatal assessment and repair of hiatal laxity and herniation.

Gastroesophageal reflux disease: A clinical overview for primary care physicians

OBJECTIVE

GERD is among the most common outpatient disease processes encountered by clinicians on a daily basis. This review provides insights about how to approach GERD in terms of disease management and treatment.

METHODS

Review articles were searched using PUBMED and MEDLINE using criteria that included English language articles published in the last 5 years concerning studies carried out only in humans. The key words used in the searches were GERD, PPI, and erosive esophagitis. Recommendations from the American College of Gastroenterology are also included in this manuscript.

RESULTS

The search resulted in ∼260 articles. The manuscript brings together and presents the results of recent recommendations from professional societies and recently published review articles on GERD.

CONCLUSION

GERD is one of the most common diagnoses made by gastroenterologists and primary care physicians. It is important to recognize the typical and atypical presentations of GERD. This paper helps primary care physicians understand the disease's pathophysiology, and when, how, and with what to treat GERD before referring patients to gastroenterologists or surgeons.

Symptoms, endoscopic findings and reflux monitoring results in candidates for bariatric surgery

BACKGROUND

Gastroesophageal reflux disease (GERD) is common in patients with obesity. Diagnosing GERD is important as bariatric operations have different influence on GERD. We assessed reflux symptoms and objective findings prior to surgery.

METHODS

Work-up included esophageal symptoms quantification by VAS-scores, esophagogastroduodenoscopy (EGD) and 24-h impedance-pH (imp-pH) monitoring off PPI therapy. Imp-pH was classified as abnormal if either %time pH<4 was abnormal, total number of reflux episodes was elevated or symptom index (SI) was positive.

RESULTS

Among 100 consecutive patients (68F, age 40±11years, BMI 44.9±6.9kg/m²) 54% reported heartburn and/or regurgitation, 71% had objective evidence of GERD (38% endoscopic lesions and 33% only abnormal imp-pH results). Imp-pH was superior to EGD in identifying GERD (sensitivity 85% vs. 54%, p<0.01). Symptomatic and asymptomatic patients had similar prevalence of esophageal lesions (37% vs. 39%) and abnormal imp-pH findings (68% vs. 50%). Sixty nine percent of patients with abnormal %time pH<4 had a normal number of reflux episodes.

CONCLUSION

Half of patients with obesity reported typical GERD symptoms and >70% had evidence of GERD. Poor acid clearance was the main mechanisms. Since typical reflux symptoms don't predict objective findings, endoscopy and reflux monitoring should be part of the surgery work-up especially before restrictive procedures.

Thoracic Imaging After Bariatric Surgery

Obesity and its association with long-term health problems constitutes one of the major challenges in medicine. Though diet regulation and exercise are the primary treatment strategies, surgery is the most reliable long-term solution. Although bariatric surgical complications continue to decline, prompt recognition is essential to optimize patient outcomes. Despite their relative rarity, it is important to recognize thoracic complications, as several of these can result in severe morbidity and mortality. This article describes common bariatric surgical procedures performed, their expected postoperative appearances, and intrathoracic complications.

Gastrointestinal Complications of Obesity

Obesity usually is associated with morbidity related to diabetes mellitus and cardiovascular diseases. However, there are many gastrointestinal and hepatic diseases for which obesity is the direct cause (eg, nonalcoholic fatty liver disease) or is a significant risk factor, such as reflux esophagitis and gallstones. When obesity is a risk factor, it may interact with other mechanisms and result in earlier presentation or complicated diseases. There are increased odds ratios or relative risks of several gastrointestinal complications of obesity: gastroesophageal reflux disease, erosive esophagitis, Barrett's esophagus, esophageal adenocarcinoma, erosive gastritis, gastric cancer, diarrhea, colonic diverticular disease, polyps, cancer, liver disease including nonalcoholic fatty liver disease, cirrhosis, hepatocellular carcinoma, gallstones, acute pancreatitis, and pancreatic cancer. Gastroenterologists are uniquely poised to participate in the multidisciplinary management of obesity as physicians caring for people with obesity-related diseases, in addition to their expertise in nutrition and endoscopic interventions.

Obesity-associated digestive cancers: A review of mechanisms and interventions

The prevalence of obesity has steadily increased over the past few decades. Previous studies suggest that obesity is an oncogenic factor and that over 20% of all cancers are obesity-related. Among such cancers, digestive system malignancies (including esophageal adenocarcinomas, colorectal cancers, and cancers of the gastric cardia, liver, and pancreas) are reported most frequently. While the 5-year survival rates of cancers of the breast and prostate are 90%, that rate is only 45% for digestive cancers. In this review, the mechanisms of obesity-associated digestive cancers are discussed, with an emphasis on obesity-related gene mutations, insulin and insulin-like growth factor signaling pathways, chronic inflammation, and altered adipokine levels. Evidence that these factors often function interdependently rather than independently in carcinogenesis is presented. Recommended interventions that may reduce the burden of obesity-associated digestive cancers, such as participation in physical activity, diet modulation, and calorie restriction, are also described.

Should bariatric surgery be performed in adolescents?

Adolescent obesity has markedly increased worldwide in both its extent and prevalence in recent decades and obesity prevention strategies are failing. As a result, effective treatment strategies are urgently needed. As behavioral and pharmacological treatment approaches have only moderate effects in severe obesity, bariatric surgery has begun to emerge as a treatment option. In this debate article, we offer arguments opposing and supporting bariatric surgery in the treatment of severe obesity in adolescents. Bariatric surgery has superior therapeutic outcomes with respect to weight loss and resolution of comorbid diseases over other existing treatments. However, long-term outcomes after bariatric surgery in adolescents are only just beginning to emerge. Furthermore, the procedures are generally considered irreversible, apart from gastric banding. Most importantly, not all adolescents seem to benefit greatly from bariatric surgery and we are not yet able to reliably identify those who stand to gain the greatest benefit. The authors agree that adolescent bariatric surgery should be offered exclusively within formal adolescent obesity programs, delivered by specialist multidisciplinary child/adolescent obesity teams, and within specialist centers, in order to optimize outcomes and minimize potential detrimental effects. Patients and their family/carers must be educated regarding the benefits and risks, potential side effects, expected changes in eating behavior and the lifelong requirement for regular medical follow-up after surgery. Before embarking upon a surgical treatment pathway in adolescents with severe obesity, it may also be beneficial to ensure compliance to treatment is demonstrated, in order to minimize the risk of nutritional deficiencies and associated potential complications.

The Quality of Care for Gastroesophageal Reflux Disease

Improving the quality of healthcare delivery is a cornerstone of modern medical care shared between all stakeholders. However, effectively improving quality requires both an understanding of the tenets of healthcare quality and how they relate to an individual disease process. This is especially important for common diseases, such as gastroesophageal reflux disease (GERD), where wide variations in practice exist. The high prevalence of GERD coupled with wide variation in clinical approach results in significant economic burden and poor quality of care. Thus, GERD serves as a useful framework to highlight the opportunities and current challenges of delivering high-quality care. In this article, we identify quality metrics in GERD and the areas in need of research to improve the quality of the management of GERD. Additionally, we suggest strategies for improvement as it relates to the proper diagnostic testing utilization and the decision-making process.

Cost-Utility Analysis of Bariatric Surgery in Italy: Results of Decision-Analytic Modelling

OBJECTIVE

To evaluate the cost-effectiveness of bariatric surgery in Italy from a third-party payer perspective over a medium-term (10 years) and a long-term (lifetime) horizon.

METHODS

A state-transition Markov model was developed, in which patients may experience surgery, post-surgery complications, diabetes mellitus type 2, cardiovascular diseases or die. Transition probabilities, costs, and utilities were obtained from the Italian and international literature. Three types of surgeries were considered: gastric bypass, sleeve gastrectomy, and adjustable gastric banding. A base-case analysis was performed for the population, the characteristics of which were obtained from surgery candidates in Italy.

RESULTS

In the base-case analysis, over 10 years, bariatric surgery led to cost increment of EUR 2,661 and generated additional 1.1 quality-adjusted life years (QALYs). Over a lifetime, surgery led to savings of EUR 8,649, additional 0.5 life years and 3.2 QALYs. Bariatric surgery was cost-effective at 10 years with an incremental cost-effectiveness ratio of EUR 2,412/QALY and dominant over conservative management over a lifetime.

CONCLUSION

In a comprehensive decision analytic model, a current mix of surgical methods for bariatric surgery was cost-effective at 10 years and cost-saving over the lifetime of the Italian patient cohort considered in this analysis.

Surgery for Gastroesophageal Reflux Disease in the Morbidly Obese Patient

The prevalence of gastroesophageal reflux disease (GERD) has mirrored the increase in obesity, and GERD is now recognized as an obesity-related comorbidity. There is growing evidence that obesity, specifically central obesity, is associated with the complications of chronic reflux, including erosive esophagitis, Barrett's esophagus, and esophageal adenocarcinoma. While fundoplication is effective in creating a competent gastroesophageal junction and controlling reflux in most patients, it is less effective in morbidly obese patients. In these patients a bariatric operation has the ability to correct both the obesity and the abnormal reflux. The Roux-en-Y gastric bypass is the preferred procedure.

Comparison of the Carlsson-Dent and GERD-Q questionnaires for gastroesophageal reflux disease symptom detection in a general population

INTRODUCTION

Gastroesophageal reflux disease (GERD) is an extremely common pathology in the general population and one of the main reasons for consultation in gastroenterology. There are different instruments for detecting its symptoms, but few studies comparing one tool with another have been conducted in Mexico.

AIMS

To compare the effectiveness of the Carlsson-Dent questionnaire (CDQ) and the GERD-Q questionnaire (GQQ) in detecting GERD symptoms in a general population.

MATERIALS AND METHODS

A prospective, descriptive, cross-sectional study was conducted on 220 individuals in an open population within the time frame of May-June 2015. The subjects were evaluated through the self-assessment CDQ and GQQ. The positive scores from the CDQ (≥ 4) were compared with those of the GQQ (≥ 8), to determine which of the two instruments more easily detected patients with GERD symptoms.

RESULTS

Fifty-seven percent of the patients were men and the mean patient age was 38.1 years. Fifty percent of the subjects presented with GERD symptoms with a positive score in at least one questionnaire; 45% had positive CDQ results and 23% had positive GQQ results. Fifty-seven percent of the patients with a positive CDQ score presented with overweight/obesity, as did 72% of the patients with a positive GQQ result. Finally, 20% of the individuals had positive results for reflux symptoms in both questionnaires.

CONCLUSIONS

There was a prevalence of GERD symptoms in 50% of the individuals studied from a general population. The GQQ detected a greater number of GERD symptoms in patients that presented with overweight/obesity and the CDQ was considered easier for patients to understand and answer. It is striking that there was only 20% agreement between the two questionnaires, suggesting that they may be useful for identifying GERD symptoms in different populations.

Dietary carbohydrate intake, insulin resistance and gastro-oesophageal reflux disease: a pilot study in European- and African-American obese women

BACKGROUND

Although obesity rates are higher in African-American than European-American women, gastro-oesophageal reflux disease (GERD) and its comorbidities are more prevalent in European-American women. A common denominator for increased adiposity, and consequent insulin resistance, is excess dietary macronutrient intake - which may promote greater prevalence and severity of GERD in women.

AIM

To investigate whether GERD is more robustly associated with dietary carbohydrate intake, particularly dietary simple carbohydrate intake, and insulin resistance in European-American women.

METHODS

About 144 obese women were assessed at baseline and 16 weeks after consuming a high-fat/low-carbohydrate diet. GERD diagnosis and medication usage was confirmed in medical records with symptoms and medications assessed weekly.

RESULTS

About 33.3% (N = 33) of European-American and 20.0% (N = 9) of African-American women had GERD at baseline. Total carbohydrate (r = 0.34, P < 0.001), sugars (r = 0.30, P = 0.005), glycaemic load (r = 0.34, P = 0.001) and HOMA_IR (r = 0.30, P = 0.004) were associated with GERD, but only in European-American women. In response to high-fat/low-carbohydrate diet, reduced intake of sugars was associated with reduced insulin resistance. By the end of diet week 10, all GERD symptoms and medication usage had resolved in all women.

CONCLUSIONS

GERD symptoms and medication usage was more prevalent in European-American women, for whom the relationships between dietary carbohydrate intake, insulin resistance and GERD were most significant. Nevertheless, high-fat/low-carbohydrate diet benefited all women with regard to reducing GERD symptoms and frequency of medication use.

Long-term pharmacotherapy considerations in the bariatric surgery patient

PURPOSE

Pharmacists' role in optimizing long-term pharmacotherapy for bariatric surgery patients is detailed.

SUMMARY

Bariatric surgery patients provide a difficult challenge in terms of many pharmacotherapy issues, especially in the chronic care setting, where data on long-term effects of bariatric surgery are limited. The most common procedures are Roux-en-Y gastric bypass (RYGB), adjustable gastric banding, and sleeve gastrectomy. Sleeve gastrectomy has become the most common procedure in the United States, primarily because it has less overall chronic malabsorption effects than RYGB. Pharmacotherapy management is complicated by rapid weight loss combined with a number of pharmacokinetic changes, such as decreased absorption of some medications due to altered gastrointestinal tract anatomy and potentially increased concentrations of some medications due to a decreased volume of distribution resulting from weight loss. Nutritional and metabolic supplementation are of the utmost importance in order to limit deficiencies that can lead to a number of conditions. Many chronic diseases, including hypertension, diabetes, gastroesophageal reflux disease, and urinary incontinence, are improved by bariatric surgery but require close monitoring to ensure the effectiveness of maintenance pharmacotherapy and avoidance of adverse effects. Psychotropic medication management is also an important pharmacotherapy concern, as evidenced by antidepressants being the most commonly used medication class among preoperative bariatric surgery patients.

CONCLUSION

Pharmacists have an increasing role in the chronic management of the bariatric surgery patient due to their knowledge of medication dosage forms and expertise in disease states affected by bariatric surgery.

Lifestyle Intervention in Gastroesophageal Reflux Disease

BACKGROUND & AIMS

Gastroesophageal reflux disease (GERD) affects up to 30% of adults in Western populations and is increasing in prevalence. GERD is associated with lifestyle factors, particularly obesity and tobacco smoking, which also threatens the patient's general health. GERD carries the risk of several adverse outcomes and there is widespread use of potent acid-inhibitors, which are associated with long-term adverse effects. The aim of this systematic review was to assess the role of lifestyle intervention in the treatment of GERD.

METHODS

Literature searches were performed in PubMed (from 1946), EMBASE (from 1980), and the Cochrane Library (no start date) to October 1, 2014. Meta-analyses, systematic reviews, randomized clinical trials (RCTs), and prospective observational studies were included.

RESULTS

Weight loss was followed by decreased time with esophageal acid exposure in 2 RCTs (from 5.6% to 3.7% and from 8.0% to 5.5%), and reduced reflux symptoms in prospective observational studies. Tobacco smoking cessation reduced reflux symptoms in normal-weight individuals in a large prospective cohort study (odds ratio, 5.67). In RCTs, late evening meals increased time with supine acid exposure compared with early meals (5.2% point change), and head-of-the-bed elevation decreased time with supine acid exposure compared with a flat position (from 21% to 15%).

CONCLUSIONS

Weight loss and tobacco smoking cessation should be recommended to GERD patients who are obese and smoke, respectively. Avoiding late evening meals and head-of-the-bed elevation is effective in nocturnal GERD.

Laparoscopic sleeve gastrectomy: More than a restrictive bariatric surgery procedure?

Sleeve gastrectomy (SG) is a restrictive bariatric surgery technique that was first used as part of restrictive horizontal gastrectomy in the original Scopinaro type biliopancreatic diversion. Its good results as a single technique have led to a rise in its use, and it is currently the second most performed technique worldwide. SG achieves clearly better results than other restrictive techniques and is comparable in some aspects to the Roux-en-Y gastric bypass, the current gold standard in bariatric surgery. These benefits have been associated with different pathophysiologic mechanisms unrelated to weight loss such as increased gastric emptying and intestinal transit, and activation of hormonal mechanisms such as increased GLP-1 hormone and decreased ghrelin. The aim of this review was to highlight the salient aspects of SG regarding its historical evolution, pathophysiologic mechanisms, main results, clinical applications and perioperative complications.

Stomach intestinal pylorus sparing surgery (SIPS) with laparoscopic fundoplication (LF): a new approach to gastroesophageal reflux disease (GERD) in the setting of morbid obesity

The increase in the prevalence of obesity and gastroesophageal reflux disease (GERD) has paralleled one another. Laparoscopic fundoplication (LF) (Nissen or Toupet) is a minimally invasive form of anti-reflux surgery. The duodenal switch is a highly effective weight loss surgery with a proven record of long term weight loss success. However, fundoplication alone does not give satisfactory results when used for GERD in morbidly obese patients. Here we present a novel approach combining stomach intestinal pylorus sparing surgery (SIPS) with LF for morbidly obese patients with GERD. The data from patients who underwent the SIPS procedure along with LF in past year was retrospectively analyzed. The variables collected were age, sex, height, weight, intra-operative and post-operative complications, length of stay, operative time, and estimated blood loss. All revisions were excluded. Descriptive statistics such as mean and standard deviation were used to analyze the data. The total sample size of the study was 5 patients, with a mean age of 59.6 ± 16.4 years, a mean weight of 292.1 ± 73.6 lbs., and a mean body mass index (BMI) of 43.4 ± 6.3. Weight loss patterns were the same as those without LF. All the 5 patients had resolution or improvement in their GERD symptoms within 6 months. SIPS with LF provides substantial and sustained weight loss and GERD resolution. Long term follow ups and further study on this novel surgical technique is recommended.

Impact of sleeve gastrectomy on gastroesophageal reflux disease in a morbidly obese population undergoing bariatric surgery

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has established popularity as a weight loss procedure based on its success. However, LSG's effect on gastroesophageal reflux disease (GERD) is unknown.

OBJECTIVES

To analyze the incidence of GERD after LSG and to compare the results in patients with preexisting and de novo GERD.

SETTING

Tertiary Medical center.

METHODS

The authors performed a retrospective review of primary LSG from 2005 to 2013 and compared patients with pre-existing and de novo GERD who underwent LSG.

RESULTS

A total of 919 patients underwent LSG. GERD was present in 38 (4%) of the LSG cohort. We identified 2 groups: Group A consisted of 25 (3%) patients with de novo GERD, and Group B consisted of 13 (1%) patients with pre-existing GERD. Diagnosis of GERD in both groups was determined by symptoms and history of proton pump inhibitor (PPI) treatment, upper gastrointestinal endoscopy, esophagogastroduodenoscopy, and pH manometry. In Group A, 1 (4%) patient was managed with over-the-counter drugs, 17 (68%) patients were treated with low-dose PPI, 6 (24%) patients were treated with high-dose PPI, and 1 (4%) patient was lost to follow-up. Group B consisted of 9 (69%) patients treated with low-dose PPI and 4 (31%) patients treated with high-dose PPI. Medical treatment failed in 4 patients (10.5%) who subsequently required conversion to laparoscopic Roux-en-Y gastric bypass (LRYGB). In Group A, 1 patient (4%) required LRYGB, and in Group B, 3 patients (23%) required LRYGB. The outcome of conversion for Group A was incomplete resolution of symptoms in the 1 patient, whereas in Group B, all 3 patients (100%) had complete resolution of GERD symptoms after LRYGB.

CONCLUSIONS

In this study, 3% of patients developed de novo GERD, but most responded to either low- or high-dose PPI, with 4% requiring conversion to LRYGB.

Laparoscopic Nissen fundoplication with gastric plication as a potential treatment of morbidly obese patients with GERD, first experience and results

BACKGROUND

Laparoscopic Nissen fundoplication is an effective treatment for gastroesophageal reflux disease (GERD). However, there is no consensus for the surgical treatment of GERD in morbidly obese patients.

METHODS

Twenty-five morbidly obese patients with GERD underwent our novel procedure, laparoscopic Nissen fundoplication with gastric plication (LNFGP), and were monitored for 6 to 18 months. Operative complication, weight loss, and GERD symptoms were monitored.

RESULTS

The study subjects consisted seven males and 18 females. The average age was 38.2 years (from 18 to 58), and the mean BMI was 37.9 kg/m(2) (from 31.5 to 56.4). The mean operative time was 145.6 min (from 105 to 190). All procedures were performed via laparoscopic surgery. Two patients (8%) displayed a major 30-day perioperative complication. The first patient had an acute leak on the second postoperative day. The patient received a laparoscopic revision sleeve gastrectomy and was discharged 5 days later after an uneventful recovery. Another patient developed an intra-abdominal abscess 3 weeks after surgery and received laparoscopic drainage and a revision sleeve gastrectomy. Upon follow-up, only four (16%) patients experienced occasional acid regurgitation symptoms; however, no anti-acid medication was required. A significant decrease in the prevalence of erosive esophagitis (80 vs. 17%) after LNFGP was observed. The mean weight loss was 9.7, 14.1, 17.9, and 18.1% at 1, 3, 6 and 12 months, respectively. The mean BMI decreased to 30.8 kg/m(2) 1 year post surgery with a mean body weight loss of 25 kg.

CONCLUSIONS

LNFGP appears to be an acceptable treatment option for treating GERD in morbidly obese patients who refuse Roux-en-Y gastric bypass. However, further study is indicated to verify this novel procedure.

Laparoscopic sleeve gastrectomy and gastroesophageal reflux disease: a systematic review and meta-analysis

BACKGROUND

The effect of sleeve gastrectomy (SG) on the prevalence of gastroesophageal reflux disease (GERD) remains unclear. We aimed to outline the currently available literature.

DATA SOURCES

All relevant databases were searched for publications examining the effect of laparoscopic SG on GERD. Primary outcome measure was change in prevalence of GERD symptoms, antireflux medication use, and esophageal function tests. Secondary outcomes were prevalence of new-onset GERD and esophagitis. Thirty-three articles were included. Eleven studies used questionnaires to assess changes in the prevalence of GERD symptoms, with a risk difference in prevalence of 4.3%. Eight studies used esophageal function tests, with paradoxical results. Pooled incidence of new-onset GERD symptoms was 20%, with a strong suggestion of heterogeneity. New-onset esophagitis ranged from 6.3% to 63.3%.

CONCLUSIONS

Because of high heterogeneity among available studies and paradoxical outcomes of objective esophageal function tests, the exact effect of laparoscopic SG on the prevalence of GERD remains unanswered. Surgeons should carefully evaluate preoperative GERD symptoms when choosing the proper bariatric technique.

Pathophysiological mechanisms linking obesity and esophageal adenocarcinoma

In recent decades there has been a dramatic rise in the incidence of esophageal adenocarcinoma (EAC) in the developed world. Over approximately the same period there has also been an increase in the prevalence of obesity. Obesity, especially visceral obesity, is an important independent risk factor for the development of gastro-esophageal reflux disease, Barrett’s esophagus and EAC. Although the simplest explanation is that this mediated by the mechanical effects of abdominal obesity promoting gastro-esophageal reflux, the epidemiological data suggest that the EAC-promoting effects are independent of reflux. Several, not mutually exclusive, mechanisms have been implicated, which may have different effects at various points along the reflux-Barrett’s-cancer pathway. These mechanisms include a reduction in the prevalence of Helicobacter pylori infection enhancing gastric acidity and possibly appetite by increasing gastric ghrelin secretion, induction of both low-grade systemic inflammation by factors secreted by adipose tissue and the metabolic syndrome with insulin-resistance. Obesity is associated with enhanced secretion of leptin and decreased secretion of adiponectin from adipose tissue and both increased leptin and decreased adiponectin have been shown to be independent risk factors for progression to EAC. Leptin and adiponectin have a set of mutually antagonistic actions on Barrett’s cells which appear to influence the progression of malignant behaviour. At present no drugs are of proven benefit to prevent obesity associated EAC. Roux-en-Y reconstruction is the preferred bariatric surgical option for weight loss in patients with reflux. Statins and aspirin may have chemopreventative effects and are indicated for their circulatory benefits.

The role of obesity in oesophageal cancer development

The incidence of oesophageal adenocarcinoma has increased dramatically in the developed world in the last half century. Over approximately the same period there has been an increase in the prevalence of obesity. Multiple epidemiological studies and meta-analyses have confirmed that obesity, especially abdominal, visceral obesity, is a risk factor for gastro-oesophageal reflux, Barrett's oesophagus and oesophageal adenocarcinoma. Although visceral obesity enhances gastro-oesophageal reflux, the available data also show that visceral obesity increases the risk of Barrett's oesophagus and adenocarcinoma via reflux-independent mechanisms. Several possible mechanisms could link obesity with the risk of oesophageal adenocarcinoma in addition to mechanical effects increasing reflux. These include reduced gastric Helicobacter pylori infection, altered intestinal microbiome, factors related to lifestyle, the metabolic syndrome and associated low-grade inflammation induced by obesity and the secretion of mediators by adipocytes which may directly influence the oesophageal epithelium. Of these adipocyte-derived mediators, increased leptin levels have been independently associated with progression to oesophageal adenocarcinoma and in laboratory studies leptin enhances malignant behaviours in cell lines. Adiponectin is also secreted by adipocytes and levels decline with obesity: decreased serum adiponectin levels are associated with malignant progression in Barrett's oesophagus and experimentally adiponectin exerts anticancer effects in Barrett's cell lines and inhibits growth factor signalling. At present there are no proven chemopreventative interventions that may reduce the incidence of obesity-associated oesophageal cancer: observational studies suggest that the combined use of a statin and aspirin or another cyclo-oxygenase inhibitor is associated with a significantly reduced cancer incidence in patients with Barrett's oesophagus.

Surgery for weight loss in adults

BACKGROUND

Bariatric (weight loss) surgery for obesity is considered when other treatments have failed. The effects of the available bariatric procedures compared with medical management and with each other are uncertain. This is an update of a Cochrane review first published in 2003 and most recently updated in 2009.

OBJECTIVES

To assess the effects of bariatric surgery for overweight and obesity, including the control of comorbidities.

SEARCH METHODS

Studies were obtained from searches of numerous databases, supplemented with searches of reference lists and consultation with experts in obesity research. Date of last search was November 2013.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing surgical interventions with non-surgical management of obesity or overweight or comparing different surgical procedures.

DATA COLLECTION AND ANALYSIS

Data were extracted by one review author and checked by a second review author. Two review authors independently assessed risk of bias and evaluated overall study quality utilising the GRADE instrument.

MAIN RESULTS

Twenty-two trials with 1798 participants were included; sample sizes ranged from 15 to 250. Most studies followed participants for 12, 24 or 36 months; the longest follow-up was 10 years. The risk of bias across all domains of most trials was uncertain; just one was judged to have adequate allocation concealment.All seven RCTs comparing surgery with non-surgical interventions found benefits of surgery on measures of weight change at one to two years follow-up. Improvements for some aspects of health-related quality of life (QoL) (two RCTs) and diabetes (five RCTs) were also found. The overall quality of the evidence was moderate. Five studies reported data on mortality, no deaths occurred. Serious adverse events (SAEs) were reported in four studies and ranged from 0% to 37% in the surgery groups and 0% to 25% in the no surgery groups. Between 2% and 13% of participants required reoperations in the five studies that reported these data.Three RCTs found that laparoscopic Roux-en-Y gastric bypass (L)(RYGB) achieved significantly greater weight loss and body mass index (BMI) reduction up to five years after surgery compared with laparoscopic adjustable gastric banding (LAGB). Mean end-of-study BMI was lower following LRYGB compared with LAGB: mean difference (MD) -5.2 kg/m² (95% confidence interval (CI) -6.4 to -4.0; P < 0.00001; 265 participants; 3 trials; moderate quality evidence). Evidence for QoL and comorbidities was very low quality. The LRGYB procedure resulted in greater duration of hospitalisation in two RCTs (4/3.1 versus 2/1.5 days) and a greater number of late major complications (26.1% versus 11.6%) in one RCT. In one RCT the LAGB required high rates of reoperation for band removal (9 patients, 40.9%).Open RYGB, LRYGB and laparoscopic sleeve gastrectomy (LSG) led to losses of weight and/or BMI but there was no consistent picture as to which procedure was better or worse in the seven included trials. MD was -0.2 kg/m² (95% CI -1.8 to 1.3); 353 participants; 6 trials; low quality evidence) in favour of LRYGB.  No statistically significant differences in QoL were found (one RCT). Six RCTs reported mortality; one death occurred following LRYGB. SAEs were reported by one RCT and were higher in the LRYGB group (4.5%) than the LSG group (0.9%). Reoperations ranged from 6.7% to 24% in the LRYGB group and 3.3% to 34% in the LSG group. Effects on comorbidities, complications and additional surgical procedures were neutral, except gastro-oesophageal reflux disease improved following LRYGB (one RCT). One RCT of people with a BMI 25 to 35 and type 2 diabetes found laparoscopic mini-gastric bypass resulted in greater weight loss and improvement of diabetes compared with LSG, and had similar levels of complications.Two RCTs found that biliopancreatic diversion with duodenal switch (BDDS) resulted in greater weight loss than RYGB in morbidly obese patients. End-of-study mean BMI loss was greater following BDDS: MD -7.3 kg/m² (95% CI -9.3 to -5.4); P < 0.00001; 107 participants; 2 trials; moderate quality evidence). QoL was similar on most domains. In one study between 82% to 100% of participants with diabetes had a HbA1c of less than 5% three years after surgery. Reoperations were higher in the BDDS group (16.1% to 27.6%) than the LRYGB group (4.3% to 8.3%). One death occurred in the BDDS group.One RCT comparing laparoscopic duodenojejunal bypass with sleeve gastrectomy versus LRYGB found BMI, excess weight loss, and rates of remission of diabetes and hypertension were similar at 12 months follow-up (very low quality evidence). QoL, SAEs and reoperation rates were not reported. No deaths occurred in either group.One RCT comparing laparoscopic isolated sleeve gastrectomy (LISG) versus LAGB found greater improvement in weight-loss outcomes following LISG at three years follow-up (very low quality evidence). QoL, mortality and SAEs were not reported. Reoperations occurred in 20% of the LAGB group and in 10% of the LISG group.One RCT (unpublished) comparing laparoscopic gastric imbrication with LSG found no statistically significant difference in weight loss between groups (very low quality evidence).  QoL and comorbidities were not reported. No deaths occurred. Two participants in the gastric imbrication group required reoperation.

AUTHORS' CONCLUSIONS

Surgery results in greater improvement in weight loss outcomes and weight associated comorbidities compared with non-surgical interventions, regardless of the type of procedures used. When compared with each other, certain procedures resulted in greater weight loss and improvements in comorbidities than others. Outcomes were similar between RYGB and sleeve gastrectomy, and both of these procedures had better outcomes than adjustable gastric banding. For people with very high BMI, biliopancreatic diversion with duodenal switch resulted in greater weight loss than RYGB. Duodenojejunal bypass with sleeve gastrectomy and laparoscopic RYGB had similar outcomes, however this is based on one small trial. Isolated sleeve gastrectomy led to better weight-loss outcomes than adjustable gastric banding after three years follow-up. This was based on one trial only.  Weight-related outcomes were similar between laparoscopic gastric imbrication and laparoscopic sleeve gastrectomy in one trial. Across all studies adverse event rates and reoperation rates were generally poorly reported. Most trials followed participants for only one or two years, therefore the long-term effects of surgery remain unclear.

Gastro-oesophageal reflux disease and obesity: pathogenesis and response to treatment

The link between obesity and GERD is clear on all measures of the disease: clinical symptoms, erosive oesophagitis, acid esophageal exposure, and complications. The pathogenesis of this link may be due to general factors such as visceral adiposity, oestrogen levels, or decrease of Helicobacter pylori infection with increased gastric acid secretion. Increased abdominal pressure leads to disruption of the esophago-gastric junction and hiatal hernia, and esophageal motility may be modified by obesity. Weight loss does improve GERD, but lifestyle modifications and diet are usually insufficient in the long-term for morbid obesity. GERD and hiatal hernia are key issues in bariatric surgery, and are widely discussed because of important implications. It is not currently certain which procedure should be favoured in case of GERD; yet gastric bypass offers the best guarantee of success. Hiatal hernia repair is also deemed necessary by some authors at the same time of the bariatric surgery. Minimally invasive techniques pose a new challenge to this issue, both technically and theoretically.

Complications of bariatric surgery: dumping syndrome, reflux and vitamin deficiencies

Bariatric surgical procedure are increasingly and successfully applied in the treatment of morbid obesity. Nevertheless, these procedures are not devoid of potential long-term complications. Dumping syndrome may occur after procedures involving at least partial gastric resection or bypass, including Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy. Diagnosis is based on clinical alertness and glucose tolerance testing. Treatment may involve dietary measures, acarbose and somatostatin analogues, or surgical reintervention for refractory cases. Gastro-esophageal reflux disease (GERD) can be aggravated by vertical banded gastroplasty and sleeve gastrectomy procedures, but pre-existing GERD may improve after RYGB and with adjustable gastric banding. Nutrient deficiencies constitute the most important long-term complications of bariatric interventions, as they may lead to haematological, metabolic and especially neurological disorders which are not always reversible. Malabsorptive procedures, poor postoperative nutrient intake, recurrent vomiting and poor compliance with vitamin supplement intake and regular follow-up are important risk factors. Preoperative nutritional assessment and rigourous postoperative follow-up plan with administration of multi-vitamin supplements and assessment of serum levels is recommended in all patients.

Outcome of sleeve gastrectomy as a primary bariatric procedure

BACKGROUND

Sleeve gastrectomy is being performed increasingly in Europe. Data on long-term outcome would be helpful in defining the role of sleeve gastrectomy. The aim of this study was to evaluate the outcome of sleeve gastrectomy as a primary bariatric procedure.

METHODS

Medical charts of all patients who underwent a primary sleeve gastrectomy at the authors' institution between August 2006 and December 2012 were reviewed retrospectively using a prospective online data registry. For evolution of weight loss and co-morbidity, only patients with follow-up of at least 1 year were included. A subgroup analysis was done to compare patients with an intended stand-alone procedure and those with an intended two-stage procedure.

RESULTS

A total of 1041 primary sleeve gastrectomies were performed in the study period. Median duration of surgery was 47 min, and median hospital stay was 2 days. Intra-abdominal bleeding occurred in 27 patients (2·6 per cent) and staple-line leakage in 24 (2.3 per cent). Some 866 patients had at least 1 year of follow-up. Mean excess weight loss was 68.4 per cent after 1 year (P < 0.001) and 67.4 per cent after 2 years. Smaller groups of patients achieved a mean excess weight loss of 69.3 per cent (163 patients), 70.5 per cent (62) and 58.3 per cent (19) after 3, 4 and 5 years respectively. No difference in postoperative complications was found between the subgroups. Seventy-one (8.2 per cent) of 866 patients had a revision of the sleeve gastrectomy; reflux or dysphagia was the indication in 34 (48 per cent) of these patients.

CONCLUSION

Sleeve gastrectomy is a safe and effective bariatric procedure. Maximum weight loss was achieved after 4 years. Long-term results regarding weight loss and co-morbidities were satisfactory.