Laparoscopic fundoplication compared with laparoscopic gastric bypass in morbidly obese patients with gastroesophageal reflux disease

BackgroundGastroesophageal reflux disease (GERD) is commonly associated with morbid obesity. Laparoscopic fundoplication is a standard surgical treatment for GERD, and laparoscopic gastric bypass has been shown to effectively resolve GERD symptoms in the morbidly obese. We sought to compare the in-hospital outcomes of morbidly obese patients who underwent laparoscopic fundoplication for the treatment of GERD versus laparoscopic gastric bypass for the treatment of morbid obesity and related conditions, including GERD, at U.S. academic medical centers.MethodsUsing the “International Classification of Diseases, 9th Revision” procedural and diagnoses codes for morbidly obese patients with GERD, we obtained data from the University HealthSystem Consortium database for all patients who underwent laparoscopic fundoplication or laparoscopic gastric bypass from October 2004 to December 2007 (n = 27,264). The outcome measures included the patient demographics, length of stay, in-hospital overall complications, mortality, risk-adjusted mortality ratio (observed to expected mortality), and hospital costs.ResultsCompared with the patients who underwent laparoscopic gastric bypass, those who underwent laparoscopic fundoplication had a lower severity of illness score (P <.05). The overall in-hospital complications were significantly lower in the laparoscopic gastric bypass group (P <.05). The mean length of stay, observed mortality, risk-adjusted mortality, and hospital costs were comparable between the 2 treatment groups.ConclusionLaparoscopic gastric bypass is as safe as laparoscopic fundoplication for the treatment of GERD in the morbidly obese. Hence, morbidly obese patients with GERD should be referred for bariatric surgery evaluation and offered laparoscopic gastric bypass as a surgical option.     

Evolution of the laparoscopic gastric bypass

Obesity is recognized as a health problem of epidemic proportions. Surgical intervention for the treatment of obesity is a well-studied and effective method. Various procedures have been utilized over the past decades. Roux-en-Y gastric bypass has emerged over the last 20 years and is currently the most commonly offered surgical treatment. Within the last decade, advances in laparoscopic technology and surgical experience have allowed the application of laparoscopic techniques to the surgical treatment of obesity. Many centers and individuals have developed excellent techniques through experience over time as well as improvements in instrumentation. Hand-assisted laparoscopy was reported as a technique, but has mostly fallen out of favor. Currently, laparoscopic application of adjustable gastric band and laparoscopic Roux-en-Y gastric bypass are widely used throughout the United States. Data have been generated to demonstrate the improvement in surgical outcomes associated with minimally invasive surgical techniques for the surgical treatment of obesity. Further advances will allow continued improvement in patient outcomes utilizing a variety of minimally invasive surgical approaches to the treatment of this difficult disease.     

The effect of total and anterior partial fundoplication on antireflux mechanisms of the gastroesophageal junction

BACKGROUND: The effect of total (Nissen) and anterior partial fundoplication (APF) for the surgical treatment of gastroesophageal reflux disease (GERD) on the motor behavior of the esophagogastric axis has not been fully assessed. The purpose of this study was to assess any alterations in lower esophageal sphincter (LES) and gastric fundus motor parameters in GERD patients after Nissen or APF fundoplication. METHODS: Twenty four patients with documented GERD underwent either laparoscopic Nissen fundoplication (n = 12) or laparoscopic APF (n = 12). Preoperative and postoperative stationary esophageal manometry included assessment of LES resting and postdeglutition relaxation pressures, intragastric pressure, and LES transient relaxations in the left lateral and upright positions and after gastric distension. RESULTS: Both types of fundoplication resulted in significant increases in LES resting (P <0.001) and postdeglutition relaxation pressure (P <0.001) in both positions and after gastric distention. Intragastric pressure increased only after Nissen fundoplication in the postgastric distention state (P = 0.01). Transient LES relaxations were equally abolished after both procedures. All postoperative changes were to a similar level after either procedure with the exception of intragastric pressure after gastric distention, which was significantly higher after total than after partial fundoplication (P = 0.04). CONCLUSIONS: Both procedures equally increase LES resting and postdeglutition relaxation pressures and abolish transient LES relaxations at all states. The significantly higher intragastric pressure at the postgastric distention state after Nissen fundoplication could possibly explain the higher incidence of epigastric fullness and discomfort after this type of antireflux surgery.     

Current status of laparoscopic gastric bypass

Laparoscopic gastric bypass is emerging as a commonly performed procedure for the treatment of morbid obesity. This article discusses the indications for surgery, patient selection, surgical technique, management of complications, and outcomes of laparoscopic gastric bypass.     

Laparoscopically Assisted ERCP in a Case of Acute Cholangitis in a Patient with Biliopancreatic Diversion with Distal Gastric Preservation

Roux-en-Y gastric bypass, biliopancreatic diversion (BPD; Scopinaro's technique), and BPD with distal gastric preservation (BPDGP) are different surgical procedures, currently performed with laparoscopic assistance, successfully used as a treatment for morbid obesity. All of these modalities bear the burden of a difficult access when it comes to explore and work within the biliary tract. We present a case of acute cholangitis due to choledocholithiasis in a patient with BPDGP for morbid obesity successfully managed by laparoscopy-assisted endoscopic retrograde cholangiopancreatography through the gastric remnant.     

Practical approaches to the surgical management of achalasia

Achalasia is a primary motor disorder of the esophagus characterized by an abnormal hypertensive, nonrelaxing lower esophageal sphincter (LES) and nonfunctioning, aperistaltic esophageal body resulting in significant regurgitation and dysphagia. The primary goal of treatment is palliation of symptoms. At present, all treatment techniques are directed at relieving the functional obstruction at the level of the LES by disruption or paralysis of the esophageal muscle constituting the LES. Destruction of the LES function also places the patient at risk for pathologic gastroesophageal reflux disease. Therefore, the treatment of patients with achalasia must strike a balance between the relief of dysphagia and potential creation of pathologic gastroesophageal reflux. The advent of laparoscopic esophageal myotomy for the treatment of achalasia over the past decade has resulted in most patients with the disease being referred to surgeons for definitive treatment. At the time of consultation the patient may present with a myriad of symptoms, investigative results, and previous treatments. Based on our experience of over 300 patients treated with surgery at our institution between 1990 and 2007, this review will address the practical problems encountered in the surgical management of achalasia.     

Five-Year Follow-up after Laparoscopic Roux-en-Y Gastric and Partial Ileal Bypass for Treatment of Morbid Obesity and Uncontrolled Hyperlipidemia

BACKGROUND: Morbid obesity is associated with significant co-morbid illnesses and mortality. Hyperlipidemia is strongly associated with atherosclerosis and cardiovascular disease. Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a proven and effective procedure for the treatment of morbid obesity and its related co-morbid illnesses. In a randomized prospective clinical trial, partial ileal bypass showed sustained control of hyperlipidemia and reduced comorbidities. Given risks of surgery, pharmacologic agents are the current primary therapy for hyperlipidemia. However, a morbidly obese patient with medically refractory hyperlipidemia may benefit from a combined laparoscopic Roux-en-Y gastric bypass and partial ileal bypass. We are describing the first case of a totally laparoscopic approach. METHODS: A 56-year-old female patient with morbid obesity (BMI 45.2 kg/m(2)) and medically refractive hyperlipidemia underwent a combined LRYGB and partial ileal bypass in 2002. She was continuously followed for 5 years for weight profile, hyperlipidemia, post-operative complications, and morbidity. RESULTS: Five-year follow-up of the patient showed sustained excess body weight loss. Her lipid profile has approached normal ranges with less medication. She experienced no comorbidities related to surgery or hyperlipidemia. CONCLUSIONS: Laparoscopic Roux-en-Y gastric bypass and partial ileal bypass may be the best option for the patient who has morbid obesity and medically refractory hyperlipidemia and should be considered for select patients.     

Treatment of morbid obesity with laparoscopic adjustable gastric banding affects esophageal motility

BACKGROUND: Laparoscopic adjustable gastric banding has become the prefered method for the surgical treatment of morbid obesity in Europe. It is not known whether this procedure may induce gastroesophageal reflux and whether it may impair esophageal peristalsis. METHODS: Laparoscopic adjustable gastric banding (Swedish band) was performed in 43 patients (median body mass index [BMI] 42.5 kg/m(2)). Preoperatively and 6 months postoperatively all patients were assessed for reflux symptoms. In addition all patients underwent preoperative and postoperative endoscopy, esophageal barium studies and manometry, and 24-hour esophageal pH-monitoring. RESULTS: The median BMI dropped significantly to 33.1 kg/m(2) (P <0.05). Preoperatively 12 patients complained of reflux symptoms. Mild esophagitis was detected in 10 patients. Postoperatively only 1 patient complained of heartburn and mild esophagitis was diagnosed in another patient. None of the patients had dysphagia. Preoperatively a defective LES and pathologic pH-testing were found in 9 and 15 patients, respectively. These parameters were normal in all of the patients postoperatively. Postoperatively there was significant impairment of LES relaxation and deterioration of esophageal peristalsis with dilatation of the esophagus in some of the patients. CONCLUSION: Laparoscopic adjustable gastric banding provides a sufficient antireflux barrier and therefore prevents pathologic gastroesophageal reflux. However, it impairs relaxation of the LES, leading to weak esophageal peristalsis.     

Esophageal Motility and Reflux Symptoms Before and After Bariatric Surgery

Background: Surgical treatment is the most effective method for weight reduction in morbid obesity. The most common operations are gastric banding and gastric bypass. The effect of these interventions on esophageal function and gastroesophageal reflux symptoms has not been adequately investigated. Methods: Patients undergoing obesity surgery were prospectively included in an observational study. Before surgery, each of the 53 patients underwent pulmonary function tests, esophageal manometry, and gastroscopy. Drug medication and esophageal symptoms were recorded. "Non-sweet eater" patients with good compliance underwent laparoscopic adjustable gastric banding (LAGB). In "sweet-eating" or non-compliant patients, gastric bypass (GBP) was carried out. Results: Between July 1997 and April 2000, 53 patients (9 males and 44 females) were consecutively operated on. 32 patients (median BMI 46.4 kg/m² ±5.4 SD) received LAGB, and 21 patients (BMI 54.0 kg/m² ±10.7) GBP. Median follow-up was 22 months, and only 3 patients were lost to yearly follow-up. Preoperatively, 6 LAGB patients had reflux symptoms, which postoperatively resolved in 3 of them, while the other 3 noted no change. Three patients who had no preoperative reflux symptoms developed them after LAGB. In the GBP group, no patient had esophageal dysmotility or incompetent esophageal sphincter function pre- or postoperatively. The incidence of postoperative esophageal symptoms was independent of operative technique (Wilcoxon U-Test: p= 0.75). Conclusion: The present results do not show any effect of gastric reduction surgery on postoperative esophageal function or gastroesophageal reflux symptoms.     

Simultaneous Surgical Management of Achalasia and Morbid Obesity

Achalasia presenting in the context of morbid obesity is rare. The case is presented of a woman with achalasia and morbid obesity who was treated with simultaneous laparoscopic esophageal myotomy and gastric bypass. The sparse literature addressing these rare patients is reviewed and management considerations discussed. Simultaneous laparoscopic esophageal myotomy and gastric bypass is safe, feasible and provides good results. RWO receives support from the Society of American Gastrointestinal and Endoscopic Surgeons, the Medical Research Foundation of Oregon, and from an American Surgical Association Foundation Fellowship Award.     

Bariatric Surgery in the Management of Childhood Obesity: Should There be an Age Limit?

We report a case of a 6-year-old girl suffering from morbid obesity, Blount`s disease, and significant social and functional impairment who underwent a laparoscopic sleeve gastrectomy. One year later, she has shown remarkable improvement in all aspects of her health emphasizing the success of the procedure. A follow-up laparoscopic Roux-en-Y gastric bypass or biliopancreatic diversion (BPD) are options if she regains weight as she gets older. This case is noteworthy for several reasons. The age of the patient is younger than any currently on record who has had this treatment. Additionally, the utilization of a sleeve gastrectomy as a first-step procedure, to be followed by Roux-en-Y gastric bypass or BPD, remains a novel treatment for morbid obesity in a pediatric population.     

Laparoscopic paraesophageal hernia repair

The term paraesophageal hernia is described as a herniation of the gastric fundus through the open hiatus into the thoracic cavity while the lower esophageal sphincter (LES) remains in its normal anatomic position. This is considered a rolling esophageal hernia (Type II), and it is the least commonly encountered hiatal hernia. A more commonly encountered herniation of the fundus of the stomach is the Type III hernia, in which both the LES and the fundus herniate into the chest. This has also been classified as a paraesophageal hernia. The most common hiatal hernia is a sliding hiatal hernia (Type I), which consists of herniation of the stomach through the esophageal hiatus, causing the LES and gastric cardia to lie in the thoracic cavity. There are several controversial issues involved in paraesophageal hernia repair, including indications for surgery, the most appropriate surgical approach, and the need for a concomitant antireflux procedure. The increasing popularity of laparoscopic paraesophageal hernia repair has dramatically altered the approach to these patients and has allowed patients at higher risk to better tolerate this procedure with a decrease in morbidity and mortality. However, they remain difficult surgical procedures.     

Laparoscopic Roux-en-Y Gastric Bypass with Remnant Gastrectomy for Focal Intestinal Metaplasia of the Gastric Antrum

Background: Inaccessibilility of the excluded stomach after isolated gastric bypass prevents postoperative evaluation and treatment of disorders of the gastric remnant. Bleeding complications, peptic ulcer disease, and gastric malignancy in the gastric remnant have all been reported. We report a patient with morbid obesity and focal intestinal metaplasia in the antrum of the stomach that was treated with laparoscopic Roux-en-y gastric bypass (LRYGBP) with remnant gastrectomy. Case Report: A 46-year-old female with a long history of morbid obesity presented with a BMI of 47 kg/m². Preoperative upper endoscopy revealed focal intestinal metaplasia. Since intestinal metaplasia is a risk factor for gastric cancer, a LRYGBP with remnant gastrectomy was performed. Conclusions: LRYGBP with remnant gastrectomy is a safe and cost-effective treatment for morbidly obese patients with focal intestinal metaplasia of the stomach.     

Is Preoperative Manometry in Restrictive Bariatric Procedures Necessary?

BACKGROUND: Restrictive bariatric procedures are frequently considered for patients with morbid obesity, because the weight loss and reduction of comorbidities are good. An impact on gastroesophageal reflux disease (GERD), which is common in this population, may be anticipated. Converse results of GERD symptoms are reported for patients after adjustable gastric banding (AGB), sleeve gastrectomy (SG), and Roux-en-Y gastric bypass (RYGBP). METHODS: A literature search was performed and, with our personal experience, are summarized. RESULTS: Esophageal manometry is a practical tool to identify functional disorders of the esophageal body and the lower esophageal sphincter (LES). For patients with weak esophageal body motility, AGB should not be considered as a therapeutic option because esophageal dilation, esophageal stasis, and consequent esophagitis often occur during long-term follow-up, and band deflation is inevitable. Stable body weight can therefore not be achieved in these patients. Low resting pressure of the LES may be a contraindication for SG, because taking away the angle of His further impairs the antireflux mechanism at the cardia. So far, RYGBP is an option for all morbidly obese patients regardless of the results of esophageal manometry. CONCLUSION: Preoperative esophageal manometry is advised for restrictive procedures such as AGB and SG.     

Morbid Obesity with Achalasia: A Surgical Challenge

Achalasia is a relatively rare medical condition that is classically not associated with obesity. The surgical treatment of a simultaneous occurrence of these two diseases requires careful consideration, and only a few reports can be found in the literature combining a Heller myotomy with gastric bypass, duodenal switch, or gastric banding. We report the case of a 69-year-old female patient with early achalasia and obesity who underwent simultaneous laparoscopic gastric sleeve resection and robotic Heller myotomy. No intra- or postoperative complications occurred. A follow-up at 6 weeks showed a significant weight loss and resolved symptoms of achalasia. The case illustrates that a simultaneous gastric sleeve resection and robotic Heller myotomy might be an option for the treatment of concurrent obesity and achalasia.     

Mallory-Weiss tear after laparoscopic Roux-en-Y gastric bypass.

In the United States, the most common surgical procedure for morbid obesity is the Roux-en-Y gastric bypass. Pulmonary embolism, leak, bowel obstruction, and gastrointestinal bleeding are among the potential early fatal complications. Early postoperative bleeding after laparoscopic gastric bypass, although uncommon, presents a dilemma because of the danger of perforation from postoperative endoscopy and the inability to access the gastric remnant easily. We describe a case of a Mallory-Weiss tear causing massive upper gastrointestinal hemorrhage 1 week after laparoscopic Roux-en-Y gastric bypass. Bariatric surgeons should consider this diagnosis, especially when encountering a patient with a history of significant retching postoperatively.     

Laparoscopic Sleeve Gastrectomy is a Novel and Effective Treatment for Obesity in Patients with Chronic Kidney Disease

Obesity increases the risk of progression of chronic kidney disease (CKD) towards kidney failure and may preclude access to kidney transplantation. Weight loss surgery remains relatively novel in obese patients with CKD, with several studies reporting results using Roux-en-Y bypass and adjustable gastric banding. However, in obese patients with CKD, kidney failure after bypass surgery and gastric band erosion after kidney transplantation have been reported. We present the first report of laparoscopic sleeve gastrectomy (LSG) performed for the treatment of obesity in patients with CKD. Weight loss, blood pressure and lipids, estimated kidney function, surgical complications and adverse events were studied. Nine obese patients with CKD (five of whom were undergoing haemodialysis treatment) underwent LSG, with median body mass index decrease of 8.4 kg/m² and excess weight loss of 43.0% after 6 months. Four of the five patients on haemodialysis were added to the kidney transplantation waiting list as a result of weight loss achieved with LSG. Adverse events occurred in three patients: myocardial infarction (one patient), acute kidney injury secondary to dehydration (one patient) and compromised dialysis access (one patient). There was one complication—a gastric leak, detected 7 months after LSG, requiring further surgical intervention and nasojejunal feeding, and no mortality. Our preliminary evidence suggests that LSG is an effective treatment for obesity in patients with CKD. However, there may be additional risk associated with the procedure in patients with CKD, requiring further study.     

Initial outcomes of laparoscopic Roux-en-Y gastric bypass in morbidly obese adolescents

BACKGROUND: Adolescent obesity is an epidemic in the United States, leading to significant morbidity. Because the impact of laparoscopic bariatric surgery in this population is not as well delineated as in adults, we examined the short-term outcome of adolescents undergoing laparoscopic Roux-en-Y gastric bypass at our institution. METHODS: The medical records of patients < or =18 years of age who had undergone laparoscopic Roux-en-Y gastric bypass for morbid obesity from 1999 to June 2005 were reviewed. The outcome variables examined included preoperative body mass index, percent of excess weight lost for those with at least 3 months of follow-up, length of hospital stay, postoperative morbidity and mortality, changes in comorbid conditions, and effects of surgical weight loss on quality of life. Data are presented as the mean +/- standard error of the mean. RESULTS: Eleven patients (seven girls and four boys) had undergone laparoscopic Roux-en-Y gastric bypass. The mean follow-up was 11.5 +/- 2.8 months (range 3-32). The average patient age was 16.5 +/- 0.2 years, and the average body mass index was 50.5 +/- 2.0 kg/m(2). The average number of comorbidities was 5.3, 70% of which improved or resolved postoperatively. No mortalities resulted. Of the 11 patients, 1 had early postoperative bleeding and 2 developed a marginal ulcer. The quality-of-life surveys obtained from 9 patients reflected an overall improvement in self-esteem, social functioning, and productivity in school or the workplace. CONCLUSIONS: The initial data suggest that laparoscopic gastric bypass is an effective weight loss treatment for morbidly obese adolescents.     

Barrett’s Esophagus: A Late Complication of Laparoscopic Adjustable Gastric Banding

Laparoscopic adjustable gastric banding has become a popular bariatric restrictive procedure in the USA. The increasing popularity of the laparoscopic adjustable gastric band procedure could, in part, be related to the lower cost and lower morbidity compared with laparoscopic gastric bypass. Although its placement is related to a lower number of perioperative complications compared with laparoscopic gastric bypass, its morbidity may be substantial. Barrett’s esophagus or esophageal intestinal metaplasia is a known complication of chronic gastro-esophageal reflux disease that, in rare occasions, progresses to dysplasia and esophageal adenocarcinoma. Barrett’s esophagus, after laparoscopic adjustable gastric banding placement, is a rare but not unexpected complication after gastric band placement. The incidence of Barrett’s esophagus after adjustable gastric banding is not known. We present a case of Barrett’s esophagus as a result of laparoscopic adjustable gastric banding placement due to a chronically and highly restrictive gastric band in a former morbidly obese patient.     

Laparoscopic versus open gastric bypass in the treatment of morbid obesity: a randomized prospective study

OBJECTIVE: The objective of the study was to compare the results of open versus laparoscopic gastric bypass in the treatment of morbid obesity. SUMMARY BACKGROUND DATA: Gastric bypass is one of the most commonly acknowledged surgical techniques for the management of morbid obesity. It is usually performed as an open surgery procedure, although now some groups perform it via the laparoscopic approach. PATIENTS AND METHODS: Between June 1999 and January 2002 we conducted a randomized prospective study in 104 patients diagnosed with morbid obesity. The patients were divided into 2 groups: 1 group with gastric bypass via the open approach (OGBP) comprising 51 patients, and 1 group with gastric bypass via the laparoscopic approach (LGBP) comprising 53 patients. The parameters compared were as follows: operating time, intraoperative complications, early (<30 days) and late (>30 days) postoperative complications, hospital stay, and short-term evolution of body mass index. RESULTS: Mean operating time was 186.4 minutes (125-290) in the LGBP group and 201.7 minutes (129-310) in the OGBP group (P < 0.05). Conversion to laparotomy was necessary in 8% of the LGBP patients. Early postoperative complications (<30 days) occurred in 22.6% of the LGBP group compared with 29.4% of the OGBP group, with no significant differences. Late complications (>30 days) occurred in 11% of the LGBP group compared with 24% of the OGBP group (P < 0.05). The differences observed between the 2 groups are the result of a high incidence of abdominal wall hernias in the OGBP group. Mean hospital stay was 5.2 days (1-13) in the LGBP group and 7.9 days (2-28) in the OGBP group (P < 0.05). Evolution of body mass index during a mean follow-up of 23 months was similar in both groups. CONCLUSIONS: LGBP is a good surgical technique for the management of morbid obesity and has clear advantages over OGBP, such as a reduction in abdominal wall complications and a shorter hospital stay. The midterm weight loss is similar with both techniques. One inconvenience is that LGBP has a more complex learning curve than other advanced laparoscopic techniques, which may be associated with an increase in postoperative complications.