1. Treatment of GERD in Obese Patients David W Rattner, MD

2. MGH Weight Center

3. What is Obesity? A life-long, progressive, life-threatening, genetically- related, multi-factorial, and costly, disease of excess fat storage and multiple co-morbidities. We can further quantify obesity by the Body Mass Index (BMI) = Weight (kg) / Height (m) (BMI) = Weight (kg) / Height 2 (m) 2 GroupBMI GroupBMI Normal19-25 Overweight*25-30 Obesity> 30 Class I30-35 Class II35-40 Class III> 40

4. MGH Weight Center IMPACT OF OBESITY ON GERD Nearly all epidemiologic studies have found an association between increasing body mass index (BMI) and symptoms of gastroesophageal reflux disease (GERD).Nearly all epidemiologic studies have found an association between increasing body mass index (BMI) and symptoms of gastroesophageal reflux disease (GERD). increased prevalence of esophageal motor disordersincreased prevalence of esophageal motor disorders diminished lower esophageal sphincter (LES) pressurediminished lower esophageal sphincter (LES) pressure Hiatal HerniaHiatal Hernia Increased intragastric pressure.Increased intragastric pressure.

5. MGH Weight Center Body Weight and Disease Body Mass Index Relative Risk GallstonesDiabetes Elevated cholesterol Hypertension Venous thrombosis Mortality 20 3035404525

6. MGH Weight Center Impact of Obesity on Antireflux Surgery Surgical Endoscopy. 15(9):986-9, 2001

7. MGH Weight Center Obesity is not a contraindication to laparoscopic Nissen fundoplication Booth et al UKBooth et al UK Annals of the Royal College of Surgeons of England. 89(7):696- 702, 2007Annals of the Royal College of Surgeons of England. 89(7):696- 702, 2007 BMI> 30 = obeseBMI> 30 = obese f/u 6-12 months onlyf/u 6-12 months only OR time longer but Visick Scores similarOR time longer but Visick Scores similar

8. MGH Weight Center Obesity is not a contraindication to laparoscopic Nissen fundoplication Rosemurgy group Journal of Gastrointestinal Surgery. 9(7):949-54, 2005 Rosemurgy group Journal of Gastrointestinal Surgery. 9(7):949-54, 2005 Clinical outcomes after laparoscopic Nissen fundoplication did not differ among patients stratified by preoperative BMI. Obesity is not a contraindication to laparoscopic Nissen fundoplicationClinical outcomes after laparoscopic Nissen fundoplication did not differ among patients stratified by preoperative BMI. Obesity is not a contraindication to laparoscopic Nissen fundoplication Clinical outcomes were scored by patients with a Likert scaleClinical outcomes were scored by patients with a Likert scale

9. MGH Weight Center BMI 35 with GERD Fix GERD only??Fix GERD only?? Fix GERD and other co-morbidities!!Fix GERD and other co-morbidities!! Varela JE et alVarela JE et al Surgery for Obesity & Related Diseases. 5(2):139-43, 2009Surgery for Obesity & Related Diseases. 5(2):139-43, 2009 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.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. Laparoscopic 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. Laparoscopic 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.

10. MGH Weight Center Which operation for Obese Patient with GERD? Lap BandLap Band Sleeve GastrectomySleeve Gastrectomy VBGP with Nissen?VBGP with Nissen? Duodenal SwitchDuodenal Switch Roux en YRoux en Y

11. MGH Weight Center Try to Avoid This! Hard Re-do Fundoplication Hard Lap RYGBP

12. MGH Weight Center Laparoscopic RYGB - Gastric Pouch Creation Small pouch eliminates volume Acid production moved away from esophagus Vagi transected

13. MGH Weight Center Case History: 42 year old RN History of Obesity since age 20.History of Obesity since age 20. Yo-yo dieting for over 20 years.Yo-yo dieting for over 20 years. Co-morbidities:Co-morbidities: Sleep ApneaSleep Apnea GERDGERD Blood pressure Blood pressure Back PainBack Pain Urinary IncontinenceUrinary Incontinence GallstonesGallstones 283lbs 5’5” BMI 49283lbs 5’5” BMI 49

14. MGH Weight Center Case Outcome 44 year old R.N.44 year old R.N. Weight 147lbs 5’5” BMI 24Weight 147lbs 5’5” BMI 24 100% EBW lost100% EBW lost Co-morbidities:Co-morbidities: Sleep Apnea -curedSleep Apnea -cured High Blood pressure – curedHigh Blood pressure – cured Back Pain-curedBack Pain-cured Urinary Incontinence-curedUrinary Incontinence-cured Gallstones-curedGallstones-cured GERD-curedGERD-cured Recently MarriedRecently Married xx

15. MGH Weight Center Conclusions Obese patients have a variety of mechanisms that cause GERDObese patients have a variety of mechanisms that cause GERD Failure rate of Lap Nissen may be higher in obese patientsFailure rate of Lap Nissen may be higher in obese patients Treat the entire patient -> more benefit from RYGBPTreat the entire patient -> more benefit from RYGBP BMI 30-35- not clear what best option isBMI 30-35- not clear what best option is