Medically Refractory GERD in the Obese: Expert Opinion on the Best Surgical Approach

Maurice Page, MD, Andrew Kastenmeier, MD, Matthew I Goldblatt, MD, Matthew Frelich, MS, Matthew Bosler, BA, James Wallace, MD, PhD, Jon C Gould, MD

Medical College of Wisconsin, Department of Surgery, Division of General Surgery

Introduction: The prevalence of both obesity and gastroesophageal reflux disease (GERD) has increased in recent decades. Obesity is a risk factor for GERD. In fact, GERD is considered a comorbid medical condition of obesity and has been demonstrated to respond to bariatric surgery. In both GERD and obesity, surgery is an effective treatment for severe and medically refractory patients. Traditional antireflux procedures (fundoplication) may be associated with a higher failure rate in obese patients. For many reasons, in morbidly obese patients with medically refractory GERD, surgeons and patients alike often opt for bariatric surgery with excellent outcomes. Unfortunately for some patients, their insurance companies decline to provide benefits for bariatric surgery for the indication of GERD – often stating that this is not within the standard of care. The aim of the current study was to characterize the expert opinions of minimally invasive surgeons who often deal with the surgical treatment of both diseases regarding this controversy.

Methods: A brief 13-item survey was designed to elicit professional opinions regarding the treatment of medically refractory GERD in obese patients. A total of 550 SAGES members were randomly selected and emailed a link to an online survey. Data was collected, stripped of all identifiers, and analyzed to characterize expert opinions on GERD and obesity.

Results: A total of 92 surgeons (17%) responded. Of the respondents, 88% perform laparoscopic fundoplication for GERD, 63% perform bariatric surgery, and 58.7% performs both. 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 BMI (table).

30 kg/m235 kg/m240 kg/m245 kg/m250 kg/m255 kg/m2>60 kg/m2

The majority of respondents felt that laparoscopic Roux-en Y gastric bypass was the best option to treat medically refractory GERD in morbidly obese patients (91%) followed by laparoscopic sleeve gastrectomy (6%). 57% of surgeons responding to the survey had a morbidly obese patient with a primary surgical indication of medically refractory GERD denied a bariatric procedure by their insurance company, and 35% of those surgeons chose to do nothing rather than subject the patient to a fundoplication. Nearly all surgeons to respond to this survey (96%) felt bariatric surgery should be recognized as a standard surgical option for treating medically refractory GERD in the obese.

Conclusions: When surgical treatment of GERD is indicated in a severely obese patient, bariatric surgery rather than fundoplication should be strongly considered, especially Roux-en Y gastric bypass. Unfortunately, third party payers often decline to provide benefits for what many experts agree is the best and most appropriate procedure. Additional data is necessary to confirm our belief that the opinions elicited through this survey represent the best practices and are consistent with the standard of care as defined by the medical community.

Session: Poster Presentation

Program Number: P235

« Return to SAGES 2013 abstract archive