Advertisement

Comparison of objective outcomes following laparoscopic Nissen fundoplication versus laparoscopic gastric bypass in the morbidly obese with heartburn

  • E. J. PattersonEmail author
  • D. G. Davis
  • Y. Khajanchee
  • L. L. Swanström
Original article

Abstract

Background: Heartburn and gastroesophageal reflux disease (GERD) affects approximately 25–50% of morbidly obese patients. Although objective physiologic testing has been reported extensively in patients following Nissen fundoplication, there are no previous reports of such testing in morbidly obese patients. A life-saving surgical alternative for the morbidly obese patient is gastric bypass surgery, which usually improves heartburn symptoms in addition to many serious health conditions such as diabetes, hypertension, and sleep apnea. We hypothesized that, in morbidly obese patients, gastric bypass surgery would be as effective as Nissen fundoplication in reducing both heartburn symptoms and esophageal acid exposure, as reflected by the DeMeester score. Methods: Between 1995 and 2000, all patients undergoing laparoscopic Nissen fundoplication (LN) and laparoscopic gastric bypass (LGB) in our practice underwent preoperative and postoperative esophageal physiologic testing. Patients were included in this study that were morbidly obese and had significant heartburn symptoms or objective evidence of acid reflux, and had repeat esophageal physiologic testing after either LN or LGB. Data were obtained through retrospective review of prospectively collected data. Results: Twelve patients met the inclusion criteria: six patients who had LN and six who had LGB. The mean body mass index (BMI) was 55 kg/m2 in the LGB group and 39.8 in the LN group. After surgery, the mean DeMeester score decreased from 64.3 to 2.8 in the LN group (p = 0.01) and from 34.7 to 5.7 in the LGB group (p = 0.1). Both groups’ mean postoperative DeMeester scores were normal after surgery, and there was no significant difference between the two groups (p = 0.3). Both groups experienced a significant improvement in heartburn symptoms postoperatively. The mean preoperative symptom score improved from 3.5 to 0.5 in the LN group (p = 0.01) and from 2.2 to 0.2 in the LGB group (p = 0.003). There was no difference in the mean postoperative symptom scores between the groups (p = 0.35). After surgery, mean LES resting pressures increased from 12.9 to 35.5 (p = 0.003) in the LN group and from 23.6 to 29.7 (p = 0.45) in the LGB group. There were no complications in either group. Conclusion: Results of this study show that laparoscopic gastric bypass and laparoscopic Nissen fundoplication are both effective in treating heartburn symptoms and objective acid reflux in morbidly obese patients. The health benefits of weight loss after laparoscopic gastric bypass should make this operation the procedure of choice in the morbidly obese patient with heartburn.

Keywords

Morbid obesity Laparoscopic gastric bypass Laparoscopic Nissen fundoplication Gastroesophageal reflux disease 

References

  1. 1.
    Balsiger, BM, Murr, MM, Mai, J, Sarr, MG 2000Gastroesophageal reflux after intact vertical banded gastroplasty: correction by conversion to Roux-en-Y gastric bypass.J Gastrointest Surg4276281CrossRefPubMedGoogle Scholar
  2. 2.
    Fisher, BL, Pennathur, A, Mutnick, JL, Little, AG 1999Obesity correlates with gastroesophageal reflux.Dig Dis Sci4422902294PubMedGoogle Scholar
  3. 3.
    Gastrointestinal surgery for severe obesity1992National Institutes of Health Consensus Development Conference Statement.Am J Clin Nutr55487S619SGoogle Scholar
  4. 4.
    Hagen, J, Deitel, M, Khanna, RK, Ilves, R 1987Gastroesophageal reflux in the massively obese.Int Surg7213PubMedGoogle Scholar
  5. 5.
    Jaffin, BW, Knoepflmacher, P, Greenstein, R 1999High prevalence of asymptomatic esophageal motility disorders among morbidly obese patients.Obes Surg9390395PubMedGoogle Scholar
  6. 6.
    Jones, KB 1998Roux-en-Y gastric bypass: an effective antireflux procedure in the less than morbidly obese.Obes Surg83538PubMedGoogle Scholar
  7. 7.
    Lundell, L, Ruth, M, Sandberg, N, Bove-Nielsen, M 1995Does massive obesity promote abnormal gastroesophageal reflux?Dig Dis Sci4016321635PubMedGoogle Scholar
  8. 8.
    Mercer, WR, Wren, SF, DaCosta, LR, Beck, IT 1982Gastroesophageal pressure gradients and lower esophageal sphincter pressure in severely obese patients.Gastroenterology82A1129Google Scholar
  9. 9.
    Nguyen, NT, Ho, HS, Palmer, LS, Wolfe, BM 2000A comparison study of laparoscopic versus open gastric bypass for morbid obesity.J Am Coll Surg191149155CrossRefPubMedGoogle Scholar
  10. 10.
    Perez, AR, Moncure, AC, Rattner, DW 1999Obesity is a major cause of failure for both abdominal and transthoracic antireflux operations.Gastroenterology116A1343Google Scholar
  11. 11.
    Perez, AR, Moncure, AC, Rattner, DW 2001Obesity adversely affects the outcome of antireflux operations.Surg Endosc15986989PubMedGoogle Scholar
  12. 12.
    Peters, JH, DeMeester, TR 1995Indications, principles of procedure selection, and technique of laparoscopic Nissen fundoplication.Surg22744Google Scholar
  13. 13.
    Schauer, PR, Ikramuddin, S, Gourash, W, Ramanathan, R, Luketich, J 2000Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity.Ann Surg232515529CrossRefPubMedGoogle Scholar
  14. 14.
    Smith, SC, Edwards, CB, Goodman, GN 1997Symptomatic and clinical improvement in morbidly obese patients with gastroesophageal reflux disease following Roux-en-Y gastric bypass.Obes Surg7479484PubMedGoogle Scholar
  15. 15.
    Sugerman, HJ, Kellum, JM, DeMaria, EJ, Reines, HD 1996Conversion of failed or complicated vertical banded gastroplasty to gastric bypass in morbid obesity.Am J Surg171263269CrossRefPubMedGoogle Scholar
  16. 16.
    Velanovich, V 2000Quality of life and severity of symptoms in gastroesophageal reflux disease: a clinical review.Eur J Surg166516525CrossRefPubMedGoogle Scholar
  17. 17.
    Wajed, SA, Streets, CG, Bremner, CG, DeMeester, TR 2001Elevated body mass disrupts the barrier to gastroesophageal reflux.Arch Surg13610141018CrossRefPubMedGoogle Scholar
  18. 18.
    Wittgrove, AC, Clark, GW 2000Laparoscopic gastric bypass, Roux-en-Y 500 patients: technique and results, with 3–60 month follow-up.Obes Surg10233239PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2003

Authors and Affiliations

  • E. J. Patterson
    • 1
    Email author
  • D. G. Davis
    • 1
  • Y. Khajanchee
    • 1
  • L. L. Swanström
    • 1
  1. 1.Department of Minimally Invasive SurgeryLegacy Health System, 501 North Graham Street, Suite 120, Portland, OR 97227USA

Personalised recommendations