Author's Accepted Manuscript
Valuable Heartburn Data that may be Difficult to Swallow John C. Alverdy
www.elsevier.com/locate/buildenv
PII: DOI: Reference:
S1550-7289(14)00219-6 http://dx.doi.org/10.1016/j.soard.2014.05.017 SOARD2015
To appear in:
Surgery for Obesity and Related Diseases
Cite this article as: John C. Alverdy, Valuable Heartburn Data that may be Difficult to Swallow, Surgery for Obesity and Related Diseases, http://dx.doi.org/10.1016/j. soard.2014.05.017 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Valuable heartburn data that may be difficult to swallow – John C Alverdy Varban and his colleagues demonstrate that the use of acid-reducing medications (ARM) including PPIs and H2 blockers is significantly decreased among patients who were using them prior to bariatric surgery. Conversely ARM use is increased among patients who did not use them at baseline following bariatric surgery in a manner that is dependent on the type of procedure. The good news is that overall ARM use is significantly decreased after bariatric surgery. The authors document, as is increasingly becoming the experience of bariatric surgeons, that sleeve gastrectomy (SG) is a significant predictor for ARM use 1 year after surgery. In order of decreasing use, approximately 55% of patients following laparoscopic adjustable gastric band or roux en Y gastric bypass (RYGB) have discontinued ARM use at 1 year while approximately 40% of patients following either SG or Biliopancreatic bypass (BPD)/Duodenal Switch (DS) have discontinued ARM use at 1 year. The authors conclude that ARM use of bariatric surgery varies significantly by procedures and is most often is related to gastroesophageal reflux (GERD) symptoms. One interesting finding is that the positive effects of RYGB on GERD symptoms, and hence ARM use, is offset by the higher rate of ulcers, strictures, and leaks that occur with RYGB triggering their re- initiation, often for prolonged periods. The study is limited by the usual difficultly of incorporating individual physician practices into the database, lack of detail on individual patients eating behaviors and lifestyle, and the small percentage of actual patients participating in the 1 year follow up periods (30%). Although counterintuitive, LAGB resulted in the lowest rate of overall ARM use (26%) and the lowest proportion of patients starting an ARM at 1 year (14%). However many patients had concomitant hiatal hernia repairs at the time of the LAGB placement accounting for this finding. The real punchline of this study however is that overall GERD symptoms get better after bariatric surgery yet are common following SG and that RYGB remains plagued with ulcer formation and other complications that often trigger the use of ARMs. This important study should force a rethinking of our use of ARMs following bariatric surgery and should force surgeons to consider a more detailed workup of GERD when contemplating both the indications for bariatric surgery and the choice of procedure. Yet burning issues remain; are patients with GERD symptoms really GERD, does acid really play a role in marginal ulcer formation and treatment following RYGB, to what extent are poor eating behaviors responsible for the GERD symptom complex, and what are the real indications for ARM prescription in the postoperative management of a bariatric patient? Consider the marketing slogan of the leading PPI drug company featuring Larry the cable guy who proclaims “eat like a kid again” while holding a corndog in his hand suspended over his centrally obese abdomen. Essentially what he and the company are suggesting is that by suppressing GERD symptoms, it is now possible to eat your way to hypercholesterolemia, coronary artery disease, and diabetes without the hassle of heartburn. Along this analogy comes the following question: Is liberal and prolonged use of ARMs a risk factor for weight gain following surgery? When patients develop dyspepsia misdiagnosed for GERD, is it a signal that their eating behaviors and lifestyle (smoking, sleep, stress) are not well accommodated by a given procedure? While the authors do a good job to explain the possible anatomic and physiologic mechanisms by which one operation may predispose to GERD versus another, the within group differences are not addressed. While it is not practical to subject every patient with heartburn to a 24 pH study, an esophageal manometry, and an endoscopy, this study should make us take pause. We are relieving heartburn overall while creating it in a significant number of other cases. Yet the study by Varban highlights the magnitude of the problem and the relief of, and the risks for, GERD for a given bariatric procedure. We should all be on alert to screen for GERD symptoms, to discriminate among patients when a more extensive workup is
needed, and to tailor our indications and choices of a given operation to a more defined diagnosis of GERD. Focusing on issues relating to GERD may be the next Pandora ’s Box in bariatric surgery.
Valuable Heartburn Data that may be Difficult to Swallow John C. Alverdy
www.elsevier.com/locate/buildenv
PII: DOI: Reference:
S1550-7289(14)00219-6 http://dx.doi.org/10.1016/j.soard.2014.05.017 SOARD2015
To appear in:
Surgery for Obesity and Related Diseases
Cite this article as: John C. Alverdy, Valuable Heartburn Data that may be Difficult to Swallow, Surgery for Obesity and Related Diseases, http://dx.doi.org/10.1016/j. soard.2014.05.017 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Valuable heartburn data that may be difficult to swallow – John C Alverdy Varban and his colleagues demonstrate that the use of acid-reducing medications (ARM) including PPIs and H2 blockers is significantly decreased among patients who were using them prior to bariatric surgery. Conversely ARM use is increased among patients who did not use them at baseline following bariatric surgery in a manner that is dependent on the type of procedure. The good news is that overall ARM use is significantly decreased after bariatric surgery. The authors document, as is increasingly becoming the experience of bariatric surgeons, that sleeve gastrectomy (SG) is a significant predictor for ARM use 1 year after surgery. In order of decreasing use, approximately 55% of patients following laparoscopic adjustable gastric band or roux en Y gastric bypass (RYGB) have discontinued ARM use at 1 year while approximately 40% of patients following either SG or Biliopancreatic bypass (BPD)/Duodenal Switch (DS) have discontinued ARM use at 1 year. The authors conclude that ARM use of bariatric surgery varies significantly by procedures and is most often is related to gastroesophageal reflux (GERD) symptoms. One interesting finding is that the positive effects of RYGB on GERD symptoms, and hence ARM use, is offset by the higher rate of ulcers, strictures, and leaks that occur with RYGB triggering their re- initiation, often for prolonged periods. The study is limited by the usual difficultly of incorporating individual physician practices into the database, lack of detail on individual patients eating behaviors and lifestyle, and the small percentage of actual patients participating in the 1 year follow up periods (30%). Although counterintuitive, LAGB resulted in the lowest rate of overall ARM use (26%) and the lowest proportion of patients starting an ARM at 1 year (14%). However many patients had concomitant hiatal hernia repairs at the time of the LAGB placement accounting for this finding. The real punchline of this study however is that overall GERD symptoms get better after bariatric surgery yet are common following SG and that RYGB remains plagued with ulcer formation and other complications that often trigger the use of ARMs. This important study should force a rethinking of our use of ARMs following bariatric surgery and should force surgeons to consider a more detailed workup of GERD when contemplating both the indications for bariatric surgery and the choice of procedure. Yet burning issues remain; are patients with GERD symptoms really GERD, does acid really play a role in marginal ulcer formation and treatment following RYGB, to what extent are poor eating behaviors responsible for the GERD symptom complex, and what are the real indications for ARM prescription in the postoperative management of a bariatric patient? Consider the marketing slogan of the leading PPI drug company featuring Larry the cable guy who proclaims “eat like a kid again” while holding a corndog in his hand suspended over his centrally obese abdomen. Essentially what he and the company are suggesting is that by suppressing GERD symptoms, it is now possible to eat your way to hypercholesterolemia, coronary artery disease, and diabetes without the hassle of heartburn. Along this analogy comes the following question: Is liberal and prolonged use of ARMs a risk factor for weight gain following surgery? When patients develop dyspepsia misdiagnosed for GERD, is it a signal that their eating behaviors and lifestyle (smoking, sleep, stress) are not well accommodated by a given procedure? While the authors do a good job to explain the possible anatomic and physiologic mechanisms by which one operation may predispose to GERD versus another, the within group differences are not addressed. While it is not practical to subject every patient with heartburn to a 24 pH study, an esophageal manometry, and an endoscopy, this study should make us take pause. We are relieving heartburn overall while creating it in a significant number of other cases. Yet the study by Varban highlights the magnitude of the problem and the relief of, and the risks for, GERD for a given bariatric procedure. We should all be on alert to screen for GERD symptoms, to discriminate among patients when a more extensive workup is
needed, and to tailor our indications and choices of a given operation to a more defined diagnosis of GERD. Focusing on issues relating to GERD may be the next Pandora ’s Box in bariatric surgery.
