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Gastric bypass surgery for gastroesophageal reflux disease

An brief overview of the pathofysiology leading to GERD and reduction of the symptoms by lap-RYGB. Patient presentation and 2 critical appraisals.

Noelle Geubbels

on 4 June 2013

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Transcript of Gastric bypass surgery for gastroesophageal reflux disease

Gastric bypass surgery for gastroesophageal reflux disease A good co-indication? N. Geubbels, Slotervaartziekenhuis, 4-6-2013 Patient Mrs X. 48 yrs

Medical history
GERD >10 yrs
Lung embolus

Medication: esomeprazole 40mg 2dd2, inhalors Patient A/ "I don't care about my weight" "Because of the heartburn I am unable to go anywhere"

Ph/ Gen: dry cough, BMI 35, RR/ 180/90. Abd: epigastric tenderness

Lab/ dyslipidemia. Serology: HP neg

pH metry: DeMeesterscore 32,52. Impedance: SI 35,5%, SAP 92,9%

Manometry: normal

Upper endoscopy (2000): no -itis "Patient was referred to the slotervaarthospital for a bariatric consultation because of the positive effect weight loss will have on these symptoms" Does lap-RYGB diminish GERD?

In how many % of the cases? PICOT

P: Morbidly Obese
C: non Lap-RYGB
O: GERD (pH metry & clinical)
T: as long as possible, >5 yrs? Search terms Pubmed Filter

Clinical trials Exclusion based
on title 2 Hits gastric bypass
reflux 193 hits 13 hits Different intervention: 6
Children: 1
Just absurd: 4 Article 1: Madalosso et al. Ann Surg. 2010;251(2):244-248 Design: non-randomized, controlled, prospective

N= 86 (94 included)

Primary outcome: clinical reflux (Montreal)

Sec outcome: acid exposure by pH metry

Intevention: before and after open RYGB with fobi ring (!)

Follow up: 6 months Results article 1 Primary outcome:
Clinical GERD: 64% --> 33% = 31% decrease, p <0,001
Typical reflux syndrome: 55% --> 14% = decrease 41%, p<0,001
Troublesome heartburn: 52% --> 6% = decrease 48%
Troublesome regurgitation: 30% --> 12% = decrease 28%

Patients WITH GERD pre-RYGB:
TRS: 47 --> 10 (4 heartburn, 5 regurg, 1 both)= 79% decrease

TRS: 0 --> 4 (all regurgitation)= 10% increase, p<0,001

Heartburn ---> regurgitation Results article 1 Secondary outcome:
Total acid exposure 5,1 --> 1,1%, p<0,001
Upright: 5,4% --> 0,8%, p<0,001
Supine: 1,8 --> 0,3%, NS

Patients with ABNORMAL pH metry pre-RYGB:
58 --> 26= decrease 45%

Patients with NORMAL pH metry pre-RYGB (n= 28):
0 --> 5=increase 18%, p<0,001

Gastric pouch acidity: 74 (86%) of the post-RYGB patients Concluding from article 1... My patient has:

~80% chance of clinical GERD improvement after RYGB

~45% chance of normal pH metry post RYGB Critical appraisal of article 1 Good:
Clear in- and exlusion criteria

Loss to follow up clearly described

Golden standard diagnosis 2x

Prospective, controlled, non-randomized

2 sided! Room for improvement:
N of patients (55/58 with abnormal findings)

Fobi ring

No intention to treat

Folluw up 6 months Article 2: Meija-Rivas et al. Obes Surg. 2008;18:1217-24 Design: prospective, controlled, non-randomized

N = 20

Primary outcome: clinical reflux (CDQ)

Secondary outcome: acid exposure by pH metry

Intervention: before and after RYGB (open, lap, technique?)

Follow up: 6 months Results article 2 Primary outcome:

CDQ score pre-RYGB 20 vs 2 post-RYGB = decrease 98% Results article 2 Secondary outcome:
% acid time: pre-RYGB 10,7 min vs 1,6 min post-RYGB, p<0,001
DeMeesterscore: pre-RYGB 48,3 vs 7,7 post RYGB, p<0,001
Only 1 of 20 (5%) had an abnormal pH metry post RYGB Concluding from article 2... My patients has:

>90% change of GERD remission after RYGB

>90% change of a normal pH metry after RYGB Critical appraisal of article 2 Good:
Clear in- and exclusion criteria

No lost to follow-up

Use of gold standard pH metry

Prospective, conrolled, non-randomized Room for improvement:
Lacking a 2 sided description

N= 20

Unclear representation of the results (like n of pH metry abnormals pre-RYGB)

CDQ good instrument? Increased intra abdominal pressure Increased production
gastric juice No difference in manometric
features between normal
weight and morbidly obese
patients Higher prevalence of
hiatal hernia's Deposition of fat in cardia
changes valve function.
Blunt angle of Hiss 1. Wajed et al. Arch Surg. 2001;136:1014-9.
2. Surgerman et al. J Intern Med. 1997;241:71-9.
3. Marchand et al. Br J Surg. 1955;42:504-13. Petterson et al. Surgery. 1980;88:307-14.
4. De Vries et al. Am J Gastroenetrol. 2008;103:1349 1 2 1 3 4 Overall conclusion Article 1 > Article 2

~80% change relief GERD symptoms

~45% chance normalization pH metry
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