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The Effect of Concurrent Esophageal Pathology on Bariatric Surgical Planning

  • 2014 SSAT Plenary Presentation
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

In the presence of esophageal pathology, there is risk of worse outcomes after laparoscopic adjustable gastric banding (LAGB) and sleeve gastrectomy (SG). This study reviewed how an esophageal workup affected a bariatric operative plan in patients with concurrent esophageal pathology. We retrospectively reviewed patients planning bariatric surgery referred with significant reflux, dysphagia, and hiatal hernia (>3 cm) to determine how and why a thorough esophageal workup changed a bariatric operative plan. We identified 79 patients for analysis from 2009 to 2013. In 10/41 patients (24.3 %) planning LAGB and 5/9 patients planning SG (55.5 %), a Roux was preferred because of severe symptoms of reflux and aspiration, dysphagia, manometric abnormalities (aperistaltic or hypoperistaltic esophagus with low mean wave amplitudes), large hiatal hernia (>5 cm), and/or presence of Barrett’s esophagus. Patients without these characteristics had a decreased risk of foregut symptoms after surgery. We recommend a thorough esophageal workup in bariatric patients with known preoperative esophageal pathology. The operative plan might need to be changed to a Roux to prevent adverse outcomes including dysphagia, severe reflux, or suboptimal weight loss. An esophageal workup may improve surgical decision making and improve patient outcomes.

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References

  1. Must A, Spadano J, Coakley EH, Field AE, Colditz G, Dietz WH. The disease burden associated with overweight and obesity. J Am Med Assoc 1999;282:1523–1529

    Article  CAS  Google Scholar 

  2. Wajed SA, Streets CG, Bremner CG, DeMeester TR. Elevated body mass disrupts the barrier to gastroesophageal reflux. Arch Surg 2001;136:1014–1019

    Article  CAS  PubMed  Google Scholar 

  3. Burgerhart JS, van de Meeberg PC, Siersema PD, Smout AJ. Nocturnal and daytime esophageal acid exposure in normal-weight, overweight, and obese patients with reflux symptoms. Eur J Gastroenterol Hepatol 2014;26:6–10

    Article  CAS  PubMed  Google Scholar 

  4. Hong D, Khajanchee YS, Pereira N, Lockhart B, Patterson EJ, Swanstrom LL. Manometric abnormalities and gastroesophageal reflux disease in the morbidly obese. Obes Surg 2004;14:744–749

    Article  PubMed  Google Scholar 

  5. Merrouche M, Sabaté JM, Jouet P, Harnois F, Scaringi S, Coffin B, Msika S. Gastro-esophageal reflux and esophageal motility disorders in morbidly obese patients before and after bariatric surgery. Obes Surg 2007;17:894–900

    Article  PubMed  Google Scholar 

  6. Suter M, Dorta G, Giusti V, Calmes JM. Gastro-esophageal reflux and esophageal motility disorders in morbidly obese patients. Obes Surg 2004;14:959–966

    Article  CAS  PubMed  Google Scholar 

  7. Howard DD, Caban AM, Cendan JC, Ben-David K. Gastroesophageal reflux after sleeve gastrectomy in morbidly obese patients. Surg Obes Relat Dis 2011;7:709–713

    Article  PubMed  Google Scholar 

  8. Suter M, Dorta G, Giusti V, Calmes JM. Gastric banding interferes with esophageal motility and gastroesophageal reflux. Arch Surg 2005;140:639–643

    Article  PubMed  Google Scholar 

  9. Robert M, Golse N, Espalieu P, Poncet G, Mion F, Roman S, Boulez J, Gouillat C. Achalasia-like disorder after laparoscopic adjustable gastric banding: a reversible side effect? Obes Surg 2012;22:704–711

    Article  CAS  PubMed  Google Scholar 

  10. DuPree C, Blair K, Steele SR; Martin MJ. Laparoscopic Sleeve Gastrectomy in Patients With Preexisting Gastroesophageal Reflux Disease: A National Analysis. JAMA Surg, DOI:10.1001/jamasurg.2013.4323, February 5, 2014.

  11. Petersen H, Johannessen T, Sandvik AK, Kleveland PM, Brenna E, Waldum H, Dybdahl JD. Relationship between endoscopic hiatus hernia and gastroesophageal reflux symptoms. Scand J Gastroenterol 1991;26:921–926

    Article  CAS  PubMed  Google Scholar 

  12. Marchand P. The gastroesophageal “sphincter” and the mechanism of regurgitation. Brit J Surg 1955;42:504–513

    Article  CAS  PubMed  Google Scholar 

  13. Nguyen NT, Masoomi H, Magno CP, Nguyen XM, Laugenour K, Lane J. Trends in use of bariatric surgery, 2003–2008. J Am Coll Surg 2011;213:261–266

    Article  PubMed  Google Scholar 

  14. Nguyen NT, Nguyen B, Gebhart A, Hohmann S. Changes in the makeup of bariatric surgery: a national increase in use of laparoscopic sleeve gastrectomy. J Am Coll Surg 2013;216:252–257

    Article  PubMed  Google Scholar 

  15. ASMBS Clinical Issues Committee. Updated position statement on sleeve gastrectomy as a bariatric procedure. Surg Obes Relat Dis 2012;8:e21-26

    Article  Google Scholar 

  16. Chiu S, Birch DW, Shi X, Sharma AM, Karmali S. Effect of sleeve gastrectomy on gastroesophageal reflux disease: a systematic review. Surg Obes Relat Dis 2011;7:510–515

    Article  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. Division of Thoracic Surgery, Swedish Medical Center, Seattle, WA, USA

    Daniel Davila Bradley, Brian E. Louie, Ralph W. Aye & Alexander S. Farivar

  2. Swedish Weight Loss Services, Swedish Medical Center, Seattle, WA, USA

    Judy Chen & Ross McMahon

Authors
  1. Daniel Davila Bradley
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  2. Brian E. Louie
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  3. Judy Chen
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  4. Ralph W. Aye
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  5. Ross McMahon
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  6. Alexander S. Farivar
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Corresponding author

Correspondence to Alexander S. Farivar.

Additional information

Discussant

Dr. Joerg Zehetner (Los Angeles, CA):

Correct selection of the right bariatric procedure is the key for successful weight loss, reducing the morbid obesity-related co-morbidities and a low-side-effect profile. Therefore, your study is very important in analyzing how preoperative testing influences selection.

In your retrospective study, you could show that a thorough foregut workup including EGD, pH study, motility, and video esophagram detects patients with significant esophageal pathology leading to a change in the type of bariatric procedure in 30 %. Overall, only 10 % of your bariatric patients underwent preoperative foregut testing.

My Questions:

1. The plan changed in 10/41 LAGB patients that underwent the foregut workup, but still 50 % (15/31) of the patients that got a gastric band had significant esophageal pathology preoperatively. Why did these patients not receive a LRNYGB instead as a result of the foregut workup?

2. Going forward, we could gain more information if we would know about outcome, weight loss, and postoperative reflux symptoms in the patients with significant esophageal pathology that still got the initially planned procedure of LAGB and sleeve. Do you have any data available besides the 53 % reflux symptoms?

3. Should we recommend a thorough foregut workup anyway in every patient interested in LAGB and sleeve?

Closing Discussant

Dr. Davila Bradley:

We appreciate Dr. Joerg Zehetner for his valuable discussion and questions.

1. Initially, we had no established guidelines to recommend or suggest that a patient had a change in plan to a RYGB. All patients were fully counseled about the risks in terms of hiatal hernia recurrence and worsening or developing reflux. We also had a good number of patients who refused a RYGB and two patients who did not get approval from the insurance company to undergo RYGB. As we learned from our own esophageal workup, the recommendations became clearer and more patients had a change in plan.

2. Unfortunately, follow-up was limited to the postoperative visits in the bariatric clinic. There was no objective testing to determine what percentage of asymptomatic and symptomatic patients had abnormal pH test or manometry. We do know that patients with reflux or dysphagia after LAGB lost more weight, probably due to their symptoms and inability to eat.

3. We believe that new guidelines should include objective testing (endoscopy, pH test, manometry, esophagram) on all patients desiring LAGB or SG as it is recommended now when an antireflux procedure is planned. In the case of RYGB, it is unlikely that the plan is going to change and there is still debate as to whether EGD should be done routinely.

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Bradley, D.D., Louie, B.E., Chen, J. et al. The Effect of Concurrent Esophageal Pathology on Bariatric Surgical Planning. J Gastrointest Surg 19, 111–116 (2015). https://doi.org/10.1007/s11605-014-2626-x

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  • DOI: https://doi.org/10.1007/s11605-014-2626-x

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