The Impact of Gastric Bypass on Gastroesophageal Reflux Disease in Morbidly Obese Patients. Ann Surg. 2016;263:110-116. [PMID: 25607766 DOI: 10.1097/sla.0b013e3181bdff20]

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.

Frequency of abnormal esophageal acid exposure in patients eligible for bariatric surgery

BACKGROUND

Obesity and gastroesophageal reflux disease (GERD) are both high-prevalence diseases in developed nations. Obesity has been identified as an important risk factor in the development of GERD. The objective of this study was to determine the frequency of abnormal esophageal acid exposure in patients candidate for bariatric surgery and its relationship with any clinical and endoscopic findings before surgery.

METHODS

Data collected from a group of 88 patients awaiting bariatric surgery included a series of demographic variables and symptoms typical of GERD. The tests patients underwent included manometry, pH monitoring, and upper gastrointestinal endoscopy. Univariate and multivariate analyses were conducted on the variables related to the onset of reflux.

RESULTS

Esophageal pH monitoring tests were positive in 65% of the patients. Manometries showed lower esophageal sphincter hypotonia in 46%, while 20% returned abnormal upper endoscopy results. Out of the 45% of patients who were asymptomatic or returned normal endoscopies, half returned positive esophageal pH tests. In turn, among the 55% of patients who had symptoms or an abnormal upper endoscopy, three quarters had pH tests that diagnosed reflux. pH tests were also positive in 80% of symptomatic patients and 100% of patients with esophagitis (P<.042). No statistically significant relationship was found between body mass index, sex, age, manometry, or hiatus hernia and the positive pH monitoring.

CONCLUSION

Frequency of abnormal esophageal acid exposure among obese patients is high. There is a relationship between the presence of symptoms and reflux. But the absence of symptoms does not rule out the presence of abnormal esophageal function tests.

Comparison of ghrelin plasma levels between pre and postoperative period in patients submitted to gastric plication associated with fundoplication

BACKGROUND

The recurrence of the gastroesophageal reflux disease may be related to later postoperative weight gain, therefore increasing the chances of developing columnar metaplasia and cancer. The gastric plication associated with fundoplication can be employed in order to be treating the two issues.

AIM

To evaluate the serum ghrelin hormone in pre and postoperatively as well as weight loss and control of reflux disease in patients undergoing gastroplication associated with fundoplication.

METHODS

Was performed laparoscopic gastric plication with fundoplication in eight patients; endoscopic examinations were performed pre and postoperatively as well as blood collection for ghrelin hormonal dosage.

RESULTS

There was control of reflux symptoms and mucosal lesions. Weight loss was significant. Since the change of the hormone ghrelin was not of great significance.

CONCLUSIONS

Gastric plication associated with fundoplication was effective in treating reflux disease with surgical indication and for weight loss in obese patients. Appetite control occurs, but not due to ghrelin, because no significant decrease of its plasmatic levels was observed.

Weight loss can lead to resolution of gastroesophageal reflux disease symptoms: a prospective intervention trial

OBJECTIVE

Weight gain is an important risk factor for gastroesophageal reflux disease (GERD); however, whether weight loss can lead to resolution of GERD symptoms is not clear. Our aim was to measure the impact of weight loss on GERD symptoms.

DESIGN AND METHODS

In a prospective cohort study at a tertiary referral center, overweight/obese subjects (BMI 25-39.9 kg/m2) were enrolled in a structured weight loss program. Weight loss strategies included dietary modifications, increased physical activity and behavioral changes. At baseline and at 6 months, BMI and waist circumference were measured and all participants completed a validated reflux disease questionnaire.

RESULTS

A total of 332 adult subjects, mean age 46 years and 66% women were prospectively enrolled. At baseline, the mean body weight, BMI, and waist circumference were 101 (±18) kg, 35 (±5) kg/m2 and 103 (±13) cm. At 6 months, majority of the subjects (97%) lost weight (average weight loss: 13 ± 7.7 kg) and as compared with baseline, there was a significant decrease in the overall prevalence of GERD (15 vs. 37%; P < 0.01) and the mean GERD symptom score (1.8 vs. 5.5; P < 0.01). Overall, 81% of the subjects had reduction in GERD symptom scores; 65% had complete resolution and 15% had partial resolution of reflux symptoms. There was a significant correlation between % body weight loss and reduction in GERD symptom scores (r = 0.17, P < 0.05).

CONCLUSIONS

In conclusion, the overall prevalence of GERD symptoms is high (37%) in overweight and obese subjects. A structured weight loss program can lead to complete resolution of GERD symptoms in the majority of these subjects.

Surgical management of gastroesophageal reflux disease

Antireflux surgery has become a well-established therapy for gastroesophageal reflux disease (GERD) and its complications. The popularization of minimally invasive surgical techniques has brought about a revolution in the use of fundoplication for the long-term management of GERD. A reliable and objective understanding of the outcomes following fundoplication is important for all physicians treating GERD, so that informed decisions can be made regarding the optimal treatment strategy for a given patient. With ongoing study, the appropriate indications for surgical intervention among the array of potential antireflux therapies will continue to be elucidated.

Weight loss can lead to resolution of gastroesophageal reflux disease symptoms: a prospective intervention trial

OBJECTIVE

Weight gain is an important risk factor for gastroesophageal reflux disease (GERD); however, whether weight loss can lead to resolution of GERD symptoms is not clear. Our aim was to measure the impact of weight loss on GERD symptoms.

DESIGN AND METHODS

In a prospective cohort study at a tertiary referral center, overweight/obese subjects (BMI 25-39.9 kg/m2) were enrolled in a structured weight loss program. Weight loss strategies included dietary modifications, increased physical activity and behavioral changes. At baseline and at 6 months, BMI and waist circumference were measured and all participants completed a validated reflux disease questionnaire.

RESULTS

A total of 332 adult subjects, mean age 46 years and 66% women were prospectively enrolled. At baseline, the mean body weight, BMI, and waist circumference were 101 (±18) kg, 35 (±5) kg/m2 and 103 (±13) cm. At 6 months, majority of the subjects (97%) lost weight (average weight loss: 13 ± 7.7 kg) and as compared with baseline, there was a significant decrease in the overall prevalence of GERD (15 vs. 37%; P < 0.01) and the mean GERD symptom score (1.8 vs. 5.5; P < 0.01). Overall, 81% of the subjects had reduction in GERD symptom scores; 65% had complete resolution and 15% had partial resolution of reflux symptoms. There was a significant correlation between % body weight loss and reduction in GERD symptom scores (r = 0.17, P < 0.05).

CONCLUSIONS

In conclusion, the overall prevalence of GERD symptoms is high (37%) in overweight and obese subjects. A structured weight loss program can lead to complete resolution of GERD symptoms in the majority of these subjects.

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.

Gastroesophageal reflux disease is inversely related with glycemic control in morbidly obese patients

BACKGROUND

The link between diabetes mellitus and gastroesophageal reflux disease (GERD) is controversial. We assessed the relationship between glycemic control (GC) and GERD in morbidly obese patients.

METHODS

Consecutive patients with morbid obesity (n = 86) underwent manometry, pH-metry, endoscopy, and contrasted X-ray after responding to a GERD questionnaire and dosing fasting plasma glucose (FPG) and glycated hemoglobin (HbA1c). Patients with poor GC (HbA1c, 6.1-10% and FPG < 140 mg/dl) and those with very poor GC (HbA1c > 10% or FPG > 140 mg/dl) were compared.

RESULTS

There were 63 patients with poor GC and 17 with very poor GC. Compared to patients with very poor GC, patients with poor GC showed higher heartburn scores [8 (0-12) vs. 0 (0-4); P = 0.003]; higher total esophageal acid exposure [5.2% (2.5-10.5%) vs. 2.3% (0.8-7.5%); P = 0.041]; lower distal esophageal amplitude (105 ± 38 vs. 134 ± 63 mmHg; P = 0.019); higher expiratory gastroesophageal pressure gradient (GEPG, 7 ± 3.4 vs. 5.2 ± 3 mmHg; P = 0.050); lower ventilatory gradient (inspiratory-expiratory GEPG, 10.9 ± 3.8 vs. 13.6 ± 4.1 mmHg; P = 0.012); lower waist-to-hip ratio (0.95 vs. 1; P = 0.040); and more hiatal hernia (38% vs. 6%; P = 0.016).

CONCLUSIONS

This study suggests an inverse relation between glycemic control and GERD in morbidly obese patients. This can be partially explained by a lower frequency of hiatal hernia in patients with very poor glycemic control.

Development of a refractory gastro-oesophageal reflux score using an administrative claims database

BACKGROUND

Approximately one-third of gastro-oesophageal reflux disease (GERD) patients demonstrate refractory symptoms following treatment with proton pump inhibitor (PPI) therapy.

AIM

To develop a refractory GERD score that can be applied to predict patients' healthcare utilisation.

METHODS

We enrolled adults (≥18 years) with a diagnosis of GERD. Refractory GERD was evaluated on an 8-point scale where 1 point was given for each of the following criteria: doubling, addition, or switching of GERD medication dose, receipt of a GERD-related endoscopic procedure or surgery, or ≥3 GERD-related outpatient visits. Refractory GERD was defined as the presence of two or more points.

RESULTS

A total of 135,139 GERD patients (44% male) were analysed with a mean (±s.d.) age of 52.9 ± 15 years. The mean overall refractory GERD score was 1.12 ± 1.2 (range 0-8 on an 8-point scale); 31% of patients had refractory GERD with a mean score of 2.56 ± 0.82. Among patients with refractory GERD, 31% doubled their GERD medication, 28% added a new GERD medication, 60% switched GERD medications, 54% had a GERD-related procedure and 1% had a GERD-related surgery. Patients with refractory GERD were more likely to be female (59% vs. 55%, P < 0.001) and had a higher co-morbidity score (0.78 vs. 0.56, P < 0.001). The overall mean costs for refractory patients during the study period were significantly higher compared with treatment-responsive patients ($18,088 ± $36,220 vs. $11,044 ± $22,955, P < 0.001).

CONCLUSIONS

Refractory GERD was present in approximately one-third of the GERD patients. We created a GERD refractory score that could define need for increased anti-reflux therapy and predict higher healthcare resource utilisation.

Symptoms of gastroesophageal reflux following laparoscopic sleeve gastrectomy are related to the final shape of the sleeve as depicted by radiology

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is gaining popularity as a primary procedure in selected morbidly obese patients. Like most other bariatric procedures LSG results in alterations of the upper GI anatomy that might affect gastroesophageal reflux postoperatively. The study was conducted to assess the presence of reflux symptoms in patients before and after laparoscopic sleeve gastrectomy and any possible relation of these symptoms to the postoperative gastric anatomy as depicted by gastrografin swallow studies.

METHODS

The study included 85 consecutive morbidly obese patients who underwent LSG as a primary bariatric procedure. Patients were evaluated for symptoms of gastroesophageal reflux (heartburn, regurgitation, and vomiting) preoperatively and at 1 and 6 months and 1 year postoperatively. To assess the postoperative gastric anatomy, the gastrografin studies that were routinely performed in all patients on the third postoperative day were retrospectively evaluated. Changes of each one of the reflux symptoms were assessed in relation to the radiological pattern of the gastric sleeve.

RESULTS

Three radiological patterns of the gastric sleeve were identified: (a) the tubular (65.9%), (b) the superior pouch (25.9%), and (c) the inferior pouch pattern (8.2%). Patients showed an overall tendency towards relief of heartburn and increase of regurgitation and vomiting postoperatively. However, only changes in regurgitation and vomiting were found to be statistically significant (p < 0.01); interestingly, those were observed in patients with the tubular gastric pattern.

CONCLUSIONS

The final shape of the gastric sleeve as depicted by radiological studies seems to have an impact on reflux symptoms after laparoscopic sleeve gastrectomy.

Abdominal pain after gastric bypass: suspects and solutions

BACKGROUND

Gastric bypass remains the mainstay of surgical therapy for obesity. Abdominal pain after gastric bypass is common and accounts for up to half of all postoperative complaints and emergency room visits. This article reviews the most important causes of abdominal pain specific to gastric bypass and discusses management considerations.

METHODS

The current surgical literature was reviewed using PubMed, with a focus on abdominal pain after gastric bypass and the known pathologies that underlie its pathogenesis.

RESULTS

The etiologies of abdominal pain after gastric bypass are diverse. A thorough understanding of their pathogenesis impacts favorably on clinical outcomes.

CONCLUSIONS

The differential diagnosis for abdominal pain after gastric bypass is large and includes benign and life-threatening entities. Its diverse causes require a broad evaluation that should be directed by history and clinical presentation. In the absence of a clear diagnosis, the threshold for surgical exploration in patients with abdominal pain after gastric bypass should be low.

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.