Can bariatric surgery improve cardiovascular risk factors in the metabolically healthy but morbidly obese patient?

BackgroundBariatric surgery has been shown to be effective in resolving co-morbid conditions even in patients with a body mass index (BMI)<35 kg/m². A question arises regarding the metabolic benefits of bariatric surgery in metabolically healthy but morbidly obese (MHMO) patients, characterized by a low cardiometabolic risk. The objective of this study was to assess the effects of bariatric surgery on cardiometabolic risk factors among MHMO and metabolically unhealthy morbidly obese (MUMO) adults.MethodsA nonrandomized, prospective cohort study was conducted on 222 severely obese patients (BMI>40 kg/m²) undergoing either laparoscopic roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy. Patients were classified as MHMO if only 1 or no cardiometabolic factors were present: high blood pressure, triglycerides, blood glucose (or use of medication for any of these conditions), decreased high-density lipoprotein-cholesterol (HDL-C) levels, and insulin resistance defined as homeostasis model assessment for insulin-resistance (HOMA-IR)> 3.29.ResultsForty-two (18.9%) patients fulfilled the criteria for MHMO. They were younger and more frequently female than MUMO patients. No differences between groups were observed for weight, BMI, waist and hip circumference, total and LDL-C. MHMO patients showed a significant decrease in blood pressure, plasma glucose, HOMA-IR, total cholesterol, LDL-C and triglycerides and an increase in HDL-C 1 year after bariatric surgery. Weight loss 1 year after bariatric surgery was similar in both groups.ConclusionEighteen percent of patients with morbid obesity fulfilled the criteria for MHMO. Although cardiovascular risk factors in these patients were within normal range, an improvement in all these factors was observed 1 year after bariatric surgery. Thus, from a metabolic point of view, MHMO patients benefited from bariatric surgery.     

The effect of bariatric surgery on hypothyroidism: Sleeve gastrectomy versus gastric bypass

Background

Hypothyroidism is prevalent in morbidly obese patients and may improve after a weight reduction surgery.

Bariatric surgery: A safe and effective conduit to cardiac transplantation

BackgroundObesity and obesity-related co-morbidities, including advanced heart failure, are epidemic. Some of these patients will progress to require cardiac allografts as the only means of long-term survival. Unfortunately, without adequate weight loss, they may never be deemed acceptable transplant candidates. Often surgical weight loss may be the only effective and durable option for these complex patients. The objective of this study was to assess whether bariatric surgery is feasible and safe in patients with severe heart failure, which in turn, after adequate weight loss, would allow these patients to be listed for a heart transplant.MethodsFour patients who underwent bariatric procedures, such as laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (SG), for the purpose of attaining adequate weight loss with the goal to improve their eligibility for orthotopic heart transplants are presented.ResultsAll patients did well around the time of surgery, and 3 of the 4 progressed to receiving a heart transplant. The fourth patient will be listed pending attaining adequate weight loss.ConclusionBariatric surgery may be an important bridge to transplantation for morbidly obese patients with severe heart failure. With the appropriate infrastructure, bariatric surgery is a feasible and effective weight loss method in this population.     

Bariatric surgery outcomes in oxygen-dependent patients: analysis of the MBSAQIP database

BackgroundThe number of bariatric procedures performed on complex, oxygen-dependent patients has increased. These patients often have other medical co-morbidities that can be improved after bariatric surgery; however, questions remain regarding their perioperative risk.ObjectiveTo assess the safety of bariatric surgery among oxygen-dependent patients, and to compare outcomes in this patient group after laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy.SettingUniversity and private hospitals enrolled in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry.MethodsThe Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data from 2015 to 2017 was analyzed. A multivariable regression analysis was performed looking at 30-day serious complications for oxygen-dependent patients, with a secondary propensity-matched analysis performed comparing patients undergoing laparoscopic sleeve gastrectomy versus laparoscopic Roux-en-Y gastric bypass.ResultsIn total, 430,396 patients were analyzed, 3034 (0.7%) of whom were oxygen dependent. The absolute 30-day complication rate among oxygen-dependent patients was more than twice as high (8.24% versus 3.46%, P < .001). The postoperative leak (.69% versus .41%, P = .017), bleed (2.08% versus .91%, P < .001), cardiac event (.16% versus .07%, P = .034), and pneumonia rate (.89% versus .19%, P < .001) were all significantly higher. Mortality was significantly higher among oxygen-dependent patients (.49% versus .09%, P < .001). On multivariable analysis, oxygen dependency was an independent predictor of adverse outcomes (odds ratio 1.30 [1.22–1.50], P < .001). Laparoscopic Roux-en-Y gastric bypass was associated with a statistically significant higher complication rate compared with laparoscopic sleeve gastrectomy (13.23% versus 5.16%, P < .001).ConclusionOxygen-dependent patients undergoing bariatric surgery are at a higher risk of both morbidity and mortality postoperatively.     

Simultaneous laparoscopic paraesophageal hernia repair and sleeve gastrectomy in the morbidly obese

BackgroundMorbid obesity is associated with increased rates of hiatal and paraesophageal hernias. Although laparoscopic sleeve gastrectomy is gaining popularity as the procedure of choice for morbid obesity, there is little data regarding the management of paraesophageal hernias found intraoperatively. The aim of this study was to evaluate the feasibility and benefits of a combined sleeve gastrectomy and paraesophageal hernia repair in morbidly obese patients.MethodsFrom May 2011 to February 2013, 23 patients underwent laparoscopic sleeve gastrectomy combined with the repair of a paraesophageal hernia. Only 4 patients had a large hiatal hernia documented preoperatively on esophagogastroduodenoscopy (EGD). The body mass index (BMI), operative time, length of stay, and complications were evaluated.ResultsThe average operative time was 165 minutes (115–240 minutes) and length of stay was 2.83 days (2–6 days). All patients were female except for one, with an average age of 53.4 years and a BMI of 41.9 kg/m². There were no complications during the procedures. Mean follow-up was 6.16 months (1–19 months), and mean excess weight loss was 39%. The average cost of admission for a combined procedure ($10,056), was slightly higher than a laparoscopic sleeve gastrectomy ($8905) or laparoscopic paraesophageal hernia repair ($8954) done separately.ConclusionsLaparoscopic sleeve gastrectomy combined with a paraesophageal hernia repair is well-tolerated and feasible in morbidly obese patients. Surgeons should be aware that preoperative EGD is not effective at diagnosing large hiatal or paraesophageal hernias. Surgeons with the skill set to repair paraesophageal hernias should do a combined procedure because it is well-tolerated, feasible, and can reduce the cost of multiple hospital admissions.     

腹腔镜Roux-en-Y胃旁路术的研究现状

肥胖及肥胖引起的心血管疾病、高血压、高血脂等并发症已成为当今社会很严重的公共卫生问题。1975~2016年,全球大部分地区的肥胖症患病率呈现上升趋势,其中以亚洲地区的上升趋势尤为显著。到2016年,我国已是全世界肥胖症及2型糖尿病患者最多的国家。外科减重手术是目前治疗肥胖症及相关并发症的主要手段,其中应用最为广泛的减重手术为腹腔镜Roux-en-Y胃旁路术(laparoscopic Roux-en-Y gastric bypass,LRYGB)、腹腔镜袖状胃切除术。笔者对LRYGB的研究现状做一综述。     

Impact of laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy on gut microbiota: a metagenomic comparative analysis

BackgroundBariatric surgery is an effective therapeutic procedure for morbidly obese patients. The 2 most common interventions are sleeve gastrectomy (SG) and laparoscopic Roux-en-Y gastric bypass (LRYGB).ObjectivesThe aim of this study was to compare microbiome long-term microbiome after SG and LRYGB surgery in obese patients.SettingUniversity Hospital, France; University Hospital, United States; and University Hospital, Switzerland.MethodsEighty-nine and 108 patients who underwent SG and LRYGB, respectively, were recruited. Stools were collected before and 6 months after surgery. Microbial DNA was analyzed with shotgun metagenomic sequencing (SOLiD 5500 xl Wildfire). MSPminer, a novel innovative tool to characterize new in silico biological entities, was used to identify 715 Metagenomic Species Pan-genome. One hundred forty-eight functional modules were analyzed using GOmixer and KEGG database.ResultsBoth interventions resulted in a similar increase of Shannon’s diversity index and gene richness of gut microbiota, in parallel with weight loss, but the changes of microbial composition were different. LRYGB led to higher relative abundance of aero-tolerant bacteria, such as Escherichia coli and buccal species, such as Streptococcus and Veillonella spp. In contrast, anaerobes, such as Clostridium, were more abundant after SG, suggesting better conservation of anaerobic conditions in the gut. Enrichment of Akkermansia muciniphila was also observed after both surgeries. Function-level changes included higher potential for bacterial use of supplements, such as vitamin B12, B1, and iron upon LRYGB.ConclusionMicrobiota changes after bariatric surgery depend on the nature of the intervention. LRYGB induces greater taxonomic and functional changes in gut microbiota than SG. Possible long-term health consequences of these alterations remain to be established.     

Impact of accreditation in bariatric surgery

BackgroundSeveral studies have shown improved outcomes associated with accredited bariatric centers. The aim of our study was to examine the outcomes of bariatric surgery performed at accredited versus nonaccredited centers using a nationally representative database. Additionally, we aimed to determine if the presence of bariatric surgery accreditation could lead to improved outcomes for morbidly obese patients undergoing other general laparoscopic operations.MethodsUsing the Nationwide Inpatient Sample database, for data between 2008 and 2010, clinical data of morbidly obese patients who underwent bariatric surgery, laparoscopic antireflux surgery, cholecystectomy, and colectomy were analyzed according to the hospital’s bariatric accreditation status.ResultsA total of 277,068 bariatric operations were performed during the 3-year period, with 88.4% of cases performed at accredited centers. In-hospital mortality was significantly lower at accredited compared to nonaccredited centers (.08% versus .19%, respectively). Multivariate analysis showed that nonaccredited centers had higher risk-adjusted mortality for bariatric procedures compared to accredited centers (odds ratio [OR] 3.1, P<.01). Post hoc analysis showed improved mortality for patients who underwent gastric bypass and sleeve gastrectomy at accredited centers compared to nonaccredited centers (.09% versus .27%, respectively, P<.01). Patients with a high severity of illness who underwent bariatric surgery also had lower mortality rates when the surgery was performed at accredited versus nonaccredited centers (.17% versus .45%, respectively, P<.01). Multivariate analysis showed that morbidly obese patients who underwent laparoscopic cholecystectomy (OR 2.4, P<.05) and antireflux surgery (OR 2.03, P<.01) at nonaccredited centers had higher rates of serious complications.ConclusionAccreditation in bariatric surgery was associated with more than a 3-fold reduction in risk-adjusted in-hospital mortality. Resources established for bariatric surgery accreditation may have the secondary benefit of improving outcomes for morbidly obese patients undergoing general laparoscopic operations.     

Management of gallstone disease prior to and after metabolic surgery: a single-center observational study

BackgroundRapid weight loss after bariatric surgery is a risk factor for gallstone formation. There are different strategies regarding its management in bariatric patients, including prophylactic cholecystectomy (CCE) in all patients, concomitant CCE only in symptomatic patients, or concomitant CCE in all patients with known gallstones. We present the safety and long-term results of the last concept.MethodRetrospective single-center analysis of a prospective database on perioperative and long-term results of patients with laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) over a 15-year period. The minimal follow-up was 24 months. Concomitant CCE was intended for all patients with gallstones detected by preoperative sonography.SettingAcademic teaching hospital in Switzerland.ResultsAfter exclusion of patients with a history of CCE (11.5%), a total of 1174 patients (69.6% LRYGB, 30.4% LSG) were included in the final analysis. Preoperative gallbladder pathology was detected in 21.2% of patients, of whom 98.4%, or 20.9% of the total patients, received a concomitant CCE. The additional procedure prolonged the average operation time by 38 minutes (not significant) and did not increase the complication rate compared with bariatric procedure without CCE (3.7% versus 5.7%, P = .26). No complication was directly linked to the CCE. Postoperative symptomatic gallbladder disease was observed in 9.3% of patients (LRYGB 7.0% versus LSG 2.3%, P = .15), with 19.8% of those patients initially presenting with a complication.ConclusionThe concept of concomitant CCE in primary bariatric patients with gallstones was feasible and safe. Nevertheless, 9.3% of primary gallstone-free patients developed postoperative symptomatic gallbladder disease and required subsequent CCE despite routine ursodeoxycholic acid prophylaxis.     

Laparoscopic bariatric surgery for those with body mass index of 70–125 kg/m2

BackgroundData on laparoscopic bariatric surgery in the extremely obese are limited. Technical difficulties, in addition to the patients' severe weight-related co-morbidities, can compromise the safety of bariatric surgery in these patients. Our objectives were to assess the safety and feasibility of laparoscopic bariatric surgery in extremely obese patients and to compare the outcomes of different surgical approaches at a bariatric surgery center of excellence in an academic medical center.MethodsWe reviewed our prospectively collected database and identified all patients with a body mass index (BMI) of ≥70 kg/m² who had undergone bariatric surgery. The data on patient demographics, baseline characteristics, and outcomes of bariatric surgery were retrieved.ResultsA total of 49 patients with a mean BMI of 80.7 kg/m² (range 70–125) underwent 61 bariatric procedures. Of the 49 patients, 26 underwent sleeve gastrectomy, 11 gastric bypass, and 12 underwent a 2-stage procedure (sleeve gastrectomy followed by gastric bypass). At a mean follow-up of 17.4 months, the average BMI had decreased to 60.9 kg/m² (36% excess weight loss). Overall, the patients who underwent a 2-stage procedure achieved greater percentage of excess weight loss (54.5%) than did those who underwent either single-stage sleeve gastrectomy or gastric bypass (25.4%, P = .002 and 43.8%, P = .519, respectively). Of the 61 cases, 60 (98.4%) were completed laparoscopically. The early complication rate was 16.4% overall; most were minor complications. The late complication rate was 14.8%. A single late mortality occurred in this series.ConclusionLaparoscopic bariatric surgery can be performed safely on patients with a BMI of ≥70 kg/m². A staged approach might offer better weight loss results.     

Differences in the effects of laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass on gut hormones: systematic and meta-analysis

BackgroundLaparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) procedures are becoming more popular in the world of bariatric surgery.ObjectivesThis study investigates how LSG and LRYGB affect gut hormones and examines their differences.SettingSystematic review and meta-analysis.MethodsThe literature was retrieved from PubMed, Web of Science, Embase, and the Cochrane Library database before April 2020.ResultsWe included 53 articles in our meta-analysis. After bariatric surgery, the patients’ ghrelin, fasting acyl-ghrelin, fasting peptide YY (PYY), and their AUC in the LSG group were significantly lower than those in LRYGB group. Fasting ghrelin levels were significantly reduced in patients who received LSG. After LRYGB, the postoperative fasting PYY was higher than at baseline, and the results were statistically significant. Additionally, we found an increase in fasting ghrelin levels after LRYGB. Lastly, insulin levels were both reduced after LSG and LRYGB with no significant difference.ConclusionsIn terms of gut hormones, ghrelin decreased significantly after LSG, while PYY increased after LRYGB. However, the impacts caused by the change in gut hormones after undergoing either LSG and LRYGB on patients are complicated, therefore, the results should be interpreted cautiously.     

Is age a real or perceived discriminator for bariatric surgery? A long-term analysis of bariatric surgery in the elderly

BackgroundBariatric surgery is the most effective treatment of obesity. There are few studies evaluating long-term outcomes in elderly patients.ObjectivesOur study was designed to evaluate the safety and long-term outcomes of bariatric surgery in the elderly compared with a contemporary medically managed cohort.SettingUniversity hospital.MethodsThree hundred thirty-seven patients age ≥60 who underwent a sleeve gastrectomy or Roux-en-Y gastric bypass between January 2007 and April 2017 were identified (ElderSurg) and compared with a matched cohort of medically managed elderly patients with obesity (ElderNonSurg).ResultsThirty-two patients underwent laparoscopic sleeve gastrectomy, 190 underwent laparoscopic Roux-en-Y gastric bypass, and 115 underwent open Roux-en-Y gastric bypass. The cohort was a mean of 64.4-years old, 75.4% female, mean preoperative body mass index was 46.9, and 62.6% had type 2 diabetes. During a median follow-up period of 56.2 months (confidence interval 49.5–62.9), mean percent excess weight loss (EWL) at nadir was 72.1 ± 24.7% and EWL at 36 months or beyond was 60.9 ± 27.6%. On regression analysis, diabetes, body mass index, and laparoscopic sleeve gastrectomy were negatively associated with EWL at all time periods (P < .05). Mean %EWL was greater for Roux-en-Y gastric bypass compared with laparoscopic sleeve gastrectomy (61.7 versus 41.2; P = .039). Diabetes remission rate was 45.8%. There was a statistically significant decrease in the risk of death in ElderSurg (hazard ratio .584, 95% confidence interval .362–.941) compared with ElderNonSurg.ConclusionsOur study supports that bariatric surgery is safe in elderly patients with effective long-term control of obesity, diabetes, and with improved overall survival.     

Intestinal Malrotation Discovered at the Time of Laparoscopic Roux-en-Y Gastric Bypass

Four morbidly obese women who met the NIH criteria for bariatric surgery had laparoscopic Roux-en-Y gastric bypass. At operation, each was found to have intestinal malrotation. Two cases were completed laparoscopically, and two were converted to open operation because of difficulty defining the anatomy. All four operations were successful with no immediate complications and patients tolerated the procedures well. We present the four cases and offer recommendations should this unusual congenital defect be discovered at the time of laparoscopic gastric bypass.     

Laparoscopic sleeve gastrectomy versus Roux-en-Y gastric bypass for quality of life: a systematic review and meta-analysis

Laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) are the mainstays of bariatric surgery in recent years. In addition, there has been an increased interest in the quality of life (QoL) of obese patients after surgery. This study examined the QoL of patients who had undergone either LSG or LRYGB. We retrieved the literature from PubMed, Web of Science, Embase, and the Cochrane Library database before November 2019. A total of 10 articles and 2327 obese patients were included in our meta-analysis. The QoL scoring tools included in the statistical analysis are the following: the gastrointestinal quality of life index, 36-items short-form health survey, bariatric analysis and reporting outcome system, and the Moorehead-Ardelt quality of life questionnaire II. Although the QoL score of the LRYGB group was higher than that of the LSG group in the bariatric analysis and reporting outcome system subgroup, statistical analysis showed no difference in the postoperative QoL of LSG and LRYGB. In our study, no difference was found in the QoL between LSG and LRYGB. Therefore, in terms of postoperative QoL, surgical methods should be selected on the basis of the patients’ condition and level of understanding of the surgeries.     

Laparoscopic sleeve gastrectomy for morbid obesity

The epidemic of obesity in the United States is a major public health issue and more than a third of adults are now considered obese (body mass index ≥ 30 kg/m²). Surgery for morbid obesity, bariatric surgery, is the most durable treatment for this disease and about 140,000 cases are performed annually. Laparoscopic sleeve gastrectomy (LSG) has been advocated as the first of a 2-stage procedure for the high-risk, super-obese patient. More recently, LSG has been studied as a single-stage procedure for weight loss in the morbidly obese. LSG has been shown in initial studies to produce excellent excess weight loss comparable with laparoscopic Roux-en-Y gastric bypass in many series with a very low incidence of major complications and death. We describe our technique for LSG.     

The effects of sevoflurane and desflurane on the hemodynamics and respiratory functions in laparoscopic sleeve gastrectomy

Study objectivesSleeve gastrectomy has been one of the most commonly performed bariatric surgery methods. The study aimed to compare the effects of 2 most commonly used inhalation anesthetics, sevoflurane and desflurane, on the peroperative hemodynamic alterations and postoperative respiratory functions in morbidly obese patients undergoing sleeve gastrectomy.DesignNonrandomized cohort.SettingsOperating room, postoperative period.PatientsEighty-four morbidly obese patients with a body mass index greater than 40 kg/m² who had scheduled to undergo sleeve gastrectomy operation were prospectively included in the study.InterventionsPatients were divided into 2 groups. The maintenance of inhalation anesthesia was performed by sevoflurane in 1 group (sevoflurane group) and desflurane (desflurane group) in the other group.MeasurementsDemographic features, peroperative hemodynamic alterations, and the results of preoperative and postoperative 24th hour respiratory function tests were recorded.ResultsThere was not any statistically significant difference between groups regarding age, sex, body mass index, anesthesia time, peroperative mean arterial pressure, arterial oxygen saturation, end-tidal carbon dioxide, and preoperative or postoperative forced expiratory volume 1/forced vital capacity ratios.ConclusionWe determined that both desflurane and sevoflurane provide similar intraoperative hemodynamic and early postoperative respiratory functions in morbidly obese patients in laparoscopic sleeve gastrectomy. Both agents can be regarded as alternatives for inhalation anesthetics in maintenance of anesthesia.     

Gastropleural fistula after single anastomosis gastric bypass. A case report and review of the literature

IntroductionPulmonary complications after bariatric surgeries are rare but usually serious. They often occur early after surgery but the presentation might be delayed for several months. Gastropleural fistula after bariatric surgery is extremely rare and has been reported in a very small number of patients post sleeve gastrectomy and gastric bypass.Case presentationA 37-year-old lady presented with left sided pleural effusion and empyema 2 years post single anastomosis gastric bypass surgery. She was found to have a large gastropleural fistula and was managed by surgical repair of the fistula with conversion to gastric bypass and decortication of the affected pleura. That resulted in significant clinical improvement and resolution of the empyema.ConclusionGastropleural fistula is a very rare complication of bariatric surgeries and should be considered in patients who present with chronic or recurrent pulmonary infections.     

Primary midline peritoneal access with optical trocar is safe and effective in morbidly obese patients

BackgroundThe bladed optical access trocar is widely used and provides convenient, safe peritoneal entry. However, it has only been approved for use after insufflation. We used this device as our primary method of entry before insufflation in bariatric surgery and provide an overview of our cumulative experience. In addition, we provide a comprehensive analysis of the published data with respect to optical access as both primary and secondary methods of peritoneal access.MethodsFrom July 30, 2001 to April 4, 2008, laparoscopic access for all bariatric surgery at a single center was achieved using the 5–12-mm optical bladed trocar without previous insufflation for 2207 cases, including 1692 laparoscopic gastric bypass procedures and 515 laparoscopic adjustable gastric band placements.ResultsFour vascular injuries occurred (.18%) in our series. Three required conversion to laparotomy and vascular repair, and one was managed laparoscopically. All injuries occurred with off-midline placement. No mortalities occurred secondary to the use of the optical trocar.ConclusionThe present report is as the greatest volume series detailing the safe and effective use of the bladed optical trocar without previous insufflation as the primary method of peritoneal access in the morbidly obese. The insertion of this device in the midline appears to be a safe method of entry.     

Improvement in gastroesophageal reflux disease symptoms after various bariatric procedures: Review of the Bariatric Outcomes Longitudinal Database

BackgroundThe prevalence of gastroesophageal reflux disease (GERD) in the morbidly obese population is as high as 45%. The objective of this study was to compare the efficacy of various bariatric procedures in the improvement of GERD.MethodsThe Bariatric Outcomes Longitudinal Database is a prospective database of patients who undergo bariatric surgery by a participant in the American Society of Metabolic and Bariatric Surgery Center of Excellence program. GERD is graded on a 6-point scale, from 0 (no history of GERD) to 5 (prior surgery for GERD). Patients with GERD severe enough to require medications (grades 2, 3, and 4) from June 2007 to December 2009 are identified; the resolution of GERD is noted based on 6-month follow-up.ResultsOf a total of 116,136 patients, 36,938 patients had evidence of GERD preoperatively. After excluding patients undergoing concomitant hiatal hernia repair or fundoplication, there were 22,870 patients with 6-month follow-up. Mean age was 47.6±11.1 years, with an 82% female population. Mean BMI was 46.3±8.0 kg/m². Mean preoperative GERD score for patients with Roux-en-Y gastric bypass (RYGB) was 2.80±.56, and mean postoperative score was 1.33±1.41 (P<.0001). Similarly, adjustable gastric banding (AGB, 2.77±.57 to 1.63±1.37, P<.0001) and sleeve gastrectomy (SG, 2.82±.57 to 1.85±1.40, P<.0001) had significant improvement in GERD score. GERD score improvement was best in RYGB patients (56.5%; 7955 of 14,078) followed by AGB (46%; 3773 of 8207) and SG patients (41%; 240 of 585).ConclusionAll common bariatric procedures improve GERD. Roux-en-Y gastric bypass is superior to adjustable gastric banding and sleeve gastrectomy in improving GERD. Also, the greater the loss in excess weight, the greater the improvement in GERD score.     

Comparison of objective outcomes following laparoscopic Nissen fundoplication versus laparoscopic gastric bypass in the morbidly obese with heartburn

Background: Heartburn and gastroesophageal reflux disease (GERD) affects approximately 25–50% of morbidly obese patients. Although objective physiologic testing has been reported extensively in patients following Nissen fundoplication, there are no previous reports of such testing in morbidly obese patients. A life-saving surgical alternative for the morbidly obese patient is gastric bypass surgery, which usually improves heartburn symptoms in addition to many serious health conditions such as diabetes, hypertension, and sleep apnea. We hypothesized that, in morbidly obese patients, gastric bypass surgery would be as effective as Nissen fundoplication in reducing both heartburn symptoms and esophageal acid exposure, as reflected by the DeMeester score. Methods: Between 1995 and 2000, all patients undergoing laparoscopic Nissen fundoplication (LN) and laparoscopic gastric bypass (LGB) in our practice underwent preoperative and postoperative esophageal physiologic testing. Patients were included in this study that were morbidly obese and had significant heartburn symptoms or objective evidence of acid reflux, and had repeat esophageal physiologic testing after either LN or LGB. Data were obtained through retrospective review of prospectively collected data. Results: Twelve patients met the inclusion criteria: six patients who had LN and six who had LGB. The mean body mass index (BMI) was 55 kg/m² in the LGB group and 39.8 in the LN group. After surgery, the mean DeMeester score decreased from 64.3 to 2.8 in the LN group (p = 0.01) and from 34.7 to 5.7 in the LGB group (p = 0.1). Both groups mean postoperative DeMeester scores were normal after surgery, and there was no significant difference between the two groups (p = 0.3). Both groups experienced a significant improvement in heartburn symptoms postoperatively. The mean preoperative symptom score improved from 3.5 to 0.5 in the LN group (p = 0.01) and from 2.2 to 0.2 in the LGB group (p = 0.003). There was no difference in the mean postoperative symptom scores between the groups (p = 0.35). After surgery, mean LES resting pressures increased from 12.9 to 35.5 (p = 0.003) in the LN group and from 23.6 to 29.7 (p = 0.45) in the LGB group. There were no complications in either group. Conclusion: Results of this study show that laparoscopic gastric bypass and laparoscopic Nissen fundoplication are both effective in treating heartburn symptoms and objective acid reflux in morbidly obese patients. The health benefits of weight loss after laparoscopic gastric bypass should make this operation the procedure of choice in the morbidly obese patient with heartburn.