Gastroesophageal reflux in obesity: the effect of lap-band placement

The Effect of Bariatric Surgery and Endoscopic Procedures on Gastroesophageal Reflux Disease

Obesity is a global epidemic posing a significant burden on patients and healthcare systems. Gastroesophageal reflux disease is associated with obesity and its prevalence is also growing worldwide. Numerous bariatric surgeries and endoscopic procedures have arisen to assist with weight loss and management of obesity-related conditions. However, the effect of these interventions on reflux is variable and the evidence is often conflicting. To date, Roux-en-Y gastric bypass remains the gold-standard for attaining both reflux and weight loss management, however novel endoscopic techniques are quickly becoming more prevalent as an alternative to surgery. This review aims to summarize currently available endoscopic and surgical weight loss procedures and their impact on reflux symptoms while emphasizing areas requiring additional investigation.

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.

The Physiology and Pathophysiology of Gastroesophageal Reflux in Patients with Laparoscopic Adjustable Gastric Band

INTRODUCTION

The effect of the laparoscopic adjustable gastric band (LAGB) on esophageal acid exposure and reflux is poorly understood. Optimal technique and normative values for acid exposure have not been established in this group.

METHODS

High-resolution manometry (HRM) and 24-h ambulatory esophageal pH monitoring were performed in three groups: asymptomatic LAGB, symptomatic LAGB, and pre-operative reflux patients. This technique utilized intraluminal pressure signatures during HRM to guide accurate pH sensor placement.

RESULTS

The LAGB groups were well matched: age 48 vs 51 years (p = 0.249), weight loss 27.3 vs 26.7 kg (p = 0.911). The symptomatic group had a larger gastric pouch (5.2 vs 3.3 cm, p = 0.012), with higher esophageal acid exposure (10.8 vs 0.9%, p < 0.001). Two acidification patterns were observed: irritant and volume acidification, associated with substantial supine acidification. Symptomatic LAGB had altered esophageal motility, with poorer lower esophageal sphincter basal tone (8.0 vs 17.7 mmHg, p = 0.022) and impaired contractility of the lower esophageal segment (90 vs 40%, p = 0.009). Compared to pre-operative reflux patients, symptomatic LAGB patients demonstrated higher total and supine esophageal acid exposure (10.8 vs 7.0%, p = 0.010; 14.9 vs 5.1%, p < 0.001), less symptoms (2 vs 6, p = 0.001) and lower symptom index (0.7 vs 0.9, p = 0.010).

CONCLUSIONS

Ambulatory pH monitoring is an effective technique if the pH sensor is positioned appropriately using HRM. The correctly positioned LAGB appears associated with low esophageal acidification. In contrast, patients with symptoms or pouch dilatation can have markedly elevated esophageal acidification, particularly when supine. This is a different pattern compared to pre-operative patients and importantly can be disproportionate to symptoms.

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

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

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.

Effect of morbid obesity, gastric banding and gastric bypass on esophageal symptoms, mucosa and function

BACKGROUND

Obesity and gastroesophageal reflux disease (GERD) are commonly associated diseases. Bariatric surgery has been shown to have various impacts on esophageal function and GERD. Our aim was to evaluate changes in symptoms, endoscopic findings, bolus passage and esophageal function in patients after primary gastric bypass surgery as compared to patients converted from gastric banding to gastric bypass.

METHODS

Obese patients scheduled for laparoscopic Roux-en-Y gastric bypass (naïve-to-bypass) and patients who previously underwent gastric banding and were considered for conversion from gastric banding to gastric bypass (band-to-bypass) were included. Patients rated esophageal and epigastric symptoms (100 point VAS) and underwent upper endoscopy, impedance-manometry, and modified "timed barium swallow" before/after surgery.

RESULTS

Data from 66 naïve-to-bypass patients (51/66, 77 % females, mean age 41.2 ± 11.1 years) and 68 band-to-bypass patients (53/68, 78 % females, mean age 43.8 ± 10.0 years) were available for analysis. Esophageal symptoms, esophagitis, esophageal motility abnormalities and impaired esophageal bolus transit were more common in patients that underwent gastric banding compared to those that underwent gastric bypass. The majority of symptoms, lesions and abnormalities induced by gastric banding were decreased by conversion to gastric bypass. Esophagitis was present in 28/68 (41 %) and 13/47 (28 %) patients in the band-to-bypass group, pre- versus postoperatively, respectively, (p < 0.05). The percentage of swallows with normal bolus transit increased following transformation from gastric band to gastric bypass (57.9 ± 4.1 and 83.6 ± 3.4 %, respectively, p < 0.01).

CONCLUSIONS

From an esophageal perspective, gastric bypass surgery induces less motility disorders and esophageal symptoms and should be therefore favored over gastric banding in difficult to treat obese patients at risk of repeated 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.

Impact of obesity treatment on gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a frequently encountered disorder. Obesity is an important risk factor for GERD, and there are several pathophysiologic mechanisms linking the two conditions. For obese patients with GERD, much of the treatment effort is focused on weight loss and its consistent benefit to symptoms, while there is a relative lack of evidence regarding outcomes after novel or even standard medical therapy is offered to this population. Physicians are hesitant to recommend operative anti-reflux therapy to obese patients due to the potentially higher risks and decreased efficacy, and these patients instead are often considered for bariatric surgery. Bariatric surgical approaches are broadening, and each technique has emerging evidence regarding its effect on both the risk and outcome of GERD. Furthermore, combined anti-reflux and bariatric options are now being offered to obese patients with GERD. However, currently Roux-en-Y gastric bypass remains the most effective surgical treatment option in this population, due to its consistent benefits in both weight loss and GERD itself. This article aims to review the impact of both conservative and aggressive approaches of obesity treatment on GERD.

Laparoscopic adjustable gastric banding outcomes in patients with gastroesophageal reflux disease or hiatal hernia

BACKGROUND

Gastroesophageal reflux disease (GERD) and hiatal hernia (HH) are classically considered contraindications to bariatric restrictive procedures. Despite the high number of studies that have been published, the relationship between laparoscopic adjustable gastric banding (LAGB) and GERD/HH is still not clear.

METHODS

We have retrospectively analyzed the outcomes of LAGB in patients operated in 2010 with HH and/or GERD. The gastroesophageal reflux was diagnosed if the patients had heartburn and regurgitation more than once a week, and hiatal hernia was assessed by esophagogastroduodenoscopy and/or upper GI radiogram with swallow. Data on heartburn, assumption of antacid medication, weight loss, and rate of complications in both patients with and without GERD or HH were collected.

RESULTS

One hundred and twenty patients that underwent LAGB at our department were enrolled in our study; 40 had symptoms of GERD and 25 had hiatal hernia preoperatively. There was no difference of percentage excess weight loss (%EWL) at 12 months (45.4 ± 20.4 vs 4.6 ± 19.5 kg/m(2)) and 36 months follow-up (49.4 ± 16.5 vs 48.6 ± 18.9 kg/m(2)) between asymptomatic patients and patients with HH or GERD symptoms. The number of patients with preoperative heartburn (40 to 10) and/or assumption of antacid drugs (38 to 7) significantly decreased after LAGB CONCLUSIONS: LAGB is an effective and safe surgical treatment for morbidly obesity in patients with GERD or HH, since it induces both a significant weight loss and an improvement of reflux symptoms.

Gastroesophageal reflux disease in the obese: Pathophysiology and treatment

Obesity is a condition that has increased all over the world in the last 3 decades. Overweight and gastroesophageal reflux disease (GERD) are related. GERD may have different causative factors in the obese compared with lean individuals. This review focuses on the proper treatment for GERD in the obese based on its pathophysiology. Increased abdominal pressure may play a more significant role in obese subjects with GERD than the defective esophagogastric barrier usually found in nonobese individuals. A fundoplication may be used to treat GERD in these individuals; however, outcomes may be not as good as in nonobese patients and it does not act on the pathophysiology of the disease. All bariatric techniques may ameliorate GERD symptoms owing to a decrease in abdominal pressure secondary to weight loss. However, some operations may lead to a disruption of natural anatomic antireflux mechanisms or even lead to slow gastric emptying and/or esophageal clearance and thus be a refluxogenic procedure. Roux-en-Y gastric bypass decreases both acid and bile reflux from the stomach into the esophagus. On the other hand, gastric banding is a refluxogenic operation, and sleeve gastrectomy may show different outcomes based on the anatomy of the gastric tube.

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.

Lifestyle measures in the management of gastro-oesophageal reflux disease: clinical and pathophysiological considerations

Several lifestyle and dietary factors are commonly cited as risk factors for gastro-oesophageal reflux disease (GORD) and modification of these factors has been advocated as first-line measures for the management of GORD. We performed a systematic review of the literature from 2005 to the present relating to the effect of these factors and their modification on GORD symptoms, physiological parameters of reflux as well as endoscopic appearances. Conflicting results existed for the association between smoking, alcohol and various dietary factors in the development of GORD. These equivocal findings are partly due to methodology problems. There is recent good evidence that weight reduction and smoking cessation are beneficial in reducing GORD symptoms. Clinical and physiological studies also suggest that some physical measures as well as modification of meal size and timing can also be beneficial. However, there is limited evidence for the role of avoiding alcohol and certain dietary ingredients including carbonated drinks, caffeine, fat, spicy foods, chocolate and mint.

Trans-thoracic peri-oesophageal adjustable band for intractable reflux

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Laparoscopic adjustable gastric bands improve symptoms of reflux.

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Adjustable band placed via trans-thoracic approach due to hostile abdomen.

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Peri-oesophageal band for reflux.

Introduction

Gastric bands for obesity have the beneficial side-effect of improving reflux symptoms in patients; however placement of these on patients with multiple prior abdominal surgeries can be challenging.

Presentation of case

We present two cases where gastric bands were placed in a peri-oesophageal position via a left thoracotomy due to multiple previous abdominal surgeries in an attempt to treat their intractable reflux.

Discussion

At three month follow up, both patients have reported improvement in their symptoms of GORD.

Conclusion

A peri-oesophageal position adjustable gastric band is a possible solution for patients with intractable reflux and hostile abdomens.

Interventions to improve long-term weight loss in patients following bariatric surgery: challenges and solutions

Bariatric surgery aims to provide long-term weight loss and improvement in weight-related comorbidities. Unfortunately, some patients do not achieve predicted weight loss targets and many regain a portion of their lost weight within 2-10 years postsurgery. A review of the literature found that behavioral, dietary, psychological, physical, and medical considerations can all play a role in suboptimal long-term weight loss. Recommendations to optimize long-term weight loss include ensuring that the patient understands how the procedure works, preoperative and postoperative education sessions, tailored nutritional supplements, restraint with liquid kilojoules, pureed foods, grazing and eating out of the home, an average of 60 minutes of physical activity per day, and lifelong annual medical, psychological, and dietary assessments.

Obesity does not affect the outcome of laparoscopic antireflux surgery

BACKGROUND

Obesity has been reported to adversely affect the outcome of laparoscopic antireflux surgery (LARS). This study examined pre- and postoperative clinical and objective outcomes and quality of life in obese and normal-weight patients following LARS at a specialized centre.

METHODS

Prospective data from patients subjected to LARS (Nissen or Toupet fundoplication) for symptomatic gastroesophageal reflux disease in the General Public Hospital of Zell am See were analyzed. Patients were divided in two groups: normal weight [body mass index (BMI) 20-25 kg/m(2)] and obese (BMI ≥ 30 kg/m(2)). Gastrointestinal quality of life index (GIQLI), symptom grading, esophageal manometry and multichannel intraluminal impedance monitoring data were documented and compared preoperatively and at 1 year postoperatively.

RESULT

The study cohort included forty normal-weight and forty obese patients. Mean follow-up was 14.7 ± 2.4 months. The mean GIQLI improved significantly after surgery in both groups (p < 0.001, for both). Clinical outcomes improved following surgery regardless of BMI. There were significant improvements of typical and atypical reflux symptoms in normal weight and obese (p = 0.007; p = 0.006, respectively), but no difference in gas bloat and bowel dysfunction symptoms could be found. No intra- or perioperative complications occurred. A total of six patients had to be reoperated (7.5 %), two (5 %) in the obese group and four (10 %) in the normal-weight group, because of recurrent hiatal hernia and slipping of the wrap or persistent dysphagia due to closure of the wrap.

CONCLUSION

Obesity is not associated with a poorer clinical and objective outcome after LARS. Increased BMI seems not to be a risk factor for recurrent symptomatology and reoperation.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Improvement in gastroesophageal reflux disease symptoms after various bariatric procedures: review of the Bariatric Outcomes Longitudinal Database

BACKGROUND

The prevalence of gastroesophageal reflux disease (GERD) in the morbidly obese population is as high as 45%. The objective of this study was to compare the efficacy of various bariatric procedures in the improvement of GERD.

METHODS

The Bariatric Outcomes Longitudinal Database is a prospective database of patients who undergo bariatric surgery by a participant in the American Society of Metabolic and Bariatric Surgery Center of Excellence program. GERD is graded on a 6-point scale, from 0 (no history of GERD) to 5 (prior surgery for GERD). Patients with GERD severe enough to require medications (grades 2, 3, and 4) from June 2007 to December 2009 are identified; the resolution of GERD is noted based on 6-month follow-up.

RESULTS

Of a total of 116,136 patients, 36,938 patients had evidence of GERD preoperatively. After excluding patients undergoing concomitant hiatal hernia repair or fundoplication, there were 22,870 patients with 6-month follow-up. Mean age was 47.6±11.1 years, with an 82% female population. Mean BMI was 46.3±8.0 kg/m(2). Mean preoperative GERD score for patients with Roux-en-Y gastric bypass (RYGB) was 2.80±.56, and mean postoperative score was 1.33±1.41 (P<.0001). Similarly, adjustable gastric banding (AGB, 2.77±.57 to 1.63±1.37, P<.0001) and sleeve gastrectomy (SG, 2.82±.57 to 1.85±1.40, P<.0001) had significant improvement in GERD score. GERD score improvement was best in RYGB patients (56.5%; 7955 of 14,078) followed by AGB (46%; 3773 of 8207) and SG patients (41%; 240 of 585).

CONCLUSION

All common bariatric procedures improve GERD. Roux-en-Y gastric bypass is superior to adjustable gastric banding and sleeve gastrectomy in improving GERD. Also, the greater the loss in excess weight, the greater the improvement in GERD score.

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.

Effect of adjustable gastric banding on changes in gastroesophageal reflux disease (GERD) and quality of life

OBJECTIVE

Bariatric surgery is an effective treatment for the reduction of weight in obese patients (BMI ≥ 40 kg/m(2) or 30 kg/m(2) with ≥1 comorbidities), who are refractory to behavioral and medical therapies. This study examined the effect of the adjustable gastric band (AGB) system on changes in gastroesophageal reflux disease (GERD) and patient-reported outcomes, including measures of quality of life.

METHODS

Two-year interim analysis of patients (N = 171) in the 5 year, prospective APEX study who reported GERD prior to the AGB procedure. An unrecorded number of hiatal hernia repairs were conducted during the APEX study.

RESULTS

At baseline, 171 of 395 patients (43%) reported GERD requiring daily medical therapy. After 2 years, 122 patients had sufficient data to assess outcome (71%). Complete resolution of GERD was reported in 98 patients (80%), improvement in 13 (11%), no change in 9 (7%), and worsening in 2 (2%). Overall, 91% of GERD patients experienced resolution and/or improvement of GERD. Baseline BMI was not significantly different among the GERD response categories (resolved, improved, and stable/worse), p = 0.4581. Mean ΔBMI and percentage excess weight loss (%EWL) were: -8.8 kg/m(2)/-0.9%, -11.4 kg/m(2)/-53.9%, -6.4 kg/m(2)/-36.1%, and -7.1 kg/m(2)/-31.2%, respectively. There were no significant differences in reductions in BMI or %EWL between responder groups (resolved versus stable/worse ΔBMI p = 0.1031, %EWL p = 0.0667 OR resolved/improved versus stable/worse ΔBMI p = 0.0918, %EWL p = 0.0552). After 2 years, resolution or improvement occurred in pre-existing comorbidities: type 2 diabetes (96%), hypertension (91%), hyperlipidemia (77%), obstructive sleep apnea (86%), osteoarthritis (93%), and depression (75%). Patient satisfaction with AGB was assessed as: very satisfied/satisfied (87%), very satisfied (50%), dissatisfied (5.0%). Quality of life measured by the Obesity and Weight-Loss Quality of Life Instrument (GERD patients) significantly improved from baseline.

CONCLUSION

Obese patients with GERD had meaningful improvement in patient-reported outcomes with the AGB system. In addition, other obesity-related comorbidities and measures of quality of life improved.

Obesity and GERD: pathophysiology and effect of bariatric surgery

Epidemiologic, endoscopic, and pathophysiologic studies document the relationship between obesity and gastroesophageal reflux disease (GERD). Increased body mass index and accumulation of visceral fat are associated with a two- to threefold increased risk of developing reflux symptoms and esophageal lesions. Given this association, many studies were designed to evaluate the outcome of reflux symptoms following conventional and surgical treatment of obesity. Among bariatric procedures, gastric sleeve and banded gastroplasty were shown to have no effect or even worsen reflux symptoms in the postoperative setting. Gastric banding improves reflux symptoms and findings (endoscopic and pH-measured distal esophageal acid exposure) in many patients, but is associated with de novo reflux symptoms or lesions in a considerable proportion of patients. To date, Roux-en-Y gastric bypass is the most effective bariatric procedure that consistently leads to weight reduction and improvement of GERD symptoms in patients undergoing direct gastric bypass and among those converted from restrictive bariatric procedures to gastric bypass.

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.

Management of the obese patient with gastroesophageal reflux disease

Obesity and gastroesophageal reflux disease (GERD) are common chronic illnesses. They often coexist and need to be treated concomitantly. Fundoplication may be effective for the short-term control of GERD in the obese patient; however, this procedure does not induce weight loss or treat the comorbid conditions related to obesity. Roux-en-Y gastric bypass is a highly effective treatment of GERD, obesity, and the associated comorbidities. Surgeons who are not comfortable with a bariatric surgical procedure in these patients should either complete appropriate advanced training in bariatric surgery or refer those patients to a qualified surgeon who can offer these options.

BARIATRIC SURGERY IN PREGNANCY: BENEFITS, RISKS AND OBSTETRIC MANAGEMENT

Obesity is a growing problem in obstetric practice. A recent study from Glasgow (UK) showed that 50% of women of childbearing age are either overweight (Body Mass Index [BMI] = 24.9–29.9kg/m2) or obese with 18% starting pregnancy as obese. Obesity prevalence has doubled over a decade from the early 1990’s. In the US it is estimated that 30% of reproductive-age women have a BMI greater than 30 kg/m while 7% have a BMI > 40 kg/m2. A recent report from the UK found that 5% of women had a BMI >35 kg/m2, 2% > 40 kg/m2 and 0.2% >50 kg/m2 with an association not only with social deprivation, but also with a higher prevalence of pre-existing medical disorders such as diabetes and hypertension and medical complications of pregnancy such as preeclampsia. Obesity was also associated with increased rates of macrosomia, operative delivery and postpartum haemorrhage. These data highlight the fact that obesity is an increasing health concern particularly in young women of childbearing age. Obesity will expose them to significant pregnancy complications ranging from miscarriage and fetal abnormality through to operative delivery and thromboembolism. There are also challenges for the delivery of maternity care to meet the needs of these women. As obesity is associated with significant pregnancy complications it is important that women enter pregnancy with an optimum body weight. Many complications, such as fetal abnormality occur in the first trimester and so pre-pregnancy weight reduction is preferred. Further, there is insufficient evidence to recommend specific dietary and/or physical activity interventions to reduce weight or moderate weight gain during pregnancy.

Gastroesophageal reflux disease and severe obesity: Fundoplication or bariatric surgery?

Increases in the prevalence of obesity and gastroesophageal reflux disease (GERD) have paralleled one another over the past decade, which suggests the possibility of a linkage between these two processes. In both instances, surgical therapy is recognized as the most effective treatment for severe, refractory disease. Current surgical therapies for severe obesity include (in descending frequency) Roux-en-Y gastric bypass, adjustable gastric banding, sleeve gastrectomy, and biliopancreatic diversion with duodenal switch, while fundoplication remains the mainstay for the treatment of severe GERD. In several large series, however, the outcomes and durability of fundoplication in the setting of severe obesity are not as good as those in patients who are not severely obese. As such, bariatric surgery has been suggested as a potential alternative treatment for these patients. This article reviews current concepts in the putative pathophysiological mechanisms by which obesity contributes to gastroesophageal reflux and their implications with regards to surgical therapy for GERD in the setting of severe obesity.

Bariatric surgery: mechanisms, indications and outcomes

The rising problem of obesity is causing major health problems, reduced quality of life and reduced life expectancy. It now generates approximately 10% of all health costs. The progression of the problem indicates preventive measures have been unsuccessful so far. Only bariatric surgical treatments have been able to achieve substantial and durable weight loss. Gastric banding and gastric bypass are used in more than 90% of bariatric operations. The proportion of each varies from greater than 95% bands in Australia, about 50/50 in Europe and USA and nearly 100% bypass in South America. The availability of follow up is a prime determinant of choice. Understanding the mechanisms of effect for the bariatric procedures is central to optimizing their effect. The traditional narrow concepts of restrictive (blocking the transit of food) and malabsorptive (preventing the absorption of food) should be discarded and the importance of induction of satiety, change of taste, diversion of chyme, neural and hormonal mediation and the effects of aversion need to be included. The primary mechanism of effect for gastric banding is the generation of a background of satiety and early post-prandial satiation via specifically structured vagal afferents at the level of the band. At five years after banding or bypass, there is typically a loss of 30-35 kg representing 50-60% of excess weight. This weight loss has been shown to be associated with major improvement or complete resolution of multiple common and serious health problems plus improvement in quality of life and in survival. Level 1 evidence supports the use of the gastric band over optimal lifestyle therapy. Randomized controlled trials has shown gastric banding to achieve better weight loss, health and quality of life than optimal lifestyle therapies for adults above a BMI of 30 and adolescents above a BMI of 35. In adults with mild to severe obesity and type 2 diabetes gastric banding leads to remission in three out of four individuals. Perioperative risk is significant with gastric bypass and late revisional procedures can be required after both procedures. Gastric banding is indicated in any adult who has a BMI over 30, has problems with their obesity and has made substantial effort to reduce their weight by lifestyle methods. Gastric bypass or biliopancreatic diversion should be considered in those with BMI greater than 35 if banding is contraindicated or has been unsuccessful.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Manometric changes of the lower esophageal sphincter after sleeve gastrectomy in obese patients

INTRODUCTION

Laparoscopic sleeve gastrectomy has been accepted as an option for surgical treatment of obesity. After surgery, some patients present reflux symptoms associated with endoscopic esophagitis, therefore PPI's treatment must be indicated.

PURPOSE

This study aims to evaluate the manometric characteristic of the lower esophageal sphincter (LES) before and after sleeve gastrectomy

MATERIAL AND METHOD

This prospective study includes 20 patients submitted to esophageal manometry in order to determine the resting pressure, and total and abdominal LES length before and after the sleeve gastrectomy. Statistical variations on the LESP were validated according to Student's "t" test.

RESULTS

Seventeen female and three male patients were included, with a mean age of 37.6 +/- 12.6 years. All patients reduced their body weight, from an initial BMI of 38.3 kg/m(2) to 28.2 kg/m(2) 6 months after surgery. No postoperative complications were observed in these patients. Preoperative mean LESP was 14.2 +/- 5.8 mmHg. Postoperative manometry decreased in 17/20 (85%), with a mean value of 11.2 +/- 5.7 mmHg (p = 0.01). Seven of them presented LESP <12 mmHg and ten patients <6 mmHg after the operation. Furthermore, the abdominal length and total length of the high pressure zone at the esophagogastric junction were affected.

CONCLUSION

A sleeve gastrectomy produces an important decrease in LES pressure, which can in turn cause the appearance of reflux symptoms and esophagitis after the operation due to a partial resection of the sling fibers during the gastrectomy.

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.

Radiological imaging of the GI tract after bariatric surgery

BACKGROUND

Obesity is becoming epidemic in proportion and is leading to considerable morbidity and mortality in the community. Bariatric surgery offers one tested solution to sustained weight loss and comorbidity reduction. However, it is associated with a significant number of complications.

OBJECTIVE

The objective of this article is to review the utility of radiological techniques in the diagnosis of surgical complications after bariatric surgery.

DESIGN

Literature-based review and pictorial illustration in the use of imaging techniques in the diagnosis of complications after bariatric surgery.

CONCLUSIONS

Radiology plays a critical role in the diagnosis of complications after bariatric surgery. Upper GI contrast study and CT are the most commonly used imaging modalities in this regard. They are complementary in their diagnostic abilities and should be used in concert for the complete evaluation of symptomatic patients. All other radiological imaging modalities are also used in the diagnosis of complications after bariatric surgery, but much less commonly.

The liver and the waistline: Fifty years of growth

Fifty years of the Gastroenterological Society of Australia have witnessed the changing appearance of Australians. Asian immigration has transformed the dominant urban culture from European to Eurasian, with some unique Australian attributes. Meanwhile, global conditions have altered body shape, and our sports-proud country is now fat! Thus, as in North America, Europe, China, and affluent Asia-Pacific countries, prosperity and lifestyle, cheap processed foods coupled with reduced physical activity have created an epidemic of over-nutrition resulting in overweight/obesity. Additional genetic factors are at the core of the apple shape (central obesity) that typifies over-nourished persons with metabolic syndrome. Indigenous Australians, once the leanest and fittest humans, now have exceedingly high rates of obesity and type 2 diabetes, contributing to shorter life expectancy; Asian Australians are also at higher risk. Like non-steroidal anti-inflammatory drugs (NSAIDs) and cigarette smoking, obesity now contributes much to gastrointestinal morbidity and mortality (gastroesophageal reflux disease, cancers, gallstones, endoscopy complications). This review focuses on Australian research about fatty liver, particularly roles of central obesity/insulin resistance in non-alcoholic fatty liver disease/steatohepatitis (NAFLD/NASH). The outputs include many highly cited original articles and reviews and the first book on NAFLD. Studies have identified community prevalence, clinical outcomes, association with insulin resistance, metabolic syndrome and hypoadiponectinemia, developed and explored animal models for mechanisms of inflammation and fibrosis, conceptualized etiopathogenesis, and demonstrated that NASH can be reversed by lowering body weight and increasing physical activity. The findings have led to development of regional guidelines on NAFLD, the first internationally, and should now inform daily practice of gastroenterologists.

Laparoscopic upper gut surgery

Australian surgeons have been prominent in the introduction, development, and consolidation of laparoscopic surgery of the upper gut. In doing this, some of the very best principles of surgical innovation have been in evidence: preliminary animal work in which to test hypotheses and techniques, followed by careful application and documentation in the clinical setting, randomized clinical trials and finally academic reporting and ongoing development. This review documents the introduction of laparoscopic surgery for gastroesophageal reflux, hiatus hernia, achalasia, gastroesophageal malignancy, obesity, and a range of emergency conditions in Australia. Those involved are regarded as world leaders in their field. A vital component of this success has been the close cooperation between surgeons and gastroenterologists within the Gastroenterological Society of Australia.

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.

The effect of obesity on the outcome of laparoscopic antireflux surgery

BACKGROUND

Obesity has long been considered to be a predisposing factor for gastroesophageal reflux. It is also thought to predispose patients to a poorer clinical outcome following antireflux surgery. This study examined the effect of body mass index (BMI) on clinical outcomes following laparoscopic antireflux surgery.

METHODS

Patients were included if they had undergone a laparoscopic fundoplication, their presurgical BMI was known, and they had been followed for at least 12 months after surgery. The clinical outcome was determined using a structured questionnaire, and this was applied yearly after surgery. Patients were divided into four groups according to BMI: normal weight (BMI < 25), overweight (BMI 25-29.9), obese (BMI 30-34.9), and morbidly obese (BMI > or = 35). The most recent clinical outcome data was analyzed for each BMI group.

RESULTS

Patients, 481, were studied. One hundred three (21%) had a normal BMI, 208 (43%) were overweight, 115 (24%) were obese, and 55 (12%) were morbidly obese. Mean follow-up was 7.5 years. Conversion to an open operation and requirement for revision surgery were not influenced by preoperative weight. Operating time was longer in obese patients (mean 86 vs 75 min). Clinical outcomes improved following surgery regardless of BMI.

CONCLUSIONS

Preoperative BMI does not influence the clinical outcome following laparoscopic antireflux surgery. Obesity is not a contraindication for laparoscopic fundoplication.

Pregnancy after bariatric surgery: no problem?

Bariatric surgery is highly effective for weight loss in morbid obesity. With the high prevalence of severe obesity in the developed world, and the acknowledgement of the effectiveness of these procedures by National Institute for Clinical Excellence (in the UK) and the Food and Drug Administration (in the USA), women with severe obesity will increasingly seek such treatment. As the majority of these patients are women of reproductive age, obstetricians will encounter these patients frequently during pregnancy. It is therefore important for obstetricians to gain an insight into the types of surgery performed, the potential complications, including nutritional deficiency, and appropriate management of pregnancy following weight-loss surgery. In general, bariatric surgery is associated with a reduction in obesity related complication, with no apparent increased risk of adverse perinatal outcomes.

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.

The effect of Roux-en-Y gastric bypass on gastroesophageal reflux disease in morbidly obese Chinese patients

BACKGROUND

The prevalence of gastroesophageal reflux disease (GERD) is increasing in Eastern and Western countries. Obesity is recognized as a risk factor of gastroesophageal reflux disease. However, little information is available on the prevalence of gastroesophageal reflux disease in morbidly obese Chinese patients. The aim of this study was to compare the prevalence of GERD in Chinese patients with morbid obesity and age- and sex-matched controls, and we also assessed the effect of Roux-en-Y gastric bypass on reflux symptoms and erosive esophagitis.

METHODS

Between November 2006 and February 2008, 150 morbidly obese Chinese patients underwent laparoscopic Roux-en-Y gastric bypass. Gastroesophageal reflux disease questionnaires and esophagogastroduodenoscopy results were assessed in all cases before surgery. The prevalence of reflux symptoms and erosive esophagitis was compared with the prevalence in a database of 300 age- and sex-matched controls. We also compared baseline and postoperative characteristics at 12 months after operation.

RESULTS

Patients with morbid obesity had higher frequencies of reflux symptoms (16% vs. 8%, P = 0.01) and erosive esophagitis (34% vs. 17%, P < 0.01) than those of controls. Twelve months after laparoscopic Roux-en-Y gastric bypass, 26 patients received follow-up evaluations. In addition to substantial weight loss, the prevalence of reflux symptoms and erosive esophagitis decreased significantly after operation (19.2% vs. 0%, P = 0.05, and 42.3% vs. 3.8%, P < 0.01, respectively).

CONCLUSIONS

Gastroesophageal reflux disease is pervasive in Chinese patients with morbid obesity and Roux-en-Y gastric bypass substantially improves not only the reflux symptoms but also the erosive esophagitis.

The role of endoscopy in bariatric surgery

Morbid obesity is a chronic disease of excess fat storage, characterised by premature death and obesity-associated co-morbidities. The results of the current non-surgical treatment to treat obesity are disappointing, but surgical approaches may achieve a durable and longstanding weight loss with resolution and improvement of co-morbidities. Gastrointestinal complaints and digestive complications may, however, increase and may require an actively involved gastroenterologist.

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.