OBES SURG DOI 10.1007/s11695-013-1134-5
ORIGINAL CONTRIBUTIONS
Esophageal Dysmotility After Laparoscopic Gastric Band Surgery Philip A. Le Page & Sebastianus Kwon & Sarah J. Lord & Reginald V. Lord
# Springer Science+Business Media New York 2013
Abstract 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. P. A. Le Page : R. V. Lord Department of Upper Gastrointestinal Surgery, St. Vincent’s Hospital, Victoria St, Darlinghurst, Sydney, NSW 2010, Australia S. Kwon : R. V. Lord Gastroesophageal Cancer Research Program, St. Vincent’s Centre for Applied Medical Research, Darlinghurst, Sydney, Australia S. Kwon e-mail: [email protected] S. J. Lord Department of Epidemiology and Medical Statistics, School of Medicine, University of Notre Dame Australia, Darlinghurst, Sydney, NSW 2010, Australia e-mail: [email protected]
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. Keywords Obesity . Morbid obesity . Gastric band . Laparoscopic gastric band . Bariatric surgery . Esophageal dysmotility . Gastroesophageal reflux
R. V. Lord Department of Surgery, School of Medicine, University of Notre Dame Australia, Darlinghurst, Sydney, NSW 2010, Australia P. A. Le Page (*) : R. V. Lord (*) St Vincent’s Clinic, Suite 606, 438 Victoria Street, Darlinghurst, Sydney, NSW 2010, Australia e-mail: [email protected] e-mail: [email protected] R. V. Lord e-mail: [email protected]
Introduction Laparoscopic adjustable gastric band (LAGB) placement is a common bariatric operation that provides significantly better weight loss and reduction in obesity-related comorbid illnesses, especially type 2 diabetes mellitus [1–4], compared to conservative treatment options [1, 5–7].
OBES SURG
esophageal abnormality apart from hiatus hernia on a perioperative contrast study (preoperative in 47 patients and first postoperative day in three patients); and (3) at least one postoperative contrast study, with clinical data, performed more than 6 months after LAGB surgery. The swallow studies were performed as part of routine clinical care. The objective of the preoperative X-ray was to detect severe dysmotility that might contraindicate the placement of the LAGB prosthesis or to detect a hiatus hernia needing repair at the time of LAGB placement. The objective of the postoperative contrast swallow studies was to accurately fill the band to an optimum volume without the risk of port cannulation complications, creating a 3–4-mm luminal diameter with (ideally) few adjustments. Approval to conduct the study as a low-risk study not requiring individual patient consent was obtained from the ethics committee for this institution. The control perioperative contrast swallow method was based on the videoesophagram protocol developed at the University of Southern California [20]. Essentially, prone, supine, and erect video recordings of the esophagus were taken by asking the patient to swallow 10 ml boluses of mixed barium contrast agent [20].
The advantages of the LAGB operation are the low risk of major complications compared with the other bariatric operations and its reversibility [8, 9]. Disadvantages include the need for postoperative band adjustments, the occurrence of obstructive episodes during eating, and the need for band removal in a significant proportion of patients due to slippage, erosion, or difficulties with compliance and tolerability [7, 10]. The adverse effects of LAGB on the esophagus are increasingly well recognized. Although LAGB reportedly provides a significant improvement in gastroesophageal reflux as measured by distal esophageal acid exposure [11], the band can cause a bland regurgitation of recently ingested foods and drinks from the gastric pouch, which may not be detected by pH monitoring [11–13]. This reflux may manifest as cough, including nocturnal cough, as well as the typical reflux symptoms of heartburn and regurgitation. Post-LAGB reflux symptoms are variably improved by acid suppressant medications such as PPIs but usually need fluid or band removal for complete resolution. Esophageal dysmotility and dilatation as complications of LAGB have been reported in up to 69 and 26 % of patients, respectively [14–17]. These complications are thought to result in reduced esophageal clearance, which also increases the severity of gastroesophageal reflux [14, 18, 19]. Esophageal manometry studies performed at our institution on patients referred from other centers demonstrated that changes of severe dysmotility can be present after LAGB. These patients did not have preoperative motility testing, and their postoperative symptoms were severe enough to warrant referral for motility studies, so the significance of these observations is uncertain. It, nevertheless, seems noteworthy that 11 of the 13 patients studied by manometry at our institution had esophageal dysmotility, which was, primarily, low-amplitude body contractions with disordered peristalsis including pseudoachalasia patterns (median amplitude 45 mmHg, range 0–125 mmHg) or hypotonic lower esophageal sphincter. These findings together with the substantial rate of regurgitation and cough in the patients who underwent LAGB at this institution prompted this novel study on the radiological changes in the esophagus induced by LAGB and the clinical effects of these changes.
The patient was placed in modified Lloyd–Davies position with the surgeon between the patient's legs and the assistant to the left of patient. Optical entry was obtained using a 12-mm Endopath Xcel Bladeless Trocar (Ethicon Endo-Surgery, NJ, USA). After creating the pneumoperitoneum, the Nathanson liver retractor (Cook Surgical Bloomington, Indianapolis, USA) was placed through a subxiphoid incision, and three ports were placed in the right and left upper quadrants and the left flank. After excising the gastroesophageal fat pad and repairing a hiatus hernia if present, a retrogastric path for the band was created under direct vision using the pars flaccida technique. A Swedish adjustable gastric band (Obtech, Ethicon Endo-Surgery, New Jersey, USA) was secured in place with 0 Ethibond (Ethicon Endo-Surgery, NJ, USA) gastrogastric sutures. The port was subsequently secured on the external oblique aponeurosis.
Methods
Clinical Follow-up
Patients
Patients were seen by the surgeon postoperatively on day 1 and discharged on a bariatric fluid diet. They were seen again at 2 weeks, and the first band adjustment was performed at 3– 6 weeks. The band adjustments were performed under fluoroscopy in order to optimize cannulation and accurately adjust the fluid in the band. Further adjustments were performed when clinically indicated.
Fifty consecutive patients who underwent LAGB operation performed by the senior author (RVL) at this institution were studied retrospectively if they met the following inclusion criteria: (1) no history of previous gastroesophageal surgery; (2) no evidence of esophageal dysmotility, dilatation, or other
Operation
OBES SURG
Radiological Band Adjustments and Assessment of Esophageal Motility and Diameter The X-ray was done by one of three senior attending radiologists experienced in the technique. A screening shot was initially taken, and the port was cannulated with the patient in a 45° head-up position. The patient was asked to swallow barium, and dynamic images were taken focusing around the lower esophagus, hiatus, and gastric pouch. Fluid was added or removed depending on the surgeon's request and on the radiologists' assessment of contrast hold up in the pouch, stoma size, and the presence of esophageal dysmotility or dilatation. Dysmotility was defined as being present when there was clearly a significant abnormality in esophageal body motility, including the finding of stasis of contrast in the esophageal body sufficient to obscure the mucosal folds or overlying structures, significant reverse peristalsis or incoordinated tertiary waves, marked delayed passage of contrast, or diffuse esophageal spasm-like findings. Dilatation was defined as being present when the diameter of the distal esophagus was markedly increased when compared to the proximal esophagus or to that of the distal esophagus in a previous contrast videoesophagram study. In the presence of dilatation or dysmotility, fluid was removed from the band until there were dynamic signs of radiological improvement.
Symptoms that were routinely assessed and studied were dysphagia, reflux, or regurgitation requiring fluid removal. The effect of removing fluid from the band on these symptoms was also recorded and assessed. Analysis Continuous variables were summarized by calculating mean and standard deviation (SD) if normal distribution and median and range if non-normal distribution. Categorical variables were summarized by reporting frequencies. Statistical analyses were performed to explore associations between the presence of postoperative radiological abnormalities and patient age and operation outcomes (percent excess weight loss (%EWL), symptoms, symptom resolution following fluid removal, and band removal). For these analyses, two-tailed t tests for independent samples were used for continuous variables (mean age and %EWL), and Fishers exact chi-square test was used for categorical variables.For all statistical analyses, a p value of
ORIGINAL CONTRIBUTIONS
Esophageal Dysmotility After Laparoscopic Gastric Band Surgery Philip A. Le Page & Sebastianus Kwon & Sarah J. Lord & Reginald V. Lord
# Springer Science+Business Media New York 2013
Abstract 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. P. A. Le Page : R. V. Lord Department of Upper Gastrointestinal Surgery, St. Vincent’s Hospital, Victoria St, Darlinghurst, Sydney, NSW 2010, Australia S. Kwon : R. V. Lord Gastroesophageal Cancer Research Program, St. Vincent’s Centre for Applied Medical Research, Darlinghurst, Sydney, Australia S. Kwon e-mail: [email protected] S. J. Lord Department of Epidemiology and Medical Statistics, School of Medicine, University of Notre Dame Australia, Darlinghurst, Sydney, NSW 2010, Australia e-mail: [email protected]
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. Keywords Obesity . Morbid obesity . Gastric band . Laparoscopic gastric band . Bariatric surgery . Esophageal dysmotility . Gastroesophageal reflux
R. V. Lord Department of Surgery, School of Medicine, University of Notre Dame Australia, Darlinghurst, Sydney, NSW 2010, Australia P. A. Le Page (*) : R. V. Lord (*) St Vincent’s Clinic, Suite 606, 438 Victoria Street, Darlinghurst, Sydney, NSW 2010, Australia e-mail: [email protected] e-mail: [email protected] R. V. Lord e-mail: [email protected]
Introduction Laparoscopic adjustable gastric band (LAGB) placement is a common bariatric operation that provides significantly better weight loss and reduction in obesity-related comorbid illnesses, especially type 2 diabetes mellitus [1–4], compared to conservative treatment options [1, 5–7].
OBES SURG
esophageal abnormality apart from hiatus hernia on a perioperative contrast study (preoperative in 47 patients and first postoperative day in three patients); and (3) at least one postoperative contrast study, with clinical data, performed more than 6 months after LAGB surgery. The swallow studies were performed as part of routine clinical care. The objective of the preoperative X-ray was to detect severe dysmotility that might contraindicate the placement of the LAGB prosthesis or to detect a hiatus hernia needing repair at the time of LAGB placement. The objective of the postoperative contrast swallow studies was to accurately fill the band to an optimum volume without the risk of port cannulation complications, creating a 3–4-mm luminal diameter with (ideally) few adjustments. Approval to conduct the study as a low-risk study not requiring individual patient consent was obtained from the ethics committee for this institution. The control perioperative contrast swallow method was based on the videoesophagram protocol developed at the University of Southern California [20]. Essentially, prone, supine, and erect video recordings of the esophagus were taken by asking the patient to swallow 10 ml boluses of mixed barium contrast agent [20].
The advantages of the LAGB operation are the low risk of major complications compared with the other bariatric operations and its reversibility [8, 9]. Disadvantages include the need for postoperative band adjustments, the occurrence of obstructive episodes during eating, and the need for band removal in a significant proportion of patients due to slippage, erosion, or difficulties with compliance and tolerability [7, 10]. The adverse effects of LAGB on the esophagus are increasingly well recognized. Although LAGB reportedly provides a significant improvement in gastroesophageal reflux as measured by distal esophageal acid exposure [11], the band can cause a bland regurgitation of recently ingested foods and drinks from the gastric pouch, which may not be detected by pH monitoring [11–13]. This reflux may manifest as cough, including nocturnal cough, as well as the typical reflux symptoms of heartburn and regurgitation. Post-LAGB reflux symptoms are variably improved by acid suppressant medications such as PPIs but usually need fluid or band removal for complete resolution. Esophageal dysmotility and dilatation as complications of LAGB have been reported in up to 69 and 26 % of patients, respectively [14–17]. These complications are thought to result in reduced esophageal clearance, which also increases the severity of gastroesophageal reflux [14, 18, 19]. Esophageal manometry studies performed at our institution on patients referred from other centers demonstrated that changes of severe dysmotility can be present after LAGB. These patients did not have preoperative motility testing, and their postoperative symptoms were severe enough to warrant referral for motility studies, so the significance of these observations is uncertain. It, nevertheless, seems noteworthy that 11 of the 13 patients studied by manometry at our institution had esophageal dysmotility, which was, primarily, low-amplitude body contractions with disordered peristalsis including pseudoachalasia patterns (median amplitude 45 mmHg, range 0–125 mmHg) or hypotonic lower esophageal sphincter. These findings together with the substantial rate of regurgitation and cough in the patients who underwent LAGB at this institution prompted this novel study on the radiological changes in the esophagus induced by LAGB and the clinical effects of these changes.
The patient was placed in modified Lloyd–Davies position with the surgeon between the patient's legs and the assistant to the left of patient. Optical entry was obtained using a 12-mm Endopath Xcel Bladeless Trocar (Ethicon Endo-Surgery, NJ, USA). After creating the pneumoperitoneum, the Nathanson liver retractor (Cook Surgical Bloomington, Indianapolis, USA) was placed through a subxiphoid incision, and three ports were placed in the right and left upper quadrants and the left flank. After excising the gastroesophageal fat pad and repairing a hiatus hernia if present, a retrogastric path for the band was created under direct vision using the pars flaccida technique. A Swedish adjustable gastric band (Obtech, Ethicon Endo-Surgery, New Jersey, USA) was secured in place with 0 Ethibond (Ethicon Endo-Surgery, NJ, USA) gastrogastric sutures. The port was subsequently secured on the external oblique aponeurosis.
Methods
Clinical Follow-up
Patients
Patients were seen by the surgeon postoperatively on day 1 and discharged on a bariatric fluid diet. They were seen again at 2 weeks, and the first band adjustment was performed at 3– 6 weeks. The band adjustments were performed under fluoroscopy in order to optimize cannulation and accurately adjust the fluid in the band. Further adjustments were performed when clinically indicated.
Fifty consecutive patients who underwent LAGB operation performed by the senior author (RVL) at this institution were studied retrospectively if they met the following inclusion criteria: (1) no history of previous gastroesophageal surgery; (2) no evidence of esophageal dysmotility, dilatation, or other
Operation
OBES SURG
Radiological Band Adjustments and Assessment of Esophageal Motility and Diameter The X-ray was done by one of three senior attending radiologists experienced in the technique. A screening shot was initially taken, and the port was cannulated with the patient in a 45° head-up position. The patient was asked to swallow barium, and dynamic images were taken focusing around the lower esophagus, hiatus, and gastric pouch. Fluid was added or removed depending on the surgeon's request and on the radiologists' assessment of contrast hold up in the pouch, stoma size, and the presence of esophageal dysmotility or dilatation. Dysmotility was defined as being present when there was clearly a significant abnormality in esophageal body motility, including the finding of stasis of contrast in the esophageal body sufficient to obscure the mucosal folds or overlying structures, significant reverse peristalsis or incoordinated tertiary waves, marked delayed passage of contrast, or diffuse esophageal spasm-like findings. Dilatation was defined as being present when the diameter of the distal esophagus was markedly increased when compared to the proximal esophagus or to that of the distal esophagus in a previous contrast videoesophagram study. In the presence of dilatation or dysmotility, fluid was removed from the band until there were dynamic signs of radiological improvement.
Symptoms that were routinely assessed and studied were dysphagia, reflux, or regurgitation requiring fluid removal. The effect of removing fluid from the band on these symptoms was also recorded and assessed. Analysis Continuous variables were summarized by calculating mean and standard deviation (SD) if normal distribution and median and range if non-normal distribution. Categorical variables were summarized by reporting frequencies. Statistical analyses were performed to explore associations between the presence of postoperative radiological abnormalities and patient age and operation outcomes (percent excess weight loss (%EWL), symptoms, symptom resolution following fluid removal, and band removal). For these analyses, two-tailed t tests for independent samples were used for continuous variables (mean age and %EWL), and Fishers exact chi-square test was used for categorical variables.For all statistical analyses, a p value of
