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GERD After Sleeve GastrectomyWhat are the Treatment Options?
Stacy A. Brethauer, MD
Bariatric and Metabolic Institute
Disclosures
• Medtronic Consultant, Speaker
• Ethicon Consultant, Research
Possible Mechanisms
• Increased GERD after LSG– Higher intragastric pressure– Phreno-esophageal ligament disruption– Sling fiber resection– Decreased LES pressure– Decreased gastric compliance– Neofundus formation– Missed Hiatal Hernia
• Decreased GERD after LSG– Weight loss, reduced abdominal pressure– Accelerated gastric emptying– Resection, decreased parietal cell mass– Increased LES pressure
Evidence of Increased GERD after LSG
BMI 36 to 26
Pre- and Post-operative Reflux
Variable %
Preoperative GERD 25%
Preoperative radiographic evidence of reflux
4%
Postoperativeradiographic evidence of reflux
39%
Worsening GERD after LSG
23%
Satisfied with weight loss
100%
Would choose LSG again 100%
GERD complaints at 6 yearspostoperatively
Preoperative Postoperative
Stand alone LSG (30)
%EWL 53%
GERD 3.3% 23%
Vomiting 0% 18%
Stand along LSG and LSG + DS (41)
%EWL 57%
GERD 0% 26%
Vomiting 0% 21%
• GERD Prevalence Decreased
– 7 studies
– 12-60 month follow-up
• GERD Prevalence Increased
– 4 studies
– 12-24 month follow-up
• Low quality data
• No consensus
• 1,380 Surgeons
• 46,133 LSG’s
• Postoperative GERD 7.9 ± 8.2% (0-30%)
Options
• Stretta
• Muse
• LINX
• Endostim
• Revision/Conversion
Stretta
Durability of Stretta Radiofrequency Treatment for GERD:Results of an 8-Year Follow-Up
Luca Dughera,1 Gianluca Rotondano,2 Maria De Cento,3 Paola Cassolino,4 and Fabio Cisarò5
0
10
20
30
40
50
60
70
Baseline
Heartburn score GERD HQRL
26 patients 4 years 8 years
∘
∘
∗
∗
∗
∗
∗
∗∗ P < 0.001 ∘P < 0.003
SF-36 mental SF-36 physical
Baseline0
10
20
30
40
50
60
70
80
90
100
P < 0.0001
26 patients 4 years 8 years
∗∗
Durability of Stretta Radiofrequency Treatment for GERD:Results of an 8-Year Follow-Up
Luca Dughera,1 Gianluca Rotondano,2 Maria De Cento,3 Paola Cassolino,4 and Fabio Cisarò5
Treatment of refractory gastroesophageal reflux disease with radiofrequency energy (Stretta) in
patients after Roux-en-Y gastric bypass Mattar SG, Qureshi F, Taylor D, Schauer PR
Surg Endosc. 2006 Jun;20(6):850-4
• 7 patients 20 mos post RYGB
• 5 clinically improved with decreases esophageal acid exposure
• 1 did not improve
• 1 LTFU
MUSEMedigus
MUSE
Long-term follow-up results of endoscopic treatmentof gastroesophageal reflux disease with the MUSETM endoscopic
stapling deviceHong Joo Kim1, Chang-Il Kwon2, William R Kessler3, Don J Selzer4, Gail McNulty3, Amol Bapaye5, Luigi Bonavina6, Glen A. Lehman
Surg Endosc 2015
• 37 patients with 4 year follow-up
Long-term follow-up results of endoscopic treatmentof gastroesophageal reflux disease with the MUSETM endoscopic
stapling deviceHong Joo Kim1, Chang-Il Kwon2, William R Kessler3, Don J Selzer4, Gail McNulty3, Amol Bapaye5, Luigi Bonavina6, Glen A. Lehman
Surg Endosc 2015
No Data in Bariatric Patients
LYNX
Gastroesophageal Reflux Management with the LINX® Systemfor Gastroesophageal Reflux Disease Following Laparoscopic
Sleeve GastrectomyKenneth Desart1 & Georgios Rossidis1 & Michael Michel1 & Tamara Lux1 &
Kfir Ben-David2J Gastrointest Surg (2015) 19:1782–1786
Gastroesophageal Reflux Management with the LINX® Systemfor Gastroesophageal Reflux Disease Following Laparoscopic
Sleeve GastrectomyKenneth Desart1 & Georgios Rossidis1 & Michael Michel1 & Tamara Lux1 &
Kfir Ben-David2J Gastrointest Surg (2015) 19:1782–1786
Endostim
Alejandro Nieponice, Yves Borbély, Leonardo Rodriguez, Henning G Schulz, Camilo Ortiz, Michael Talbot, David Martin, Nicole Bouvy
Surg Endosc. 2016; 30:S263.
• 12 Patients• 5mA, 220uSec pulse in twelve 30 minute sessions daily• All (12/12) were on at least daily double-dose PPIs• Median esophageal pH at baseline was 16.4% which improved to
1.3% at last follow-up at least 6 month post-implant (n=6; p=0.01).• All patients improved esophageal acid exposure, 83% (5/6) patients
had normalized acid exposure and 1/6 patient had >40% improvement
• Median GERD-HRQL scores at baseline was 25 (IQR 18-31) which improved to 4 (IQR 3-10) at last follow-up (n=6; p= 0.015).
• No SAEs related to the device or procedure were reported. • No dysphagia or other GI side effects were reported.
Surgical Options
• Re-sleeve
• Conversion to RYGB
• Pouch reduction
Thank You