Gastric bypass works for GERD and obesity in patients with prior surgery

Laparoscopic gastric bypass surgery can effectively control gastroesophageal reflux disease (GERD) symptoms in morbidly obese patients who had previous antireflux surgery, with the additional benefit of weight loss and improvement of co-morbidities, according to a study published in the November issue of the journal Obesity Surgery.

The University of Pittsburgh School of Medicine study found that gastric bypass is feasible and effective in controlling GERD in patients who had previous antireflux surgery and who have subsequently gained significant weight, and in obese patients who have had previous antireflux procedures and continued to have problems with GERD.

This small study involved seven patients who underwent laparoscopic gastric bypass after having antireflux surgery to control GERD. Patients’ co-morbid medical conditions included sleep apnea, diabetes mellitus, hypertension, degenerative joint disease, depression, hypercholesterolemia, polycystic ovarian syndrome and lower extremity edema. “Despite a morbidity rate of 42.8 percent, this study showed that all patients did well with zero mortality and were satisfied with their condition during the follow-up period, suggesting that the long-term outcome of laparoscopic gastric bypass in obese patients who had previous antireflux surgery is promising. There also was a significant improvement of GERD symptoms following the laparoscopic gastric bypass, which was maintained during follow-up,” said Ioannis Raftopoulos, M.D., Ph.D., assistant professor of surgery in the division of thoracic & foregut surgery at the University of Pittsburgh School of Medicine, and principal author of the study. In addition, 70 percent of associated co-morbid medical conditions were either resolved or improved significantly.

GERD is a significant public health problem affecting up to 40 percent of the American adult population. “Although a direct cause-effect relationship between obesity and GERD has not been clearly established, obesity is often associated with GERD. Up to 55 percent of morbidly obese patients presenting for laparoscopic Roux-en-Y gastric bypass have symptoms of chronic GERD,” said James D. Luketich, M.D., professor of surgery, chief of the division of thoracic & foregut surgery, co-director of the Mark Ravitch/Leon C. Hirsch Center for Minimally Invasive Surgery, and senior author of the study.

Laparoscopic gastric bypass after antireflux surgery is a technically more difficult procedure, which is reflected in the prolonged operative time (mean 372 min.) and length of hospital stay (mean 4.8 days). “It is important to emphasize that success rates for first time redo antireflux surgery, which would be the alternative to laparoscopic gastric bypass, range between 60 percent and 80 percent and fall to 50 percent for second time redo antireflux surgery,” Dr. Raftopoulos said. “In addition, redo antireflux surgery is not associated with weight loss. In contrast, patients with prior antireflux surgery enjoyed a 70.7 percent excess weight loss after laparoscopic gastric bypass at a mean follow-up of 24 months, which translated into a postoperative reduction of body mass index from 37.5 kg/m2 to 26.8 kg/m2.”

“This degree of weight loss is equal to that experienced by patients who undergo gastric bypass surgery primarily for obesity, and is enough to impact dramatic improvements in obesity-related co-morbid medical conditions.” said Anita P. Courcoulas, M.D., assistant professor of surgery, and director of bariatric surgery at UPMC Shadyside, and a co-author of the study.

In summary, laparoscopic gastric bypass appears to be a better alternative for the morbidly obese patient with GERD and previous antireflux surgery, who 1) remains symptomatic after the first fundoplication, or 2) qualifies for gastric bypass surgery.