Treatment of GERD in Treatment of GERD in Obese PatientsObese Patients

David W Rattner, MDDavid W Rattner, MD

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What is Obesity?What is Obesity?

A life-long, progressive, life-threatening, genetically-A life-long, progressive, life-threatening, genetically-related, multi-factorial, and costly, disease of related, multi-factorial, and costly, disease of excess fat storage and multiple co-morbidities.excess fat storage and multiple co-morbidities.

We can further We can further quantify obesity by the quantify obesity by the

Body Mass Index Body Mass Index

(BMI) = Weight (kg) / (BMI) = Weight (kg) / HeightHeight2 (m)(m)2

GroupGroup BMIBMI

NormalNormal19-2519-25Overweight*Overweight* 25-3025-30ObesityObesity > 30> 30

Class IClass I 30-3530-35Class IIClass II 35-4035-40Class IIIClass III > 40> 40

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IMPACT OF OBESITY ON GERDIMPACT OF OBESITY ON GERD

• Nearly all epidemiologic studies have found Nearly all epidemiologic studies have found an association between increasing body an association between increasing body mass index (BMI) and symptoms of mass index (BMI) and symptoms of gastroesophageal reflux disease (GERD).gastroesophageal reflux disease (GERD).

• increased prevalence of esophageal motor increased prevalence of esophageal motor disordersdisorders

• diminished lower esophageal sphincter diminished lower esophageal sphincter (LES) pressure(LES) pressure

• Hiatal HerniaHiatal Hernia• Increased intragastric pressure.Increased intragastric pressure.

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Body Weight and DiseaseBody Weight and Disease

Body Mass IndexBody Mass Index

Rel

ativ

e R

isk

Rel

ativ

e R

isk

GallstonesGallstonesDiabetesDiabetesElevated cholesterolElevated cholesterolHypertensionHypertensionVenous thrombosisVenous thrombosisMortalityMortality

2020 3030 3535 4040 45452525

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Impact of Obesity on Antireflux SurgeryImpact of Obesity on Antireflux Surgery

RECURRENCES ACCORDING TO WEIGHT CATEGORY

NORMAL OVERWEIGHT OBESE

RECURRENCE 4 ( 4.5%) 7 (8.0%) 15 (31.3%)

NO

RECURRENCE

85 (95.5%) 80 ( 92.0%) 33 ( 68.7%)

P values * P= NS vs. overweight

P= .001 vs. obese P= < .0001 vs.

normal

Surgical Endoscopy. 15(9):986-9, 2001

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Obesity is not a contraindication to Obesity is not a contraindication to laparoscopic Nissen fundoplicationlaparoscopic Nissen fundoplication

• Booth et al UKBooth et al UK• Annals of the Royal College of Surgeons of England. 89(7):696-Annals of the Royal College of Surgeons of England. 89(7):696-

702, 2007702, 2007

• BMI> 30 = obeseBMI> 30 = obese• f/u 6-12 months onlyf/u 6-12 months only• OR time longer but OR time longer but Visick ScoresVisick Scores similar similar

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Obesity is not a contraindication to Obesity is not a contraindication to laparoscopic Nissen fundoplicationlaparoscopic Nissen fundoplication

• Rosemurgy group Rosemurgy group Journal of Gastrointestinal Surgery. 9(7):949-54, 2005Journal of Gastrointestinal Surgery. 9(7):949-54, 2005

• Clinical outcomes after laparoscopic Clinical outcomes after laparoscopic Nissen fundoplication did not differ among Nissen fundoplication did not differ among patients stratified by preoperative BMI. patients stratified by preoperative BMI. Obesity is not a contraindication to Obesity is not a contraindication to laparoscopic Nissen fundoplicationlaparoscopic Nissen fundoplication

• Clinical outcomes were scored by patients Clinical outcomes were scored by patients with a Likert scalewith a Likert scale

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BMI 35 with GERDBMI 35 with GERD

• Fix GERD only??Fix GERD only??• Fix GERD and other co-morbidities!!Fix GERD and other co-morbidities!!• Varela JE et alVarela JE et al

• Surgery for Obesity & Related Diseases. 5(2):139-43, 2009Surgery for Obesity & Related Diseases. 5(2):139-43, 2009

• The overall in-hospital complications were significantly lower in The overall in-hospital complications were significantly lower in the laparoscopic gastric bypass group (P<.05). The mean length the laparoscopic gastric bypass group (P<.05). The mean length of stay, observed mortality, risk-adjusted mortality, and hospital of stay, observed mortality, risk-adjusted mortality, and hospital costs were comparable between the 2 treatment groups.costs were comparable between the 2 treatment groups.

• Laparoscopic gastric bypass is as safe as laparoscopic Laparoscopic gastric bypass is as safe as laparoscopic fundoplication for the treatment of GERD in the morbidly obese. fundoplication for the treatment of GERD in the morbidly obese. Hence, morbidly obese patients with GERD should be referred Hence, morbidly obese patients with GERD should be referred for bariatric surgery evaluation and offered laparoscopic gastric for bariatric surgery evaluation and offered laparoscopic gastric bypass as a surgical option.bypass as a surgical option.

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Which operation for Obese Patient with Which operation for Obese Patient with GERD?GERD?

• Lap BandLap Band• Sleeve GastrectomySleeve Gastrectomy• VBGP with Nissen?VBGP with Nissen?• Duodenal SwitchDuodenal Switch• Roux en YRoux en Y

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Try to Avoid This!Try to Avoid This!

Hard Re-do

Fundoplication

Hard Lap RYGBP

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Laparoscopic RYGB - Gastric Pouch Creation Laparoscopic RYGB - Gastric Pouch Creation

Small pouch eliminates volume

Acid production moved away from esophagus

Vagi transected

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Case History: 42 year old RNCase History: 42 year old RN

• History of Obesity since History of Obesity since age 20.age 20.

• Yo-yo dieting for over 20 Yo-yo dieting for over 20 years.years.

• Co-morbidities:Co-morbidities:• Sleep ApneaSleep Apnea• GERDGERD• Blood pressureBlood pressure• Back PainBack Pain• Urinary IncontinenceUrinary Incontinence• GallstonesGallstones• 283lbs 5’5” BMI 49283lbs 5’5” BMI 49

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Case OutcomeCase Outcome

• 44 year old R.N.44 year old R.N.• Weight 147lbs 5’5” BMI 24Weight 147lbs 5’5” BMI 24• 100% EBW lost100% EBW lost• Co-morbidities:Co-morbidities:

• Sleep Apnea -curedSleep Apnea -cured• High Blood pressure – curedHigh Blood pressure – cured• Back Pain-curedBack Pain-cured• Urinary Incontinence-curedUrinary Incontinence-cured• Gallstones-curedGallstones-cured• GERD-curedGERD-cured

• Recently MarriedRecently Married

xx

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ConclusionsConclusions

• Obese patients have a variety of Obese patients have a variety of mechanisms that cause GERDmechanisms that cause GERD

• Failure rate of Lap Nissen may be higher in Failure rate of Lap Nissen may be higher in obese patientsobese patients

• Treat the entire patient -> more benefit Treat the entire patient -> more benefit from RYGBPfrom RYGBP

• BMI 30-35- not clear what best option isBMI 30-35- not clear what best option is