Medically refractory gastroesophageal reflux disease in the obese: what is the best surgical approach?
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Obesity is a recognized risk factor for gastroesophageal reflux disease (GERD). Traditional antireflux surgery (fundoplication) may not be appropriate in the morbidly obese, especially when other effective alternatives exist (bariatric surgery).
A 13-item survey was designed to elicit professional opinions regarding the treatment of medically refractory GERD in obese patients. Members of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) were randomly selected and emailed a link to an online survey.
A total of 550 surgeons were contacted via email, and 92 (17 %) completed the survey. Of the respondents, 88 % perform laparoscopic antireflux surgery, 63 % perform bariatric surgery, and 59 % perform both. Overall, 77 % completed a minimally invasive surgery fellowship. In response to the question “Would you perform a laparoscopic fundoplication in a patient with medically refractory GERD and a BMI of ‘X’?” surgeons were less likely to offer fundoplication at a higher body mass index (BMI). The majority of respondents felt that laparoscopic Roux-en-Y gastric bypass was the best option (91 %), followed by laparoscopic sleeve gastrectomy (6 %). Many had a morbidly obese patient with a primary surgical indication of GERD denied a bariatric procedure by their insurance company (57 %), and 35 % of those surgeons chose to do nothing rather than subject the patient to a fundoplication. Respondents uniformly felt that bariatric surgery should be recognized as a standard surgical option for treating GERD in the obese (96 %).
When surgical treatment of GERD is indicated in an obese patient, bariatric surgery is the optimal approach, in the opinion of surgeons responding to our survey. Unfortunately, third-party payers often decline to provide benefits for a bariatric procedure for this indication. Additional data is necessary to confirm our belief that the opinions elicited through this survey are consistent with the standard of care as defined by the medical community.
KeywordsFundoplication Morbid obesity GERD Survey Gastric bypass
Drs. Pagé, Kastenmeier, Goldblatt, Wallace, and Gould, Matthew Frelich, and Matthew Bosler have no conflicts of interest or financial ties to disclose.
- 6.Grant AM, Boachie C, Cotton SC, Faria R, Bojke L, Epstein DM, Ramsay CR, Corbacho B, Sculpher M, Krukowski ZH, Heading RC, Campbell MK, REFLUX trial group (2013) Clinical and economic evaluation of laparoscopic surgery compared with medical management for gastro-oesophageal reflux disease: 5-year follow-up of multicentre randomised trial (the REFLUX trial). Health Technol Assess 17(22):1–167PubMedGoogle Scholar
- 7.Colquitt JL, Picot J, Loveman E, Clegg AJ (2009) Surgery for obesity. Cochrane Database Syst Rev 15(2):CD003641Google Scholar
- 24.Iovino P, Angrisani L, Tremolaterra F, Nirchio E, Ciannella M, Borrelli V, Sabbatini F, Mazzacca G, Ciacci C (2002) Abnormal esophageal acid exposure is common in morbidly obese patients and improves after a successful Lap-band system implantation. Surg Endosc 16:1631–1635PubMedCrossRefGoogle Scholar