Abel E Bello, MD, Leena Khaitan, MD. University Hospitals Case Surgery
Restrictive bariatric procedures such as Sleeve Gastrectomy (SG), Adjustable Gastric Banding (LGB) and Vertical Band Gastroplasty (VBG) have been associated with worsening reflux symptoms in patients with and without pre-existing disease, but data is conflicting. Roux-En-Y Gastric Bypass (RYGB) has been the procedure of choice for treating gastroesophageal reflux disease (GERD) in the morbidly obese, and also a revision option for patients with GERD after weight loss surgery (WLS). There is no clear consensus on the best treatment option for bariatric patients that develop symptomatic GERD. We present a series of bariatric patients with post-operative symptomatic GERD and how manometry findings helped to guide treatment.
A retrospective review was performed from 2006-2014 of all consecutive patients with primary complaint of GERD following WLS. Patients with upper endoscopy, esophagogram and manometry were included for analysis. Data on demographics, preoperative and postoperative symptoms, weight loss, and procedure details were collected. Previous surgeries were performed at outside hospitals. Data were kept in secure database. Statistical analysis performed using SPSSV22.
Nine patients met the inclusion criteria. All patients had prior restrictive WLS as either initial or secondary procedure. Four patients had 1 prior foregut procedure. Initial WLS were 5 SG, 2 VBG and 2 LGB. Six patients had dysphagia. Mean BMI at presentation was 43.13±3.86. Mean Follow up 50.66±32.35 months. Excess Weight Loss (EWL) at presentation from WLS (Mean 37.55±10.07%) which improved after revision (Mean 47.21±10.34%). Esophageal peristalsis was normal in 8/9 patients. 7 patients had revisional surgery. Of those with prior SG, 1 had hiatal hernia repair and 3 had removal of fundus with conversion to RYGBP. The remaining 1 SG patient on manometry has short intraabdominal LES, transient relaxation with otherwise normal LESP, bolus transit and peristalsis and is awaiting HH repair. Of the 2 Prior VBG, 1 had conversion to RYGBP and 1 not wanting surgery. All RYGB conversions had high-pressure zone distal to LES noted on high-resolution manometry (HRM). One patient had LGB removal without conversion. All had resolution of symptoms after revisional surgery and procedures were completed laparoscopically. Pre-existing GERD and previous PPI use was associated with post-op dysphagia after WLS (p=0.018), but not with LES pressure abnormalities or esophageal dysmotility (p=0.59 and 0.35 respectively). Bolus transit was comparable between all patients. Not all patients required conversion to RYGBP to treat the reflux and dysphagia.
Treatments for reflux after WLS should be tailored to the cause of the problem. A high pressure zone distal to the LES seen on HRM is helpful in identifying those patients requiring conversion to RYGBP for revision. Others may just have HH repair if LES pressure normal. Thus, manometry can help to guide the surgeon in choosing the best treatment option for patients with GERD after WLS. Revisional surgery in these patients also significantly improves weight loss.