REVIEW URRENT C OPINION
Effects of bariatric surgery on gastroesophageal reflux Radu Tutuian a,b
Purpose of review Obesity and gastroesophageal reflux disease (GERD) are two prevalent conditions with important impact on health resource utilization around the world. Obesity is a known risk factor in the pathogenesis of GERD. When conservative measures fail, bariatric surgery remains the only option to lose weight and correct obesity-related comorbidities. The influence of bariatric surgery on GERD depends on which bariatric intervention is used. Recent findings Recent studies indicate that laparoscopic gastric banding and laparoscopic sleeve gastrectomy have little influence on preexisting GERD symptoms and findings, but some patients may develop GERD after laparoscopic sleeve gastrectomy. A number of studies have documented that laparoscopic Roux-en-Y gastric bypass improves GERD symptoms and findings, making it the preferred procedure for morbid obese patients with concomitant GERD. Summary Current findings provide good arguments for searching for and treating GERD in patients scheduled to undergo bariatric surgery. The presence of GERD might represent a relative contraindication for sleeve gastrectomy or gastric banding or both. Gastric bypass might be the procedure of choice in morbid obese patients with GERD symptoms or findings or both. Keywords gastric banding, gastric bypass, gastric sleeve, gastroesophageal reflux disease, upper gastrointestinal endoscopy
INTRODUCTION Gastroesophageal reflux disease (GERD) is one of the most prevalent chronic gastrointestinal diseases, with an estimated 20–30% of the US adult population experiencing heartburn or acid regurgitation or both at least once a week [1]. Obesity is considered a major risk factor in the pathogenesis of GERD, and approximately 50% of morbidly obese patients have signs or symptoms of GERD [2]. The prevalence of morbidly obese individuals [body mass index (BMI) > 35 kg/m2] more than doubled in the period from 1989–1991 to 2006–2008, rising from 7.1% to 14.8% [3], a trend that has had substantial impact on healthcare delivery resources. Since many of these patients fail conventional pharmacologic and dietary therapies for obesity, bariatric surgery remains the only viable option. Laparoscopic adjustable gastric banding (LAGB), laparoscopic sleeve gastrectomy (LSG), and Rouxen-Y gastric bypass (RYGB) are the most common bariatric interventions. Sleeve gastrectomy and gastric bypass achieve comparable weight loss results, www.co-gastroenterology.com
but the operations appear to differ in their effects on obesity-associated comorbidities (i.e. hypertension and GERD) [4]. Data from large databases suggest that all of the common bariatric procedures usually improve GERD symptoms, with RYGB being superior to LAGB and LSG in this regard [5]. Yet, smaller prospective studies indicate that LSG can induce de-novo GERD in some patients [6 ]. This review presents data from studies investigating the effects of common bariatric procedures (LAGB, LSG, and RYGB) on gastroesophageal reflux &&
a
Division of Gastroenterology, University Clinic of Visceral Surgery and Medicine, Bern University Hospital, Inselspital Bern, Bern and bDivision of Gastroenterology, Regional Hospital Langenthal, Langenthal, Switzerland Correspondence to Radu Tutuian, MD, PhD, Division of Gastroenterology, University Clinic for Visceral Surgery and Medicine, Bern University Hospital, INO A152, Inselspital Bern, CH-3010 Bern, Switzerland. Tel: +41 31 632 5900; fax: +41 31 632 5919; e-mail: [email protected] Curr Opin Gastroenterol 2014, 30:434–438 DOI:10.1097/MOG.0000000000000083 Volume 30 Number 4 July 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Effects of bariatric surgery on GERD Tutuian
KEY POINTS GERD symptoms and findings are present in more than half of obese patients. Gastric banding and sleeve gastrectomy have limited effect on GERD, although some patients may develop ‘de-novo’ GERD following these procedures. Gastric bypass is to date the optimal bariatric procedure for patients with GERD symptoms or findings or both.
and is based on original studies published in English in Medline between 2000 and 2014.
EFFECT OF BARIATRIC SURGERY ON GASTROESOPHAGEAL REFLUX DISEASE The most frequently used bariatric procedures include gastric banding, gastric bypass, and sleeve gastrectomy. These procedures have been shown to be effective in weight reduction (their primary goal), but influence gastroesophageal reflux in various ways.
Gastric banding Gastric banding is a restrictive bariatric procedure in which an adjustable band is placed around the proximal stomach along with a subcutaneous reservoir that allows adjustments in the diameter of the band, depending on the amount of fluid injected into the band. The filling of the band is adjusted according to the patient’s symptoms and weight loss. Because this procedure does not open any segment of the gastrointestinal tract, it has the lowest risk of intra-abdominal leakage among the bariatric operations. Concerns that this procedure might worsen gastroesophageal reflux have been based on the concept that fluid and food retained in the pouch easily could reflux into the esophagus and that distension of the pouch might alter LES pressure dynamics unfavorably [7]. In 2006, Tolonen et al. [8] investigated whether gastric banding reduced or increased gastroesophageal reflux. Thirty-one patients (male/female ¼ 5/26, mean age 44 11 standard deviation years) had symptom assessment, upper gastrointestinal endoscopy, and 24-h esophageal pH and manometry recordings prior to and after gastric banding. The proportion of patients reporting GERD symptoms decreased from 48.4% to 16.1% (P ¼ 0.01), the use of GERD medication decreased from 35.5% to 12.9% (P ¼ 0.05), and the proportion of patients with normal distal esophageal acid exposure on 24-h pH
monitoring increased from 22.6% to 62.5% (P ¼ 0.01). Total number of pH-detected reflux episodes decreased from 44.6 23.7 preoperatively to 22.9 17.1 postoperatively (P < 0.001), distal esophageal acid exposure (% time pH < 4) decreased from 9.5% 6.2% to 3.5% 3.7% (P < 0.001), and the DeMeester score decreased from 38.5 24.9 to 18.6 20.4 (P ¼ 0.03). On the basis of these data, the authors concluded that a correctly placed gastric band is an effective antireflux barrier. In 2007, Merrouche et al. [9] evaluated gastroesophageal reflux and esophageal motility before and after either adjustable gastric band (AGB) placement or laparoscopic Roux-en-Y gastric bypass (LRYGB). Out of 100 consecutive patients evaluated initially, four declined surgery or were lost to follow-up, 60 underwent AGB, and 36 had RYGB. Preoperative and postoperative assessment data (including symptoms, upper gastrointestinal endoscopy, esophageal manometry, and 24-h pH monitoring) were obtained from 12 of the 60 (20%) patients who underwent AGB, and 15 of the 36 (41%) who underwent LRYGB. GERD symptoms improved in both AGB (preoperatively 58.3% versus postoperatively 16.7%; P ¼ 0.09) and RYGB (preoperatively 100% versus postoperatively 42.9%; P ¼ 0.09) groups. Postoperative objective measurements found esophageal motility abnormalities in 42% of patients who had AGB (preoperatively 0%; P ¼ 0.04) but in none of the patients who had RYGB (preoperatively 7%; P ¼ ns) and found abnormal DeMeester scores in 52% of patients who had AGB (preoperatively 12%; P ¼ 0.09) but in only 6% of patients who had RYGB (preoperatively 25%; P < 0.001). On the basis of these findings, the authors concluded that AGB has an increased risk of resulting in objectively documented gastroesophageal reflux, esophageal function evaluation should be performed prior to bariatric surgery, and RYGB should be offered to patients with documented reflux. In 2010, Rebecchi et al. [10] reported on the effects of laparoscopic adjustable silicone gastric banding (LASGB) versus laparoscopic vertical banded gastroplasty (LVBG) on GERD in a series of 100 patients. Patients were randomly assigned to either LASBG or LVBG and were asked to complete the gastroesophageal reflux health-related quality-of-life (GERD-HRQOL) questionnaire at 3, 12, and 96 months after the operation. Upper gastrointestinal endoscopy, esophageal manometry, and 24-h esophageal pH monitoring were performed at 12 and 96 months postoperatively. At the one-year follow up, 13 (26%) LASGB and 11 (21.6%) LVBG patients developed GERD. In most cases, GERD was attributed to pouch dilation or poor compliance and
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was treated either with reoperation (10 LASGB patients and 3 LVBG patients) or endoscopic dilation of the neopylorus (four LVBG patients). Eight years following bariatric surgery, 3 of 26 (11.5%) patients who underwent LASGB and 4 of 45 (9%) who had LVBG were treated with proton pump inhibitors for GERD. On the basis of these data, the authors concluded that, in the long term, gastric restrictive procedures do not increase the prevalence of GERD, and the increased incidence of GERD in the early followup is often due to technical defects or poor patient compliance.
Gastric sleeve The gastric sleeve operation involves creating a tubular stomach that extends from the cardia to the pylorus, with the diameter of the tube calibrated using a bougie that is passed into the stomach intraoperatively. The resulting gastric sleeve decreases the size of the gastric reservoir and, by removing a large part of the gastric fundus, leads to decreased levels of the appetite-stimulating hormone ghrelin [11]. In 2006, Himpens et al. [12] reported on the 1-year and 3-year results of a prospective, randomized study comparing laparoscopic gastric banding (LGB) and LSG. Eighty candidates for bariatric surgery were randomized to undergo either laparoscopic gastric band (40 patients) or LSG (40 patients). At the 1-year and 3-year follow-up visits, patients who had LSG lost a median of 26 kg (range, 1–46 kg) and 29.5 kg (range, 0–45 kg), respectively, whereas patients who had LGB lost 14 kg (range, 5–38 kg) and 17 kg (range, 0–40 kg), respectively (P < 0.05 for both comparisons). ‘De-novo’ GERD symptoms were reported by 9% (LGB) and 22% (LSG) of patients at 1 year. An interesting observation was that, at 3 years, the prevalence of ‘de-novo’ GERD continued to increase in the LGB group (to 21%), but decreased in the LSG group (to 3%). Although acknowledging the increased prevalence of GERD at 1 year, the authors highlighted the observation that the prevalence of GERD decreased at 3 years after LSG. In 2011, Carter et al. [13] reported on the association between GERD and LSG. This retrospective chart review included 176 patients who underwent LSG. The preoperative average BMI was 46.6 kg/m2 (range, 33.2–79.6), and the average percentage of excess body weight lost at 6, 12, and 24 months was 54.2%, 60.7%, and 60.3%, respectively. The authors noted that, prior to the operation, 35% of patients reported GERD symptoms and 22% were taking medication specifically for GERD. After LSG, the percentage of patients with GERD symptoms 436
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increased to 49% immediately (within 30 days) after the operation, and 47% of patients had persistent GERD symptoms that lasted more than 1 month after LSG. The percentage of patients taking medications for GERD also increased postoperatively to 34%. On the basis of these findings, the authors concluded that GERD symptoms do not improve after LSG in patients with preoperative symptoms despite the significant weight loss. Tai et al. [14] reported similar findings in 2013 in a study of 66 patients (49 female/17 male) who underwent LSG. In addition to reflux symptoms, the authors performed upper gastrointestinal endoscopies before and 12 months after LSG. Even though there was a significant decrease in BMI (preoperatively 36.3 4.1 versus postoperatively 25.8 2.9 kg/m2; P < 0.001), waist circumference (preoperatively 109.5 12.8 versus postoperatively 85.7 9.5 cm; P < 0.001) and prevalence of metabolic syndrome (54.5% versus 7.6%; P < 0.001), the prevalence of GERD symptoms (12.1% versus 47%; P < 0.001), and erosive esophagitis increased (16.7% versus 66.7%; P < 0.001) after LSG. These findings suggest that LSG might not be the right bariatric procedure in patients with GERD symptoms. In summary, there is an overall trend indicating an increased prevalence in esophageal erosions and GERD symptoms in patients who have sleeve gastrectomy. Other investigators have presented data arguing that the shape of the remaining stomach, decreased wall tension, decreased acid production, and decreased abdominal obesity may influence the development of reflux, and that revising/re-designing sleeve gastrectomy with these factors in mind could help to prevent patients from developing GERD following bariatric surgery [15 ]. &
Gastric bypass Roux-en-Y gastric bypass is a complex bariatric procedure that involves stapling the stomach to create a small gastric pouch, dividing and stapling the small intestine (typically jejunum), and then re-establishing continuity of the gastrointestinal tract by attaching a loop of jejunum to the gastric pouch (gastrojejunal anastomosis) and connecting the diverted stomach, duodenum, and proximal jejunum back to the jejunum (jejunal-jejunal anastomosis). The procedure is highly effective, leading to sustained loss of 60–70% of excessive weight even 10 years after the procedure [16 ]. In a meta-analysis including 6526 patients from 32 studies, Li et al. [17] compared the long-term results of LSG and LRYGB. While LSG took significantly less time to be performed (76.6 28.0 min versus 106.2 33.2 min; P < 0.01 [18]) compared &
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Effects of bariatric surgery on GERD Tutuian
with LRYGB and achieved similar long-term weight loss results (82.7 18.0% excess weight loss versus 80.9 16.7% excess weight loss; P ¼ ns [19]), LYRGB was more likely to improve type II diabetes mellitus [odds ratio (OR): 1.49; 95% confidence interval (CI): 1.04–2.12], hypertension (OR: 1.47; 95% CI: 1.15–1.86), hypercholesterolemia (OR: 2.41; 95% CI: 1.87–3.11), and GERD (OR: 8.99; 95% CI: 4.77– 16.95). The superiority of RYGB in improving obesity-related comorbidities came at the price of higher surgical complication rates and need for reoperation compared to LSG. The authors concluded correctly that it is difficult to recommend one operation over the other for weight loss, but acknowledged that LRYGB might be preferred if the goal is to improve obesity related comorbidities. In a recently published prospective, randomized study, Peterli et al. [20 ] compared the effects of LSG and LRYGB on various comorbidities. The authors randomized 217 patients with a BMI between 35 and 61 kg/m2 to undergo either LSG (107 patients) or LRYGB (110 patients). While there was no difference between the groups in the percentage of patients with improvement of hypertension, type II diabetes, dyslipidemia, and obstructive sleep symptoms, the study revealed that only 50% of patients who underwent LSG had improved GERD compared with 75% of patients who had LRYGB (P ¼ 0.008). Furthermore, new-onset GERD was noted in 12.5% of patients who had LSG compared with only 4% of patients treated with LRYGB (P ¼ 0.12). Early in 2014, Dupree et al. [21 ] reported the largest comparison between LSG and LRYGB to date, based on data from the Bariatric Outcomes Longitudinal Database. This retrospective study included data from 4832 patients who underwent LSG and 33 867 who had LRYGB from January 1, 2007, through December 31, 2010. The authors focused the analysis on patients with preexisting GERD, which was present in 45% of patients who had LSG and 50% of those who had LRYGB. Following LSG, most patients (84.1%) continued to have GERD symptoms, and 9.0% reported worsening of their GERD symptoms. In contrast, LRYGB was associated with complete resolution of GERD symptoms in most patients (62.8%), stabilization of symptoms in 17.6%, and worsening of symptoms in only 2.2% (all P < 0.05 LRYGB versus LSG). On the basis of these findings, the authors concluded that patients should be evaluated for GERD prior to bariatric surgery, and GERD may represent a contraindication to LSG.
factor for the development of GERD. Approximately one-half of morbidly obese patients have objectively documented GERD (by either endoscopy or esophageal pH monitoring), even though some patients with these abnormalities do not report reflux symptoms. Published data on the effects of gastric banding on GERD reveal conflicting results. Sleeve gastrectomy appears to have little/no influence on preexisting GERD, but may lead to the development of GERD in up to 10% of patients without prior reflux symptoms. Large cohort data indicate that Roux-en-Y gastric bypass improves GERD symptoms and findings in most patients. In conclusion, from an esophageal perspective, the preferred bariatric procedure to date is the LRYGB, and the presence of GERD may represent a contraindication to LSG.
&
&&
SUMMARY AND CONCLUSION At the present time, obesity and GERD are two highly prevalent conditions, and obesity is a risk
Acknowledgements None. Conflicts of interest There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Locke GR III, Talley NJ, Fett SL, et al. Prevalence and clinical spectrum of gastroesophageal re-flux: a population-based study in Olmsted County, Minnesota. Gastroenterology 1997; 112:1448–1456. 2. Prachand V, Alverdy JC. Gastroesophageal reflux disease and severe obesity: fundoplication or bariatric surgery? World J Gastroenterol 2010; 16:3757– 3761. 3. Hamlin RJ, Sprung J, Hofer RE, et al. Obesity trends in the surgical population at a large academic center: a comparison between 1989–1991 to 2006– 2008 epochs. Acta Chir Belg 2013; 113:397–400. 4. Yaghoubian A, Tolan A, Stabile BE, et al. Laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy achieve comparable weight loss at 1 year. Am Surg 2012; 78:1325–1328. 5. Pallati PK, Shaligram A, Shostrom VK, et al. Improvement in gastroesophageal reflux disease symptoms after various bariatric procedures: review of the Bariatric Outcomes Longitudinal Database. Surg Obes Relat Dis 2013; pii: S1550-7289(13)00259-1 [Epub ahead of print] 6. Del Genio G, Tolone S, Limongelli P, et al. Sleeve gastrectomy and devel&& opment of ‘de novo’ gastroesophageal reflux. Obes Surg 2014; 24:71–77. Important study highlighting the development of de-novo GERD symptoms following sleeve gastrectomy. 7. O’Rourke RW, Seltman AK, Chang EY, et al. A model for gastric banding in the treatment of morbid obesity: the effect of chronic partial gastric outlet obstruction on esophageal physiology. Ann Surg 2006; 244:723–733. 8. Tolonen P, Victorzon M, Niemi R, Ma¨kela¨ J. Does gastric banding for morbid obesity reduce or increase gastroesophageal reflux? Obes Surg 2006; 16:1469–1474. 9. Merrouche M, Sabate´ JM, Jouet P, et al. Gastro-esophageal reflux and esophageal motility disorders in morbidly obese patients before and after bariatric surgery. Obes Surg 2007; 17:894–900. 10. Rebecchi F, Rocchietto S, Giaccone C, et al. Gastroesophageal reflux disease and esophageal motility in morbidly obese patients submitted to laparoscopic adjustable silicone gastric banding or laparoscopic vertical banded gastroplasty. Surg Endosc 2011; 25:795–803. 11. Langer FB, Reza Hoda MA, Bohdjalian A, et al. Sleeve gastrectomy and gastric banding: effects on plasma ghrelin levels. Obes Surg 2005; 15:1024–1029. 12. Himpens J, Dapri G, Cadie`re GB. A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: results after 1 and 3 years. Obes Surg 2006; 16:1450–1456.
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Esophagus 13. Carter PR, LeBlanc KA, Hausmann MG, et al. Association between gastroesophageal reflux disease and laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2011; 7:569–572. 14. Tai CM, Huang CK, Lee YC, et al. Increase in gastroesophageal reflux disease symptoms and erosive esophagitis 1 year after laparoscopic sleeve gastrectomy among obese adults. Surg Endosc 2013; 27:1260–1266. 15. Laffin M, Chau J, Gill RS, et al. Sleeve gastrectomy and gastroesophageal & reflux disease. J Obes 2013; 2013:741097. Excellent review of the literature highlighting the complex relationship between GERD and sleeve gastrectomy. 16. Hsieh T, Zurita L, Grover H, et al. 10-year outcomes of the vertical transected & gastric bypass for obesity: a systematic review. Obes Surg 2014; 24:456–461. Good systematic review with long-term data of vertical transected gastric bypass. 17. Li JF, Lai DD, Lin ZH, et al. Comparison of the long-term results of Roux-en-Y gastric bypass and sleeve gastrectomy for morbid obesity: a systematic review and meta-analysis of randomized and nonrandomized trials. Surg Laparosc Endosc Percutan Tech 2014; 24:1–11.
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18. Boza C, Gamboa C, Salinas J, et al. Laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy: a case–control study and 3 years of follow-up. Surg Obes Relat Dis 2012; 8:243–249. 19. Benaiges D, Flores-Le-Roux JA, Pedro-Botet J, et al. Impact of restrictive (sleeve gastrectomy) vs hybrid bariatric surgery (Roux-en-Y gastric bypass) on lipid profile. Obes Surg 2012; 22:1268–1275. 20. Peterli R, Borbe´ly Y, Kern B, et al. Early results of the Swiss Multicentre & Bypass or Sleeve Study (SM-BOSS): a prospective randomized trial comparing laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass. Ann Surg 2013; 258:690–694. Preliminary data from a prospectively designed study comparing sleeve gastrectomy and gastric bypass. 21. Dupree CE, Blair K, Steele SR, Martin MJ. Laparoscopic sleeve gastrectomy && in patients with preexisting gastroesophageal reflux disease: a national analysis. JAMA Surg 2014; 149:328–334. [Epub ahead of print] To date the largest comparison between sleeve gastrectomy and gastric bypass with respect to GERD symptoms and findings.
Volume 30 Number 4 July 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Effects of bariatric surgery on gastroesophageal reflux Radu Tutuian a,b
Purpose of review Obesity and gastroesophageal reflux disease (GERD) are two prevalent conditions with important impact on health resource utilization around the world. Obesity is a known risk factor in the pathogenesis of GERD. When conservative measures fail, bariatric surgery remains the only option to lose weight and correct obesity-related comorbidities. The influence of bariatric surgery on GERD depends on which bariatric intervention is used. Recent findings Recent studies indicate that laparoscopic gastric banding and laparoscopic sleeve gastrectomy have little influence on preexisting GERD symptoms and findings, but some patients may develop GERD after laparoscopic sleeve gastrectomy. A number of studies have documented that laparoscopic Roux-en-Y gastric bypass improves GERD symptoms and findings, making it the preferred procedure for morbid obese patients with concomitant GERD. Summary Current findings provide good arguments for searching for and treating GERD in patients scheduled to undergo bariatric surgery. The presence of GERD might represent a relative contraindication for sleeve gastrectomy or gastric banding or both. Gastric bypass might be the procedure of choice in morbid obese patients with GERD symptoms or findings or both. Keywords gastric banding, gastric bypass, gastric sleeve, gastroesophageal reflux disease, upper gastrointestinal endoscopy
INTRODUCTION Gastroesophageal reflux disease (GERD) is one of the most prevalent chronic gastrointestinal diseases, with an estimated 20–30% of the US adult population experiencing heartburn or acid regurgitation or both at least once a week [1]. Obesity is considered a major risk factor in the pathogenesis of GERD, and approximately 50% of morbidly obese patients have signs or symptoms of GERD [2]. The prevalence of morbidly obese individuals [body mass index (BMI) > 35 kg/m2] more than doubled in the period from 1989–1991 to 2006–2008, rising from 7.1% to 14.8% [3], a trend that has had substantial impact on healthcare delivery resources. Since many of these patients fail conventional pharmacologic and dietary therapies for obesity, bariatric surgery remains the only viable option. Laparoscopic adjustable gastric banding (LAGB), laparoscopic sleeve gastrectomy (LSG), and Rouxen-Y gastric bypass (RYGB) are the most common bariatric interventions. Sleeve gastrectomy and gastric bypass achieve comparable weight loss results, www.co-gastroenterology.com
but the operations appear to differ in their effects on obesity-associated comorbidities (i.e. hypertension and GERD) [4]. Data from large databases suggest that all of the common bariatric procedures usually improve GERD symptoms, with RYGB being superior to LAGB and LSG in this regard [5]. Yet, smaller prospective studies indicate that LSG can induce de-novo GERD in some patients [6 ]. This review presents data from studies investigating the effects of common bariatric procedures (LAGB, LSG, and RYGB) on gastroesophageal reflux &&
a
Division of Gastroenterology, University Clinic of Visceral Surgery and Medicine, Bern University Hospital, Inselspital Bern, Bern and bDivision of Gastroenterology, Regional Hospital Langenthal, Langenthal, Switzerland Correspondence to Radu Tutuian, MD, PhD, Division of Gastroenterology, University Clinic for Visceral Surgery and Medicine, Bern University Hospital, INO A152, Inselspital Bern, CH-3010 Bern, Switzerland. Tel: +41 31 632 5900; fax: +41 31 632 5919; e-mail: [email protected] Curr Opin Gastroenterol 2014, 30:434–438 DOI:10.1097/MOG.0000000000000083 Volume 30 Number 4 July 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Effects of bariatric surgery on GERD Tutuian
KEY POINTS GERD symptoms and findings are present in more than half of obese patients. Gastric banding and sleeve gastrectomy have limited effect on GERD, although some patients may develop ‘de-novo’ GERD following these procedures. Gastric bypass is to date the optimal bariatric procedure for patients with GERD symptoms or findings or both.
and is based on original studies published in English in Medline between 2000 and 2014.
EFFECT OF BARIATRIC SURGERY ON GASTROESOPHAGEAL REFLUX DISEASE The most frequently used bariatric procedures include gastric banding, gastric bypass, and sleeve gastrectomy. These procedures have been shown to be effective in weight reduction (their primary goal), but influence gastroesophageal reflux in various ways.
Gastric banding Gastric banding is a restrictive bariatric procedure in which an adjustable band is placed around the proximal stomach along with a subcutaneous reservoir that allows adjustments in the diameter of the band, depending on the amount of fluid injected into the band. The filling of the band is adjusted according to the patient’s symptoms and weight loss. Because this procedure does not open any segment of the gastrointestinal tract, it has the lowest risk of intra-abdominal leakage among the bariatric operations. Concerns that this procedure might worsen gastroesophageal reflux have been based on the concept that fluid and food retained in the pouch easily could reflux into the esophagus and that distension of the pouch might alter LES pressure dynamics unfavorably [7]. In 2006, Tolonen et al. [8] investigated whether gastric banding reduced or increased gastroesophageal reflux. Thirty-one patients (male/female ¼ 5/26, mean age 44 11 standard deviation years) had symptom assessment, upper gastrointestinal endoscopy, and 24-h esophageal pH and manometry recordings prior to and after gastric banding. The proportion of patients reporting GERD symptoms decreased from 48.4% to 16.1% (P ¼ 0.01), the use of GERD medication decreased from 35.5% to 12.9% (P ¼ 0.05), and the proportion of patients with normal distal esophageal acid exposure on 24-h pH
monitoring increased from 22.6% to 62.5% (P ¼ 0.01). Total number of pH-detected reflux episodes decreased from 44.6 23.7 preoperatively to 22.9 17.1 postoperatively (P < 0.001), distal esophageal acid exposure (% time pH < 4) decreased from 9.5% 6.2% to 3.5% 3.7% (P < 0.001), and the DeMeester score decreased from 38.5 24.9 to 18.6 20.4 (P ¼ 0.03). On the basis of these data, the authors concluded that a correctly placed gastric band is an effective antireflux barrier. In 2007, Merrouche et al. [9] evaluated gastroesophageal reflux and esophageal motility before and after either adjustable gastric band (AGB) placement or laparoscopic Roux-en-Y gastric bypass (LRYGB). Out of 100 consecutive patients evaluated initially, four declined surgery or were lost to follow-up, 60 underwent AGB, and 36 had RYGB. Preoperative and postoperative assessment data (including symptoms, upper gastrointestinal endoscopy, esophageal manometry, and 24-h pH monitoring) were obtained from 12 of the 60 (20%) patients who underwent AGB, and 15 of the 36 (41%) who underwent LRYGB. GERD symptoms improved in both AGB (preoperatively 58.3% versus postoperatively 16.7%; P ¼ 0.09) and RYGB (preoperatively 100% versus postoperatively 42.9%; P ¼ 0.09) groups. Postoperative objective measurements found esophageal motility abnormalities in 42% of patients who had AGB (preoperatively 0%; P ¼ 0.04) but in none of the patients who had RYGB (preoperatively 7%; P ¼ ns) and found abnormal DeMeester scores in 52% of patients who had AGB (preoperatively 12%; P ¼ 0.09) but in only 6% of patients who had RYGB (preoperatively 25%; P < 0.001). On the basis of these findings, the authors concluded that AGB has an increased risk of resulting in objectively documented gastroesophageal reflux, esophageal function evaluation should be performed prior to bariatric surgery, and RYGB should be offered to patients with documented reflux. In 2010, Rebecchi et al. [10] reported on the effects of laparoscopic adjustable silicone gastric banding (LASGB) versus laparoscopic vertical banded gastroplasty (LVBG) on GERD in a series of 100 patients. Patients were randomly assigned to either LASBG or LVBG and were asked to complete the gastroesophageal reflux health-related quality-of-life (GERD-HRQOL) questionnaire at 3, 12, and 96 months after the operation. Upper gastrointestinal endoscopy, esophageal manometry, and 24-h esophageal pH monitoring were performed at 12 and 96 months postoperatively. At the one-year follow up, 13 (26%) LASGB and 11 (21.6%) LVBG patients developed GERD. In most cases, GERD was attributed to pouch dilation or poor compliance and
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Esophagus
was treated either with reoperation (10 LASGB patients and 3 LVBG patients) or endoscopic dilation of the neopylorus (four LVBG patients). Eight years following bariatric surgery, 3 of 26 (11.5%) patients who underwent LASGB and 4 of 45 (9%) who had LVBG were treated with proton pump inhibitors for GERD. On the basis of these data, the authors concluded that, in the long term, gastric restrictive procedures do not increase the prevalence of GERD, and the increased incidence of GERD in the early followup is often due to technical defects or poor patient compliance.
Gastric sleeve The gastric sleeve operation involves creating a tubular stomach that extends from the cardia to the pylorus, with the diameter of the tube calibrated using a bougie that is passed into the stomach intraoperatively. The resulting gastric sleeve decreases the size of the gastric reservoir and, by removing a large part of the gastric fundus, leads to decreased levels of the appetite-stimulating hormone ghrelin [11]. In 2006, Himpens et al. [12] reported on the 1-year and 3-year results of a prospective, randomized study comparing laparoscopic gastric banding (LGB) and LSG. Eighty candidates for bariatric surgery were randomized to undergo either laparoscopic gastric band (40 patients) or LSG (40 patients). At the 1-year and 3-year follow-up visits, patients who had LSG lost a median of 26 kg (range, 1–46 kg) and 29.5 kg (range, 0–45 kg), respectively, whereas patients who had LGB lost 14 kg (range, 5–38 kg) and 17 kg (range, 0–40 kg), respectively (P < 0.05 for both comparisons). ‘De-novo’ GERD symptoms were reported by 9% (LGB) and 22% (LSG) of patients at 1 year. An interesting observation was that, at 3 years, the prevalence of ‘de-novo’ GERD continued to increase in the LGB group (to 21%), but decreased in the LSG group (to 3%). Although acknowledging the increased prevalence of GERD at 1 year, the authors highlighted the observation that the prevalence of GERD decreased at 3 years after LSG. In 2011, Carter et al. [13] reported on the association between GERD and LSG. This retrospective chart review included 176 patients who underwent LSG. The preoperative average BMI was 46.6 kg/m2 (range, 33.2–79.6), and the average percentage of excess body weight lost at 6, 12, and 24 months was 54.2%, 60.7%, and 60.3%, respectively. The authors noted that, prior to the operation, 35% of patients reported GERD symptoms and 22% were taking medication specifically for GERD. After LSG, the percentage of patients with GERD symptoms 436
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increased to 49% immediately (within 30 days) after the operation, and 47% of patients had persistent GERD symptoms that lasted more than 1 month after LSG. The percentage of patients taking medications for GERD also increased postoperatively to 34%. On the basis of these findings, the authors concluded that GERD symptoms do not improve after LSG in patients with preoperative symptoms despite the significant weight loss. Tai et al. [14] reported similar findings in 2013 in a study of 66 patients (49 female/17 male) who underwent LSG. In addition to reflux symptoms, the authors performed upper gastrointestinal endoscopies before and 12 months after LSG. Even though there was a significant decrease in BMI (preoperatively 36.3 4.1 versus postoperatively 25.8 2.9 kg/m2; P < 0.001), waist circumference (preoperatively 109.5 12.8 versus postoperatively 85.7 9.5 cm; P < 0.001) and prevalence of metabolic syndrome (54.5% versus 7.6%; P < 0.001), the prevalence of GERD symptoms (12.1% versus 47%; P < 0.001), and erosive esophagitis increased (16.7% versus 66.7%; P < 0.001) after LSG. These findings suggest that LSG might not be the right bariatric procedure in patients with GERD symptoms. In summary, there is an overall trend indicating an increased prevalence in esophageal erosions and GERD symptoms in patients who have sleeve gastrectomy. Other investigators have presented data arguing that the shape of the remaining stomach, decreased wall tension, decreased acid production, and decreased abdominal obesity may influence the development of reflux, and that revising/re-designing sleeve gastrectomy with these factors in mind could help to prevent patients from developing GERD following bariatric surgery [15 ]. &
Gastric bypass Roux-en-Y gastric bypass is a complex bariatric procedure that involves stapling the stomach to create a small gastric pouch, dividing and stapling the small intestine (typically jejunum), and then re-establishing continuity of the gastrointestinal tract by attaching a loop of jejunum to the gastric pouch (gastrojejunal anastomosis) and connecting the diverted stomach, duodenum, and proximal jejunum back to the jejunum (jejunal-jejunal anastomosis). The procedure is highly effective, leading to sustained loss of 60–70% of excessive weight even 10 years after the procedure [16 ]. In a meta-analysis including 6526 patients from 32 studies, Li et al. [17] compared the long-term results of LSG and LRYGB. While LSG took significantly less time to be performed (76.6 28.0 min versus 106.2 33.2 min; P < 0.01 [18]) compared &
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with LRYGB and achieved similar long-term weight loss results (82.7 18.0% excess weight loss versus 80.9 16.7% excess weight loss; P ¼ ns [19]), LYRGB was more likely to improve type II diabetes mellitus [odds ratio (OR): 1.49; 95% confidence interval (CI): 1.04–2.12], hypertension (OR: 1.47; 95% CI: 1.15–1.86), hypercholesterolemia (OR: 2.41; 95% CI: 1.87–3.11), and GERD (OR: 8.99; 95% CI: 4.77– 16.95). The superiority of RYGB in improving obesity-related comorbidities came at the price of higher surgical complication rates and need for reoperation compared to LSG. The authors concluded correctly that it is difficult to recommend one operation over the other for weight loss, but acknowledged that LRYGB might be preferred if the goal is to improve obesity related comorbidities. In a recently published prospective, randomized study, Peterli et al. [20 ] compared the effects of LSG and LRYGB on various comorbidities. The authors randomized 217 patients with a BMI between 35 and 61 kg/m2 to undergo either LSG (107 patients) or LRYGB (110 patients). While there was no difference between the groups in the percentage of patients with improvement of hypertension, type II diabetes, dyslipidemia, and obstructive sleep symptoms, the study revealed that only 50% of patients who underwent LSG had improved GERD compared with 75% of patients who had LRYGB (P ¼ 0.008). Furthermore, new-onset GERD was noted in 12.5% of patients who had LSG compared with only 4% of patients treated with LRYGB (P ¼ 0.12). Early in 2014, Dupree et al. [21 ] reported the largest comparison between LSG and LRYGB to date, based on data from the Bariatric Outcomes Longitudinal Database. This retrospective study included data from 4832 patients who underwent LSG and 33 867 who had LRYGB from January 1, 2007, through December 31, 2010. The authors focused the analysis on patients with preexisting GERD, which was present in 45% of patients who had LSG and 50% of those who had LRYGB. Following LSG, most patients (84.1%) continued to have GERD symptoms, and 9.0% reported worsening of their GERD symptoms. In contrast, LRYGB was associated with complete resolution of GERD symptoms in most patients (62.8%), stabilization of symptoms in 17.6%, and worsening of symptoms in only 2.2% (all P < 0.05 LRYGB versus LSG). On the basis of these findings, the authors concluded that patients should be evaluated for GERD prior to bariatric surgery, and GERD may represent a contraindication to LSG.
factor for the development of GERD. Approximately one-half of morbidly obese patients have objectively documented GERD (by either endoscopy or esophageal pH monitoring), even though some patients with these abnormalities do not report reflux symptoms. Published data on the effects of gastric banding on GERD reveal conflicting results. Sleeve gastrectomy appears to have little/no influence on preexisting GERD, but may lead to the development of GERD in up to 10% of patients without prior reflux symptoms. Large cohort data indicate that Roux-en-Y gastric bypass improves GERD symptoms and findings in most patients. In conclusion, from an esophageal perspective, the preferred bariatric procedure to date is the LRYGB, and the presence of GERD may represent a contraindication to LSG.
&
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SUMMARY AND CONCLUSION At the present time, obesity and GERD are two highly prevalent conditions, and obesity is a risk
Acknowledgements None. Conflicts of interest There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Locke GR III, Talley NJ, Fett SL, et al. Prevalence and clinical spectrum of gastroesophageal re-flux: a population-based study in Olmsted County, Minnesota. Gastroenterology 1997; 112:1448–1456. 2. Prachand V, Alverdy JC. Gastroesophageal reflux disease and severe obesity: fundoplication or bariatric surgery? World J Gastroenterol 2010; 16:3757– 3761. 3. Hamlin RJ, Sprung J, Hofer RE, et al. Obesity trends in the surgical population at a large academic center: a comparison between 1989–1991 to 2006– 2008 epochs. Acta Chir Belg 2013; 113:397–400. 4. Yaghoubian A, Tolan A, Stabile BE, et al. Laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy achieve comparable weight loss at 1 year. Am Surg 2012; 78:1325–1328. 5. Pallati PK, Shaligram A, Shostrom VK, et al. Improvement in gastroesophageal reflux disease symptoms after various bariatric procedures: review of the Bariatric Outcomes Longitudinal Database. Surg Obes Relat Dis 2013; pii: S1550-7289(13)00259-1 [Epub ahead of print] 6. Del Genio G, Tolone S, Limongelli P, et al. Sleeve gastrectomy and devel&& opment of ‘de novo’ gastroesophageal reflux. Obes Surg 2014; 24:71–77. Important study highlighting the development of de-novo GERD symptoms following sleeve gastrectomy. 7. O’Rourke RW, Seltman AK, Chang EY, et al. A model for gastric banding in the treatment of morbid obesity: the effect of chronic partial gastric outlet obstruction on esophageal physiology. Ann Surg 2006; 244:723–733. 8. Tolonen P, Victorzon M, Niemi R, Ma¨kela¨ J. Does gastric banding for morbid obesity reduce or increase gastroesophageal reflux? Obes Surg 2006; 16:1469–1474. 9. Merrouche M, Sabate´ JM, Jouet P, et al. Gastro-esophageal reflux and esophageal motility disorders in morbidly obese patients before and after bariatric surgery. Obes Surg 2007; 17:894–900. 10. Rebecchi F, Rocchietto S, Giaccone C, et al. Gastroesophageal reflux disease and esophageal motility in morbidly obese patients submitted to laparoscopic adjustable silicone gastric banding or laparoscopic vertical banded gastroplasty. Surg Endosc 2011; 25:795–803. 11. Langer FB, Reza Hoda MA, Bohdjalian A, et al. Sleeve gastrectomy and gastric banding: effects on plasma ghrelin levels. Obes Surg 2005; 15:1024–1029. 12. Himpens J, Dapri G, Cadie`re GB. A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: results after 1 and 3 years. Obes Surg 2006; 16:1450–1456.
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Esophagus 13. Carter PR, LeBlanc KA, Hausmann MG, et al. Association between gastroesophageal reflux disease and laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2011; 7:569–572. 14. Tai CM, Huang CK, Lee YC, et al. Increase in gastroesophageal reflux disease symptoms and erosive esophagitis 1 year after laparoscopic sleeve gastrectomy among obese adults. Surg Endosc 2013; 27:1260–1266. 15. Laffin M, Chau J, Gill RS, et al. Sleeve gastrectomy and gastroesophageal & reflux disease. J Obes 2013; 2013:741097. Excellent review of the literature highlighting the complex relationship between GERD and sleeve gastrectomy. 16. Hsieh T, Zurita L, Grover H, et al. 10-year outcomes of the vertical transected & gastric bypass for obesity: a systematic review. Obes Surg 2014; 24:456–461. Good systematic review with long-term data of vertical transected gastric bypass. 17. Li JF, Lai DD, Lin ZH, et al. Comparison of the long-term results of Roux-en-Y gastric bypass and sleeve gastrectomy for morbid obesity: a systematic review and meta-analysis of randomized and nonrandomized trials. Surg Laparosc Endosc Percutan Tech 2014; 24:1–11.
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18. Boza C, Gamboa C, Salinas J, et al. Laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy: a case–control study and 3 years of follow-up. Surg Obes Relat Dis 2012; 8:243–249. 19. Benaiges D, Flores-Le-Roux JA, Pedro-Botet J, et al. Impact of restrictive (sleeve gastrectomy) vs hybrid bariatric surgery (Roux-en-Y gastric bypass) on lipid profile. Obes Surg 2012; 22:1268–1275. 20. Peterli R, Borbe´ly Y, Kern B, et al. Early results of the Swiss Multicentre & Bypass or Sleeve Study (SM-BOSS): a prospective randomized trial comparing laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass. Ann Surg 2013; 258:690–694. Preliminary data from a prospectively designed study comparing sleeve gastrectomy and gastric bypass. 21. Dupree CE, Blair K, Steele SR, Martin MJ. Laparoscopic sleeve gastrectomy && in patients with preexisting gastroesophageal reflux disease: a national analysis. JAMA Surg 2014; 149:328–334. [Epub ahead of print] To date the largest comparison between sleeve gastrectomy and gastric bypass with respect to GERD symptoms and findings.
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