Esophageal achalasia after Roux-en-Y gastric bypass for morbid obesity
AbstractThe development of achalasia in patients with a prior Roux-en-Y gastric bypass (RYGB) is rare and it often remains unclear whether the esophageal motility disorder is a pre-existing condition in the obese patient or develops de novo after the procedure. The aim of this study was to review the available evidence regarding the management of patients with achalasia after a RYGB. Intra-sphincteric injection of botulinum toxin and pneumatic dilatation can be used to eliminate the functional obstruction at the level of the gastroesophageal junction. However, considering that achalasia patients after RYGB are often young and these treatment modalities have shown worse long-term outcomes, endoscopic or surgical myotomy is preferred. Per-oral endoscopic myotomy (POEM) is a very effective first line of treatment, and as RYGB is an excellent anti-reflux operation per se, post-POEM reflux may not be an issue in these patients. Laparoscopic Heller myotomy (LHM) is also an effective and safe therapy in achalasia patients with RYGB anatomy, and the gastric remnant can be safely used to perform a fundoplication to cover the myotomy. LHM and POEM are both acceptable primary treatment modalities in this setting. Further studies are needed to elucidate the pathophysiology and optimal management of patients with achalasia after RYGB.
ConclusionsConversion of Nissen fundoplication to RYGB allows treatment of dysphagia, which may represent a complication of the fundoplication, and is effective for management obesity and GERD. In this video we show important technical steps of this procedure.
AbstractBackgroundOAGB-MGB emerged as a standard procedure, albeit RYGB remains the most frequently performed gastric bypass. Comparative studies are scarce.MethodsProspectively collected data (July 2006 to November 2017) from a large sample size and adequate follow-up were analyzed using logistic regression and linear mixed models. Total weight loss (TWL) within the first 3 years was defined as primary outcome and duration of operation, perioperative, and late complications and comorbidity remission as secondary outcomes.ResultsThree hundred twenty-four OAGB-MGBs (age 42.51 ± 11.36 years, 74.69% females) presented ...
AbstractThe purpose of this study was to investigate the relationship between bariatric surgery (laparoscopic sleeve gastrectomy [LSG] and laparoscopic Roux-en-Y gastric bypass [LRYGB]) and gastroesophageal reflux disease (GERD). The number of obese patients with newly onset, worsened, or improved GERD after bariatric surgery in each article were extracted. In the pooled analysis, LSG was associated with a higher risk of GERD than LRYGB (odds ratio [OR] = 5.10, 95% confidence interval [CI] 3.60 –7.23,p
Gastroesophageal reflux disease (GERD) has a reported incidence of between 10% and 20% in Western populations with an even higher incidence in populations with obesity . The vast majority of patients are managed medically with surgical intervention undertaken in those with recalcitrant GERD. Populations with obesity and recalcitrant GERD who are interested in weight loss surgery have historically undergone laparoscopic Roux-en-Y gastric bypass (LRYGB). De Goot et al. , in their 2009 meta-analysis, demonstrated improvement in GERD in people with obesity after LRYGB.
Gastroesophageal reflux disease (GERD) has a reported incidence of between 10 to 20% in western populations with an even higher incidence in populations with obesity (1). The vast majority of patients are managed medically with surgical intervention undertaken in those with recalcitrant GERD. Populations with obesity and recalcitrant GERD who are interested in weight loss surgery have historically undergone Laparoscopic Roux En Y Gastric Bypass (LRYGB). De Goot et al in their 2009 meta-analysis demonstrated improvement in GERD in people with obesity following LRYGB(2).
Persistent Gastro-esophageal reflux symptoms for more than 4ys in spite of different medical treatment with persistent endoscopic signs of reflux esophagitis and gastritis especially in patient with BMI> 35 kg/m2 need special concern when seek for surgical management of obesity. Laparoscopic Roux-en-Y gastric bypass has been reported to be the most effective and less debatable option for effective treatment of morbid obesity with persistent GERD (Gastro-esophageal reflux disease). It may be associated with antireflux surgery or not.
Laparoscopic sleeve gastrectomy (LSG) is a commonly performed bariatric procedure in obesity management. Gastroesophageal reflux disease (GERD) in this population has reported rates of 23-100% GERD after LSG . GERD after LSG has been noted with recent studies demonstrating de novo reflux or symptom exacerbation despite weight loss. Fundoplication is not an option, and medically refractory GERD after LSG is usually treated with conversion to Roux-en-Y gastric bypass (RYGB). This video demonstrates the placement of a magnetic sphincter augmentation device after LSG as an alternative to conversion to RYGB.
We present a video of a 42-year old female who underwent laparoscopic MSA placement for the treatment of GERD after prior Roux-en-Y gastric bypass (RYGB) for morbid obesity. The patient had an initial body mass index of 35.8 kg/m2 and underwent a RYGB in 2006. She developed dumping syndrome treated with sclerotherapy of the gastro-jejunal anastomosis in 2009.
Subtle aberrations in the post-sleeve stomach may result in severe gastroesophageal and bile reflux. Cardiopexy of the stomach with the ligamentum teres, initially described in 1964 by Pedinielli, has been used to reinforce the lower esophageal sphincter and hinders mediastinal retraction of the stomach. However, diversion of duodenal contents is required for definitive treatment of bile reflux. The presented video depicts a case of 37 year-old female presenting with frequent regurgitation and reflux refractory to medical therapy 5 years after laparoscopic sleeve gastrectomy.
Abstract Obesity is a global health epidemic with considerable economic burden. Surgical solutions have become increasingly popular following technical advances leading to sustained efficacy and reduced risk. Sleeve gastrectomy accounts for almost half of all bariatric surgeries worldwide but concerns regarding its relationship with gastroesophageal reflux disease (GERD) has been a topic of debate. GERD, including erosive esophagitis, is highly prevalent in the obese population. The role of pre-operative endoscopy in bariatric surgery has been controversial. Two schools of thought exist on the matter, one that bel...