Laparoscopic Treatment of Obese Patients with Gastroesophageal Reflux Disease and Barrett’s Esophagus: a Prospective Study

Department of Surgery, University of Chile, Santos Dumont 999, Santiago, Chile.
Obesity Surgery (Impact Factor: 3.75). 03/2012; 22(5):764-72. DOI: 10.1007/s11695-011-0531-x
Source: PubMed


Short-segment Barrett's esophagus (SSBE) or long-segment Barrett's esophagus (LSBE) is the consequence of chronic gastroesophageal reflux disease (GERD), which is frequently associated with obesity. Obesity is a significant risk factor for the development of GERD symptoms, erosive esophagitis, Barrett's esophagus, and esophageal adenocarcinoma. Morbidly obese patients who submitted to gastric bypass have an incidence of GERD as high as 50% to 100% and Barrett's esophagus reaches up to 9% of patients.
In this prospective study, we evaluate the postoperative results after three different procedures--calibrated fundoplication + posterior gastropexy (CFPG), fundoplication + vagotomy + distal gastrectomy + Roux-en-Y gastrojejunostomy (FVDGRYGJ), and laparoscopic resectional Roux-en-Y gastric bypass (LRRYGBP)--among obese patients.
In patients with SSBE who submitted to CFPG, the persistence of reflux symptoms and endoscopic erosive esophagitis was observed in 15% and 20.2% of them, respectively. Patients with LSBE were submitted to FVDGRYGJ or LRRYGBP which significantly improved their symptoms and erosive esophagitis. No modifications of LESP were observed in patients who submitted to LRRYGBP before or after the operation. Acid reflux diminished after the three types of surgery were employed. Patients who submitted to LRRYGBP presented a significant reduction of BMI from 41.5 ± 4.3 to 25.7 ± 1.3 kg/m(2) after 12 months.
Among patients with LSBE, FVDGRYGJ presents very good results in terms of improving GERD and Barrett's esophagus, but the reduction of weight is limited. LRRYGBP improves GERD disease and Barrett's esophagus with proven reduction in body weight and BMI, thus becoming the procedure of choice for obese patients.

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    • "Likewise, the gastric sleeve resection increases the prevalence of oesophagitis from 18% to 45%.71 The only bariatric procedure that reduces reflux and reflux symptoms is the gastric bypass procedure with Roux-en-Y reconstruction.72 Some practitioners go as far as to recommend this procedure for the treatment of GORD in morbidly obese patients. "
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    ABSTRACT: The worldwide incidence of GORD and its complications is increasing along with the exponentially increasing problem of obesity. Of particular concern is the relationship between central adiposity and GORD complications, including oesophageal adenocarcinoma. Driven by progressive insight into the epidemiology and pathophysiology of GORD, the earlier belief that increased gastroesophageal reflux mainly results from one dominant mechanism has been replaced by acceptance that GORD is multifactorial. Instigating factors, such as obesity, age, genetics, pregnancy and trauma may all contribute to mechanical impairment of the oesophagogastric junction resulting in pathological reflux and accompanying syndromes. Progression of the disease by exacerbating and perpetuating factors such as obesity, neuromuscular dysfunction and oesophageal fibrosis ultimately lead to development of an overt hiatal hernia. The latter is now accepted as a central player, impacting on most mechanisms underlying gastroesophageal reflux (low sphincter pressure, transient lower oesophageal sphincter relaxation, oesophageal clearance and acid pocket position), explaining its association with more severe disease and mucosal damage. Since the introduction of proton pump inhibitors (PPI), clinical management of GORD has markedly changed, shifting the therapeutic challenge from mucosal healing to reduction of PPI-resistant symptoms. In parallel, it became clear that reflux symptoms may result from weakly acidic or non-acid reflux, insight that has triggered the search for new compounds or minimally invasive procedures to reduce all types of reflux. In summary, our view on GORD has evolved enormously compared to that of the past, and without doubt will impact on how to deal with GORD in the future.
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    ABSTRACT: Obesity is associated with common gastrointestinal (GI) diseases varying from functional symptoms to cancer [1].
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    ABSTRACT: Research progress over the past few decades has helped us understand the association between gastroesophageal reflux disease (GERD), various pulmonary diseases, and obesity. Even though the pathophysiology and mechanisms behind the association have yet to be fully elucidated, treatment for GERD in these special populations has dramatically changed over this period. While lifestyle and dietary changes remain important for the management of GERD, the results can be highly variable since they depend mostly on the compliance of the patients. Pharmacologic agents such as proton pump inhibitors (PPIs) and histamine-2 receptor antagonists are effective in reducing gastric acid and thereby improving symptoms secondary to acidic reflux; however, they do not prevent nonacidic reflux episodes and chronic microaspiration, which may contribute to poorly controlled asthma, progression to end-stage lung disease, and bronchiolitis obliterans syndrome (BOS) in lung transplant recipients. Therefore, surgical intervention may be necessary in selected patients. Today, with the advancement of laparoscopic techniques since their introduction in the 1990s, morbidity and mortality of anti-reflux and bariatric procedures have progressively improved, making them the treatment of choice for GERD in this special patient population.
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