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

Incidence of Post-operative Gastro-esophageal Reflux Disorder in Patients Undergoing Laparoscopic Sleeve Gastrectomy: A Systematic Review and Meta-analysis

Gastroesophageal reflux disease (GERD) is a common concern following laparoscopic sleeve gastrectomy (LSG). This paper aimed to assess the incidence of reflux disease following these bariatric procedures. A literature search was conducted to identify observational studies and clinical trials reporting patients developed GERD disease after LSG. Twenty-two studies included in the analysis, involve 20,495 participants, indicated that the estimated proportion of patients who developed post-surgery GERD was 0.35 (95% CI 0.30-0.41). Subgroup analysis revealed a proportion of 0.33 (95% CI 0.27-0.38) in observational studies and 0.58 (95% CI 0.39-0.75) in clinical trials. High heterogeneity was noted across studies (I2 = 98%). Sensitivity analyses and publication bias assessments were performed to enhance the robustness of the results. Our findings highlight a moderate to high risk of developing GERD following LSG surgery.

Gastro-esophageal diagnostic workup before bariatric surgery or endoscopic treatment for obesity: position statement of the International Society of Diseases of the Esophagus

Obesity is a chronic and multifactorial condition characterized by abnormal weight gain due to excessive adipose tissue accumulation that represents a growing worldwide challenge for public health. In addition, obese patients have an increased risk of hiatal hernia, esophageal, and gastric dysfunction, as well as gastroesophageal reflux disease, which has a prevalence over 40% in those seeking endoscopic or surgical intervention. Surgery has been demonstrated to be the most effective treatment for severe obesity in terms of long-term weight loss, comorbidities, and quality of life improvements and overall mortality decrease. The recent emergence of bariatric endoscopic techniques promises less invasive, more cost-effective, and reproducible approaches to the treatment of obesity. With the endorsement of the International Society for Diseases of the Esophagus, we started a Delphi process to develop consensus statements on the most appropriate diagnostic workup to preoperatively assess gastroesophageal function before bariatric surgical or endoscopic interventions. The Consensus Working Group comprised 11 international experts from five countries. The group consisted of gastroenterologists and surgeons with a large expertise with regard to gastroesophageal reflux disease, bariatric surgery and endoscopy, and physiology. Ten statements were selected, on the basis of the agreement level and clinical relevance, which represent an evidence and experience-based consensus of the International Society for Diseases of the Esophagus.

Revision Bariatric Procedures and Management of Complications from Bariatric Surgery

Bariatric surgery is effective, but may be associated with adverse events. A multi-disciplinary approach including endoscopic interventions can be effective to manage these. Endoscopists should familiarize themselves with gastrointestinal pathology which can occur after bariatric surgery, including nutritional deficiencies, acid reflux, anastomotic stenosis, gallstone disease, leaks, fistulas, and weight regain. Endoscopic interventions including anastomotic stricture dilation, control of bleeding, endoscopic ultrasound-guided approach for endoscopic retrograde cholangiopancreatography, leak or fistula closure via endoscopic suturing or stent placement, and transoral outlet reduction (TORe) or revision obesity surgery endoluminal (ROSE) to address weight regain are among the endoscopic tools which have demonstrated safety and efficacy in the management of adverse events after bariatric surgery.

Reflux, Barrett's Esophagus, and Esophageal Adenocarcinoma After Bariatric Surgery

We present the case of a patient who developed esophageal adenocarcinoma after a previous laparoscopic sleeve gastrectomy. Bariatric surgery has emerged as the most effective treatment option for weight loss and obesity-related diseases; however, sleeve gastrectomy promotes gastroesophageal reflux and leads to Barrett's esophagus in a substantial portion of patients. The natural history of Barrett's esophagus in these patients is unknown, and active surveillance is recommended until the incidence of dysplasia and adenocarcinoma in this population is clarified. Management options for these patients include conversion to Roux-en-Y gastric bypass. Although esophagectomy in patients who have previously undergone sleeve gastrectomy may require an alternative conduit, the remnant stomach can be used in carefully selected patients. Here, we review the different weight loss procedures, their effect on gastroesophageal reflux disease and Barrett's esophagus, and the treatment options for patients with esophageal cancer after sleeve gastrectomy. We report the use of preoperative coil embolization as a means of vascular preconditioning before successful use of a gastric conduit.

Gastroesophageal Reflux Disease and the Patient with Obesity

Patients with obesity who present with gastroesophageal reflux disease (GERD) require a nuanced approach. Those with lower body mass index (BMI) (less than 33) can be counseled on weight loss, and if successful may be approached with laparoscopic fundoplication. Those who are unable to achieve weight loss or those who present with a BMI greater than or equal to 35 should proceed with laparoscopic Roux-en-Y gastric bypass (LRYGB). Conversion to LRYGB from sleeve gastrectomy is a safe and effective way to manage GERD after sleeve gastrectomy.

Progress in understanding of influence of bariatric surgery on reflux esophagitis

In today's society, as the number of obese people increases year by year, the incidence of gastroesophageal reflux disease (GERD) continues to rise. Although bariatric surgery has brought good news to these patients who are unable to lose weight on their own, it is still unclear whether it is effective in relieving GERD, or even inducing or aggravating GERD. In this article, we will review and provide evidence of the effect of bariatric surgery on GERD.

GORD and Barrett's oesophagus after bariatric procedures: multicentre prospective study

INTRODUCTION

Gastro-oesophageal reflux disease (GORD) after bariatric surgery is a debated topic. This study investigated the prevalence of GORD and associated oesophageal complications following bariatric procedures-namely, adjustable gastric banding (AGB), sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and one-anastomosis gastric bypass (OAGB).

METHODS

This was a prospective multicentre study designed to evaluate the long-term effects of bariatric surgery on GORD. Patients were studied at baseline, at >10 years following AGB, SG, and RYGB, and at >3 years following OAGB (due to the more recent recognition of OAGB as a standard bariatric procedure). Patients were assessed by endoscopy and GORD symptom evaluation.

RESULTS

A total of 241 patients were enrolled. A minimum follow-up of 10 years was completed by 193 patients following AGB (57 patients), SG (95 patients), and RYGB (41 patients), and of >3 years by 48 subjects following OAGB. GORD symptoms increased following AGB and SG (from 14 to 31.6 per cent and from 26.3 to 58.9 per cent, respectively; P < 0.0001), improved following RYGB (from 36.6 to 14.6 per cent; P < 0.0001), and were unchanged following OAGB. The overall prevalence of erosive oesophagitis was greater in the SG group (74.7 per cent) than in the AGB (42.1 per cent), RYGB (22 per cent), and OAGB (22.9 per cent) groups (P < 0.0001). Barrett's oesophagus was found only in patients who had SG (16.8 per cent). Biliary-like gastric stagnation was found in a greater proportion of SG and OAGB patients (79.7 and 69.4 per cent, respectively) than in other treatment groups (P < 0.0001). The prevalence of biliary-type reflux into the oesophagus was higher in patients who underwent SG (74.7 per cent), compared with other treatment groups.

CONCLUSION

Bariatric surgery leads to gastro-oesophageal complications of variable severity, particularly SG, which can result in a large proportion of patients developing Barrett's oesophagus.

Assessment and management of gastroesophageal reflux disease following bariatric surgery

Gastroesophageal reflux disease (GERD) is a common disease in patients with obesity. The incidence of de novo GERD and the effect of bariatric surgery on patients with pre-existing GERD remain controversial. Management of GERD following bariatric surgery is complicated and can range from medical therapy to non-invasive endoscopic options to invasive surgical options. To address these issues, we performed a systematic review of the literature on the incidence of GERD and the various modalities of managing GERD in patients following bariatric surgery. Given the increased number of laparoscopic sleeve gastrectomy (LSG) procedures being performed and the high incidence of GERD following LSG, bariatric surgeons should be familiar with the options available to manage GERD following LSG as well as other bariatric procedures.

Impact of bariatric surgery on gastroesophageal reflux disease and esophageal motility

PURPOSE OF REVIEW

Obesity is rapidly increasing in prevalence, and bariatric surgery has become a popular treatment option that can improve all-cause mortality in obese individuals. Gastroesophageal reflux disease (GERD) and esophageal motility disorders are common in the obese population, and the effects of bariatric surgery on these conditions differ depending on the type of bariatric surgery performed.

RECENT FINDINGS

Laparoscopic adjustable gastric banding has declined in popularity due to its contributions to worsening GERD symptoms and the development of esophageal dysmotility. Although laparoscopic sleeve gastrectomy (LSG) is the most popular type of bariatric surgery, a comprehensive assessment for acid reflux should be performed as LSG has been linked with worsening GERD. Novel methods to address GERD due to LSG include magnetic sphincter augmentation and concomitant fundoplication. Due to the decreased incidence of postoperative GERD and dysmotility compared to other types of bariatric surgeries, Roux-en-Y gastric bypass should be considered for obese patients with GERD and esophageal dysmotility.

SUMMARY

Bariatric surgery can affect esophageal motility and contribute to worsening or development of GERD. A thorough workup of gastrointestinal symptoms before bariatric surgery should be performed with consideration for formal testing with high-resolution manometry and pH testing. Based on these results, the choice of bariatric surgery technique should be tailored accordingly to improve clinical outcomes.

Roux-en-Y gastric bypass versus one anastomosis-mini gastric bypass as a rescue procedure following failed restrictive bariatric surgery. A systematic review of literature with metanalysis

BACKGROUND

Although different procedures have been proposed as revisional surgery for patients who had previously undergone a failed primary restrictive procedure, the ideal revisional procedure is still a matter of debate.

METHODS

A systematic search was performed in all electronic databases to find studies comparing one anastomosis-mini gastric bypass (OAGB-MGB) or Roux-en-Y gastric bypass (RYGB) as revisional bariatric surgery for weight regain or intolerance/complications of a primary restrictive procedure. The data regarding sample size, patients' gender, age, primary surgery type, number of perioperative complications, operative time, pre- and post-revisional body mass index (BMI), and excess weight loss % (EWL%) at 1-year follow-up were extracted. Five studies were included in the analysis.

RESULTS

The primary bariatric procedures were represented by vertical banded gastroplasty (VBG), laparoscopic adjustable gastric band (LAGB) and laparoscopic sleeve gastrectomy (LSG). About perioperative complications, both RYGB and OAGB-MGB showed a similar rate of leaks but OAGB-MGB had a lower rate of bleedings; considering the progression from pre- to post-revisional BMI, OAGB-MGB reveals a better outcome as well as a shorter operative time.

CONCLUSIONS

Our meta-analysis has shown OAGB-MGB, used as revisional intervention after failed restrictive surgery, achieves outcomes comparable to RYGB in terms of perioperative complications providing a simpler and more effective technique.

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.

Outcomes of primary versus revisional robotically assisted laparoscopic Roux-en-Y gastric bypass: a multicenter analysis of ten-year experience

Background

Postoperative morbidity after laparoscopic bariatric surgery is considered higher for patients undergoing revisional versus primary procedures. The objective of this retrospective cohort study was to compare outcomes between patients undergoing primary versus revisional robotically assisted laparoscopic (RAL) Roux-en-Y gastric bypass (RYGB).

Methods

Data of all patients who underwent RAL primary and revisional RYGB between 2009 and 2019 at two accredited, high-volume bariatric surgery centers—the Memorial Hermann – Texas Medical Center, Houston, TX, and the Tower Health, Reading Hospital, Reading, PA, were analyzed. Primary outcomes were early (< 30 days) and overall postoperative complications. Secondary outcomes included intraoperative complications, operative times, conversions to laparotomy, length of hospital stay, early (< 30 days) postoperative readmissions and deaths.

Results

Data of 1072 patients were analyzed, including 806 primary and 266 revisional RAL RYGB procedures. Longer operative times (203 versus 154 min, P < 0.001), increased number of readmissions for oral intolerance (10.5% versus 6.7%, P = 0.046) and higher rate of gastrojejunal stricture (6.4% versus 2.7%, P = 0.013) were found in the revisional group. Gastrointestinal leak rates were 0.2% for the primary versus 1.1% for the revisional group (P = 0.101). Early (< 30 days) reoperations rates were 2.2% for the primary versus 1.1% for the revisional group (P = 0.318). There were no statistically significant differences between groups in overall and severe complication rates.

Conclusion

Patients undergoing RAL primary and revisional RYGB had comparable overall outcomes, with a non-significant higher early complication rate in the revisional group. Despite the study being underpowered to detect differences in specific complication rates, the morbidity seen in the revisional RYGB group remains markedly below literature reports of revisional laparoscopic RYGB and might suggest a benefit of robotic assistance. Further prospective studies are needed to confirm these results.

GERD outcome after bariatric surgery: A protocol for systematic review and meta analysis

BACKGROUND/AIM

Obesity is associated with increased incidence of gastroesophageal reflux disease (GERD), and it has been suggested that GERD symptoms may be improved by weight reduction. However, various patterns of bariatric surgery may affect symptoms of GERD due to the changed anatomy of stomach and esophagus. The aim of this systematic review and meta-analysis is to analyze the effect of bariatric surgery on GERD.

MATERIALS AND METHODS

A systematic literature search was performed using PubMed, EMBASE, and the Cochrane Library from January 2005 to January 2019, combining the words obesity, gastroesophageal reflux with different types of bariatric surgery and weight loss. The methodological quality of randomized controlled trials and non-randomized controlled trials published in English and have at least 1-year follow-up data were included and assessed by Cochrane Collaboration's tool for assessing risk bias and Newcastle-Ottawa scale. Only clinical trials were included, and case series or case reports were excluded.

RESULTS

We anticipate that our review will provide the exact estimates of the burden and phenotype of GERD among patients that have undergone bariatric surgery.

CONCLUSION

GERD may improve in obese patients who underwent laparoscopic sleeve gastrectomy (LSG); however, the most favorable effect is likely to be found after Roux-en-Y gastric bypass surgery.

PROSPERO REGISTRATION NUMBER

CRD42018090074.

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

PURPOSE OF REVIEW

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

FINDINGS

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

SUMMARY

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

Bariatric surgery and gastroesophageal reflux disease

With the rapidly increasing prevalence of obesity globally, the practice of bariatric surgery is being adopted routinely to prevent the development of chronic conditions as well as some forms of cancers associated with obesity. Gastroesophageal reflux disease (GERD) is one of those chronic conditions. Furthermore, there is accumulating data that obesity is associated with complications related to longstanding GERD such as erosive esophagitis (EE), Barrett's esophagus (BE), and esophageal adenocarcinoma (EAC). Central obesity, rather than body mass index (BMI), appears to be more closely associated with these complications. It should be expected, therefore, that weight loss procedures should result in improvement in GERD symptoms and its associated complications. However, in reality the different bariatric surgical procedures have unpredictable effects on an established GERD and may even produce GERD symptoms for the very first time (de novo). In this review, we explore the literature studying the effects of bariatric surgical operations on GERD. Roux-en-Y gastric bypass appears to have the most beneficial effect on GERD. On the other hand, laparoscopic sleeve gastrectomy and laparoscopic adjustable gastric banding (LAGB) are linked with long-term increased prevalence of GERD. We argue that GERD is an extremely important preoperative consideration for any patient undergoing bariatric surgery and therefore should be thoroughly investigated objectively (with 24-hour pH study and high-resolution manometry) to select the most suitable bariatric procedure for patients for their long-term success.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effects of bariatric surgery on the esophagus

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Bariatric Surgery: A Perspective for Primary Care

IN BRIEF Bariatric surgery is the most efficacious treatment for obesity, type 2 diabetes, and other obesity-related comorbidities. In this article, the authors review the current indications for bariatric surgery and discuss the most commonly performed procedures. They analyze medical outcomes of bariatric procedures by reviewing key prospective trials and discuss changes in physiology after these procedures. They conclude by discussing long-term management of bariatric patients by reviewing current guidelines for nutritional support and listing common complications related to these procedures.

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.

The Surgical Management of Obesity

In the United States, more than one-third of the population is obese. Currently, bariatric surgery is the best known treatment for obesity, and multiple meta-analyses have shown bariatric surgery to be more effective for treating obesity than diet and exercise or pharmacologic treatment. The modern era of bariatric surgery began in 2005, which is defined by a drastic increase in the use of laparoscopy. Bariatric surgery has the potential to improve obesity-related comorbidities, such as type 2 diabetes, cardiovascular disease, and sleep apnea. The effect of bariatric surgery on weight loss and comorbidities varies by the type of 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.

Surgical treatment of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a very common foregut disease prevalent worldwide. The prevalence of GERD has risen strikingly over the past decades, causing substantial health and economic burdens. Due to high rates of recurrent reflux symptoms, reoperations and complications, surgical therapy of GERD did not attach enough attention in its early stage. However, surgical therapy for GERD was subsequently revolutionized by the development of anti-reflux surgical techniques and the introduction and popularization of minimally invasive surgeries. Anti-reflux surgery has gradually proved to be a well-documented, effective, therapeutic option for GERD by long-term follow-up studies. In order to improve results and to reduce unwanted effects, surgeons should master the indications of surgery and techniques of anti-reflux surgery. Besides, choosing appropriate candidates and surgical approach is also crucial for outcomes. However, limited by the regional economy and surgeon's skill, the use of anti-reflux surgery is still very limited. The aim of this review is to analyze and discuss the current spectrum of surgical therapy of GERD, and to provide orientation for surgeons in the challenging therapy of GERD.

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.

Republished: symptomatic reflux disease: the present, the past and the future

The worldwide incidence of GORD and its complications is increasing along with the exponentially increasing problem of obesity. Of particular concern is the relationship between central adiposity and GORD complications, including oesophageal adenocarcinoma. Driven by progressive insight into the epidemiology and pathophysiology of GORD, the earlier belief that increased gastroesophageal reflux mainly results from one dominant mechanism has been replaced by acceptance that GORD is multifactorial. Instigating factors, such as obesity, age, genetics, pregnancy and trauma may all contribute to mechanical impairment of the oesophagogastric junction resulting in pathological reflux and accompanying syndromes. Progression of the disease by exacerbating and perpetuating factors such as obesity, neuromuscular dysfunction and oesophageal fibrosis ultimately lead to development of an overt hiatal hernia. The latter is now accepted as a central player, impacting on most mechanisms underlying gastroesophageal reflux (low sphincter pressure, transient lower oesophageal sphincter relaxation, oesophageal clearance and acid pocket position), explaining its association with more severe disease and mucosal damage. Since the introduction of proton pump inhibitors (PPI), clinical management of GORD has markedly changed, shifting the therapeutic challenge from mucosal healing to reduction of PPI-resistant symptoms. In parallel, it became clear that reflux symptoms may result from weakly acidic or non-acid reflux, insight that has triggered the search for new compounds or minimally invasive procedures to reduce all types of reflux. In summary, our view on GORD has evolved enormously compared to that of the past, and without doubt will impact on how to deal with GORD in the future.

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.

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.

Symptomatic reflux disease: the present, the past and the future

The worldwide incidence of GORD and its complications is increasing along with the exponentially increasing problem of obesity. Of particular concern is the relationship between central adiposity and GORD complications, including oesophageal adenocarcinoma. Driven by progressive insight into the epidemiology and pathophysiology of GORD, the earlier belief that increased gastroesophageal reflux mainly results from one dominant mechanism has been replaced by acceptance that GORD is multifactorial. Instigating factors, such as obesity, age, genetics, pregnancy and trauma may all contribute to mechanical impairment of the oesophagogastric junction resulting in pathological reflux and accompanying syndromes. Progression of the disease by exacerbating and perpetuating factors such as obesity, neuromuscular dysfunction and oesophageal fibrosis ultimately lead to development of an overt hiatal hernia. The latter is now accepted as a central player, impacting on most mechanisms underlying gastroesophageal reflux (low sphincter pressure, transient lower oesophageal sphincter relaxation, oesophageal clearance and acid pocket position), explaining its association with more severe disease and mucosal damage. Since the introduction of proton pump inhibitors (PPI), clinical management of GORD has markedly changed, shifting the therapeutic challenge from mucosal healing to reduction of PPI-resistant symptoms. In parallel, it became clear that reflux symptoms may result from weakly acidic or non-acid reflux, insight that has triggered the search for new compounds or minimally invasive procedures to reduce all types of reflux. In summary, our view on GORD has evolved enormously compared to that of the past, and without doubt will impact on how to deal with GORD in the future.

The effect of bariatric surgery on gastroesophageal reflux disease

Obesity is an epidemic that is known to play a role in the development of gastroesophageal reflux disease (GERD). Studies have shown that increasing body mass index plays a role in the incompetence of the gastroesophageal junction and that weight loss and lifestyle modifications reduce the symptoms of GERD. As a method of producing effective and sustainable weight loss, bariatric surgery plays a major role in the treatment of obesity. We reviewed the literature on the effects of different types of bariatric surgery on the symptomatic relief of GERD and its complications. Roux-en- Y gastric bypass was considered an effective method to alleviate symptoms of GERD, whereas laparoscopic sleeve gastrectomy appeared to increase the incidence of the disease. Adjustable gastric banding was seen to initially improve the symptoms of GERD; however, a subset of patients experienced a new onset of GERD symptoms during long-term follow-up. The literature suggests that different surgeries have different impacts on the symptomatology of GERD and that careful assessment may be needed before performing bariatric surgery in patients with GERD.

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.

Laparoscopic surgery for gastro-esophageal acid reflux disease

Gastro-esophageal reflux disease is a troublesome disease for many patients, severely affecting their quality of life. Choice of treatment depends on a combination of patient characteristics and preferences, esophageal motility and damage of reflux, symptom severity and symptom correlation to acid reflux and physician preferences. Success of treatment depends on tailoring treatment modalities to the individual patient and adequate selection of treatment choice. PubMed, Embase, The Cochrane Database of Systematic Reviews, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched for systematic reviews with an abstract, publication date within the last five years, in humans only, on key terms (laparosc* OR laparoscopy*) AND (fundoplication OR reflux* OR GORD OR GERD OR nissen OR toupet) NOT (achal* OR pediat*). Last search was performed on July 23nd and in total 54 articles were evaluated as relevant from this search. The laparoscopic Toupet fundoplication is the therapy of choice for normal-weight GERD patients qualifying for laparoscopic surgery. No better pharmaceutical, endoluminal or surgical alternatives are present to date. No firm conclusion can be stated on its cost-effectiveness. Results have to be awaited comparing the laparoscopic 180-degree anterior fundoplication with the Toupet fundoplication to be a possible better surgical alternative. Division of the short gastric vessels is not to be recommended, nor is the use of a bougie or a mesh in the vast majority of GERD patients undergoing surgery. The use of a robot is not recommended. Anti-reflux surgery is to be considered expert surgery, but there is no clear consensus what is to be called an 'expert surgeon'. As for setting, ambulatory settings seem promising although high-level evidence is lacking.

Esophageal dysmotility after laparoscopic gastric band surgery

BACKGROUND

The effect of the laparoscopic adjustable gastric band (LAGB) on the esophagus has been the subject of few studies despite recognition of its clinical importance. The aim of this study was to investigate the frequency and clinical effect of esophageal dysmotility and dilatation after LAGB.

METHODS

We undertook a retrospective analysis of 50 consecutive patients with no dysmotility on perioperative video contrast swallow who underwent primary LAGB operation. All patients had serial focused postoperative contrast studies for band adjustments at least 6 months post-LAGB. Clinical and radiological outcomes were assessed.

RESULTS

Median follow-up time was 18 months (range 7-39 months), and the median number of contrast swallows per patient was 5. The mean excess weight loss (EWL) overall was 47 % (standard deviation (SD) 22.3). Radiological abnormalities were recorded in 17 patients (34 %, 95 % confidence interval (CI) 21-49 %), of whom 15 had radiological dysmotility and 7 had esophageal dilatation (five patients had both dysmotility and dilatation). Of these 17 patients, six (35 %) developed significant symptoms of dysphagia, gastroesophageal reflux disease (GERD) or regurgitation requiring fluid removal. In comparison, 12 of 33 (36 %) patients without radiological abnormalities developed symptoms requiring fluid removal (p = 1.00). Patients with radiological abnormalities were significantly older than those without these abnormalities. Symptoms were alleviated by removing fluid in most patients.

CONCLUSIONS

The LAGB operation results in the development of radiological esophageal dysmotility in a significant proportion of patients. It is not clear if these changes are associated with an increased risk of significant symptoms. Fluid removal can reverse these abnormalities and their associated symptoms.

Airway management concerns in patient with gastric banding procedures

Laparoscopic adjustable gastric band (LAGB) is considered a relatively safe and effective treatment for obesity. Even after weight loss patients with LAGB are at increased risk of pulmonary aspiration during induction of general anaesthesia, possibly due to LAGB-induced anatomical and functional changes. We present a case of aspiration in a patient with LAGB following significant weight loss and 14 h of preoperative fasting and review the literature. In the presence of LAGB we propose specific anaesthesia management at least consisting of anti-Trendelenburg positioning; avoidance of mask-ventilation; use of the local rapid sequence induction strategy with endotracheal intubation and fully awake extubation.

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.

Esophageal motor responses to increasing adjustment of an implanted gastric band

BACKGROUND

The adjustable gastric band is an effective surgical treatment to induce weight loss in patients with morbid obesity. We aimed to assess the effects of band placement and stepwise adjustment on esophageal motility, using high-resolution manometry (HRM).

METHODS

Patients underwent esophageal HRM before and 6 weeks after gastric band placement. During postoperative assessment, HRM was combined with intraband pressure measurement at increasing filling volumes.

KEY RESULTS

In total, 15 patients were studied. Mean DCI (±SD) decreased from 1085.3 ± 1064.1 mmHg s(-1)  cm(-1) before to 507 ± 347.2 mmHg s(-1)  cm(-1) (P = 0.015) after band placement, mean IBP from 10.7 ± 1.7 mmHg to 7.7 ± 1.6 mmHg (P = 0.01). Stepwise band adjustment from 1 to 8 mL had an immediate and profound effect on swallow-induced esophageal contractions: DCI increased from 766 ± 590.4 to 7231 ± 6298.1 mmHg s(-1)  cm(-1) , IBP from 4.3 mmHg to 31.1 ± 17.3 mmHg, and intraband pressure increased from -109.1 ± 60.6 mmHg to 150.2 ± 65 mmHg. During band filling with volumes >5 mL, upward displacement of the LES was observed, indicative of shortening of the esophagus; the distance between the UES and LES decreased from 23.5 ± 1.3 cm at 0 mL to 19.9 ± 2 cm at 8 mL.

CONCLUSIONS & INFERENCES

Stepwise gastric band adjustment leads to immediate enforcement of esophageal peristalsis associated with an increase in intrabolus pressure and with pronounced esophageal shortening. Subjects who lack these responses to outflow obstruction may be more prone to dysphagia after band placement.

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.

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.

Impact of bariatric surgery on comorbidities

Published data show that bariatric surgery not only leads to significant and sustained weight loss but also resolves or improves multiple comorbidities associated with morbid obesity. Evidence suggests that the earlier the intervention the better the resolution of comorbidities. Patients with metabolic syndrome and comorbidities associated with morbid obesity should be promptly referred for consideration for bariatric surgery earlier in the disease process.

Gastric emptying of orally administered glucose solutions and incretin hormone responses are unaffected by laparoscopic adjustable gastric banding

BACKGROUND

Laparoscopic adjustable gastric banding (LAGB) provides weight loss in obese individuals and is associated with improved glucose homeostasis and resolution of type 2 diabetes. However, in most available reports, potentially inappropriate methodology has been applied when measuring the impact of LAGB on glucose intolerance. In order to clarify the applicability of the diagnostic 75 g-oral glucose tolerance test (OGTT) to measure the effect of LAGB on glucose metabolism, we investigated the effect of LAGB on gastric emptying for liquids as well as pancreatic and incretin hormone responses.

METHODS

Eight obese patients (three with normal glucose tolerance, three with impaired glucose tolerance, and two with type 2 diabetes; age 47.5 ± 1.1 years (mean±SEM); body mass index 44 ± 1 kg/m²; HbA(1)c 6.2 ± 0.4%) underwent a 75 g-oral glucose tolerance test with 1 g acetaminophen before and ~6 weeks after LAGB.

RESULTS

A small weight reduction was seen after LAGB (125 ± 8 vs. 121 ± 8 kg, P = 0.014). No differences in determinants of gastric emptying were observed before and after LAGB (area under the serum acetaminophen curve 10.1 ± 0.6 vs. 9.8 ± 0.5 mM x 4 h, P = 0.8; peak acetaminophen concentration 62 ± 3 vs. 61 ± 3 μM, P = 0.8; acetaminophen peak time 98 ± 6 vs. 100 ± 6 min, P = 0.9). No differences in plasma glucose, insulin, C-peptide, glucagon, glucose-dependent insulinotropic polypeptide, or glucagon-like peptide-1 responses to the OGTT were observed before as compared to after LAGB.

CONCLUSIONS

OGTT can be used to evaluate glucose tolerance in obese patients before and after LAGB without bias from changes in gastric emptying. LAGB has no direct impact on incretin hormone secretion.

Mechanisms of bolus clearance in patients with laparoscopic adjustable gastric bands

BACKGROUND

The components of esophageal function important to success with laparoscopic adjustable gastric banding (LAGB) are not well understood. A pattern of delayed, however, successful bolus transit across the LAGB is observed.

METHODS

Successful LAGB patients underwent a high-resolution video manometry study in which bolus clearance, flow, and intraluminal pressures were recorded. Liquid and semi-solid swallows and stress barium (a combination of semi-solid swallows and liquid barium) were performed. A new measurement, the lower esophageal contractile segment (LECS), was defined and evaluated.

RESULTS

Twenty patients participated (mean age 48.3 +/- 12.0 years, four men, %excess weight loss 65.6 +/- 18.0). During semi-solid swallows, two patterns of esophageal clearance were observed: firstly, a native pattern (n = 10) similar to that which is expected in non-LAGB patients; secondly, a lower esophageal sphincter-dependent pattern (n = 7), where flow only occurred when the intrabolus pressure increased during the lower esophageal sphincter (LES) aftercontraction. In both patterns, if there was incomplete bolus clearance, reflux was observed and was usually followed by another swallow. A mean of 4.5 +/- 2.9 contractions were required to clear the semi-solid bolus. Contractions with an intact LECS demonstrated longer flow duration: 7.1 +/- 3.8 vs.1.6 +/- 3.2 s, p < 0.005. During the stress barium, an intrabolus pressure of 44.5 +/- 16.0 mm Hg leads to cessation of intake.

CONCLUSIONS

In LAGB patients, normal esophageal peristaltic contractions transition to a LES aftercontraction, producing trans-LAGB flow. Repeated contractions are required to clear a semi-solid bolus. Incorporating measurements of the LECS into assessments of esophageal motility in LAGB patients may improve the usefulness of this investigation.

Criteria for assessing esophageal motility in laparoscopic adjustable gastric band patients: the importance of the lower esophageal contractile segment

BACKGROUND

Esophageal function appears critical in laparoscopic adjustable gastric band (LAGB) patients; however, conventional motility assessments have not proven to be clinically useful. Recent combined video fluoroscopic and high-resolution manometric studies have identified important components of esophageal function in LAGB patients.

METHODS

Successful and symptomatic LAGB patients, with normal or mildly impaired esophageal peristalsis, underwent a standardized, water swallow, high-resolution manometry protocol designed specifically to assess the lower esophageal contractile segment (LECS), in combination with conventional measures of esophageal motility. Differences in response to changes in LAGB volume were assessed.

RESULTS

There were 101 symptomatic and 29 successful patients. More symptomatic patients had a mild impairment in esophageal motility (39.6% vs. 3.4%, p < 0.005). Successful patients demonstrated an intact LECS during normal swallows more frequently than symptomatic patients (95% vs. 43%, p < 0.005). Absolute intraluminal pressures were not different between the groups. Removing all fluid from the LAGB revealed more hypotensive swallows in the symptomatic patients (30% vs. 17%, p = 0.002), an effect not observed when the LAGB volume was increased (8% vs. 5%, p = 0.21). Receiver operator characteristic analysis determined that an intact LECS in 70% of normal swallows defined normal motility in LAGB patients.

CONCLUSIONS

The LECS is a valuable measure of esophageal function in LAGB patients and complements conventional manometric criteria. Symptomatic patients have less normal swallows; however, these also frequently demonstrate a deficient LECS. Further information can be elucidated by performing swallows at differing LAGB volumes. High-resolution manometry, using these adapted criteria, is now a useful in the investigation in symptomatic LAGB patients.