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Certain Bariatric Procedures Linked to Higher Risk for GERD, Esophagitis
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WASHINGTON — Patients who undergo Roux-en-Y-gastric bypass have lower odds of developing GERD and esophagitis after they undergo surgery, compared with other gastric bypass surgery types, according to data presented at Digestive Disease week.
“There’s limited data comparing the various bariatric procedures with regard to long-term changes to the esophagus,” Lisa Bevilacqua, MD, of Stony Brook University School of Medicine, said during her presentation. “However, there is some emerging data that sleeve gastrectomy may predispose to reflux and its complications.”
Bevilacqua and colleagues used data from the New York Statewide database to investigate any associations between surgery type and post-operative diagnoses. They searched for all adult patients who underwent biliopancreatic diversion (BPD), adjustable gastric banding (AGB), Roux-en-Y-gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) between 1995 and 2010.
The study comprised 48,991 patients (mean age, 42.8 years; 78.4% women; 61.3% Caucasian). Of this cohort, 30.3% had a diagnosis of GERD before their operation. These patients were more likely to develop GERD (OR = 2.2; 95% CI, 2.1–2.3), esophagitis (OR = 1.4; 95% CI, 1.3–1.5) and Barret’s esophagus (OR = 2; 95% CI, 1.7–2.4) after surgery.
After excluding patients with a diagnosis before surgery, Bevilacqua and colleagues compared incidence of the conditions for patients that underwent RYGB and the other three procedures. They found that patients who underwent AGB were more likely to develop GERD (OR = 1.61; 95% CI, 1.51–1.71) and esophagitis (OR = 1.92; 95% CI, 1.68–2.18) following surgery compared with patients who underwent RYGB. They also found that patients who underwent LSG were more likely to develop GERD (OR = 1.63; 95% CI, 1.44–1.84) and esophagitis (OR = 1.62; 95% CI, 1.25–2.1) than patients in the RYGB cohort. The researchers did not find that same pattern when they compared the procedures for incidence of BE or esophageal adenocarcinoma (EAC), although Bevilacqua said a longer follow-up may be needed to track the development of EAC.
“No specific procedure increases the risk for EAC development,” she said. “Which is a novel finding and may help assuage fears among bariatric surgeons when picking a procedure.” – by Alex Young
Reference:
Bevilacqua LA, et al. Abstract 213. Presented at: Digestive Disease Week; June 2-5, 2018; Washington, D.C.
Disclosures: Bevilacqua reports no relevant financial disclosures. Please see the DDW faculty disclosure index for a list of all other authors’ relevant financial disclosures.
Perspective
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Kenneth DeVault, MD, FACG
There has been a marked increase in the use of bariatric surgery over the past decade. Obesity is a common, perhaps the most common, risk factor for GERD, so it is not surprising that there is considerable overlap between obesity and GERD. This study used a database to compare the development of reflux after various types of bariatric surgery. Patients who underwent adjustable gastric banding (AGB), as well as those undergoing laparoscopic sleeve gastrectomy, were more likely to develop a new diagnosis of GERD or esophagitis than patients undergoing Roux-en-Y gastric bypass. There was no clear increase in either Barrett’s esophagus or cancer, but the follow-up was not sufficient to see a difference in these more long-term complications. Those with GERD before bariatric surgery were more likely to develop esophagitis or Barrett’s esophagus.
In patients with known reflux or with substantial hiatal hernias, bariatric surgery with the lowest risk for reflux and its complications should be selected (gastric bypass). Many centers have abandoned AGB due to both its increase risk for esophageal complications (reflux and esophageal dysmotility) and inferior weight control. Other centers are combining a gastric procedure with either fundoplication or endoscopic procedures at the esophagogastric junction to overcome post-operative GERD. Neither of these approaches has been proven to be effective in appropriately powered, long-term studies. The bottom line is that the health of the esophagus should be taken into consideration when contemplating bariatric surgery and when caring for patients after that surgery.
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