gerd after sleeve gastrectomy what are the treatment options? · 2017-06-13 · durability of...
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GERD After Sleeve GastrectomyWhat are the Treatment Options?
Stacy A. Brethauer, MD
Bariatric and Metabolic Institute
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Disclosures
• Medtronic Consultant, Speaker
• Ethicon Consultant, Research
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Possible Mechanisms
• Increased GERD after LSG– Higher intragastric pressure– Phreno-esophageal ligament disruption– Sling fiber resection– Decreased LES pressure– Decreased gastric compliance– Neofundus formation– Missed Hiatal Hernia
• Decreased GERD after LSG– Weight loss, reduced abdominal pressure– Accelerated gastric emptying– Resection, decreased parietal cell mass– Increased LES pressure
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Evidence of Increased GERD after LSG
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BMI 36 to 26
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Pre- and Post-operative Reflux
Variable %
Preoperative GERD 25%
Preoperative radiographic evidence of reflux
4%
Postoperativeradiographic evidence of reflux
39%
Worsening GERD after LSG
23%
Satisfied with weight loss
100%
Would choose LSG again 100%
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GERD complaints at 6 yearspostoperatively
Preoperative Postoperative
Stand alone LSG (30)
%EWL 53%
GERD 3.3% 23%
Vomiting 0% 18%
Stand along LSG and LSG + DS (41)
%EWL 57%
GERD 0% 26%
Vomiting 0% 21%
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• GERD Prevalence Decreased
– 7 studies
– 12-60 month follow-up
• GERD Prevalence Increased
– 4 studies
– 12-24 month follow-up
• Low quality data
• No consensus
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• 1,380 Surgeons
• 46,133 LSG’s
• Postoperative GERD 7.9 ± 8.2% (0-30%)
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Options
• Stretta
• Muse
• LINX
• Endostim
• Revision/Conversion
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Stretta
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Durability of Stretta Radiofrequency Treatment for GERD:Results of an 8-Year Follow-Up
Luca Dughera,1 Gianluca Rotondano,2 Maria De Cento,3 Paola Cassolino,4 and Fabio Cisarò5
0
10
20
30
40
50
60
70
Baseline
Heartburn score GERD HQRL
26 patients 4 years 8 years
∘
∘
∗
∗
∗
∗
∗
∗∗ P < 0.001 ∘P < 0.003
SF-36 mental SF-36 physical
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Baseline0
10
20
30
40
50
60
70
80
90
100
P < 0.0001
26 patients 4 years 8 years
∗∗
Durability of Stretta Radiofrequency Treatment for GERD:Results of an 8-Year Follow-Up
Luca Dughera,1 Gianluca Rotondano,2 Maria De Cento,3 Paola Cassolino,4 and Fabio Cisarò5
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Treatment of refractory gastroesophageal reflux disease with radiofrequency energy (Stretta) in
patients after Roux-en-Y gastric bypass Mattar SG, Qureshi F, Taylor D, Schauer PR
Surg Endosc. 2006 Jun;20(6):850-4
• 7 patients 20 mos post RYGB
• 5 clinically improved with decreases esophageal acid exposure
• 1 did not improve
• 1 LTFU
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MUSEMedigus
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MUSE
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Long-term follow-up results of endoscopic treatmentof gastroesophageal reflux disease with the MUSETM endoscopic
stapling deviceHong Joo Kim1, Chang-Il Kwon2, William R Kessler3, Don J Selzer4, Gail McNulty3, Amol Bapaye5, Luigi Bonavina6, Glen A. Lehman
Surg Endosc 2015
• 37 patients with 4 year follow-up
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Long-term follow-up results of endoscopic treatmentof gastroesophageal reflux disease with the MUSETM endoscopic
stapling deviceHong Joo Kim1, Chang-Il Kwon2, William R Kessler3, Don J Selzer4, Gail McNulty3, Amol Bapaye5, Luigi Bonavina6, Glen A. Lehman
Surg Endosc 2015
No Data in Bariatric Patients
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LYNX
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Gastroesophageal Reflux Management with the LINX® Systemfor Gastroesophageal Reflux Disease Following Laparoscopic
Sleeve GastrectomyKenneth Desart1 & Georgios Rossidis1 & Michael Michel1 & Tamara Lux1 &
Kfir Ben-David2J Gastrointest Surg (2015) 19:1782–1786
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Gastroesophageal Reflux Management with the LINX® Systemfor Gastroesophageal Reflux Disease Following Laparoscopic
Sleeve GastrectomyKenneth Desart1 & Georgios Rossidis1 & Michael Michel1 & Tamara Lux1 &
Kfir Ben-David2J Gastrointest Surg (2015) 19:1782–1786
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Endostim
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Alejandro Nieponice, Yves Borbély, Leonardo Rodriguez, Henning G Schulz, Camilo Ortiz, Michael Talbot, David Martin, Nicole Bouvy
Surg Endosc. 2016; 30:S263.
• 12 Patients• 5mA, 220uSec pulse in twelve 30 minute sessions daily• All (12/12) were on at least daily double-dose PPIs• Median esophageal pH at baseline was 16.4% which improved to
1.3% at last follow-up at least 6 month post-implant (n=6; p=0.01).• All patients improved esophageal acid exposure, 83% (5/6) patients
had normalized acid exposure and 1/6 patient had >40% improvement
• Median GERD-HRQL scores at baseline was 25 (IQR 18-31) which improved to 4 (IQR 3-10) at last follow-up (n=6; p= 0.015).
• No SAEs related to the device or procedure were reported. • No dysphagia or other GI side effects were reported.
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Surgical Options
• Re-sleeve
• Conversion to RYGB
• Pouch reduction
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Thank You