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GERD after VSG V Congreso Internacional de Cirugia Bariatrica y Metabolica Mendoza Argentina May 19 & 20, 2011 10 min
GERD after VSG
Incidence of GERD 2-25% after VSG Soricelli E, Casella G, Rizzello M, Calì B, Alessandri G, Basso N. Initial experience with laparoscopic crural closure in the management of hiatal hernia in obese patients undergoing sleeve gastrectomy. Obes Surg 2010;20:1149–53.
LES sphincter pressures lower after VSG Braghetto I,Lanzarini E,V alladares H, V alladares H, Molina JC, Henriquez A. Manometric changes of the lower esophageal sphincter after sleeve gastrectomy in obese patients. Obes Surg 2010;20:357– 62. Prospective manometric analysis of 20 patients. 85% low LES pressure post operative
GERD symptoms to not correlate with preoperative manometry and pH studies Merrouche M, Sabate J, Jouet P, et al. Gastroesophageal reflux and esophageal motility disorders in morbidly obese patients before and after bariatric surgery. Obes Surg 2007;17:894 –900.
Is this a real problem?
6 months - 5 years
Definition of GERD manometry (1) questionnaire (4) PPI use (2) not stated (8)
(4) studies showed increased GERD
(7) studies showed reduced GERD
(3) studies only reported post-op GERD
15 published articles - ∅ GERD as primary outcome
GERD not well defined
Time sensitive - Himpens: ↑ GERD post op, then ↓ GERD @ 2-3 years
30-51% patients developed GERD after VSG 176 patients 2 year F/U Diagnosis of GERD - subjective; no preoperative pH, manometry or routine endoscopy HH “repaired” with anterior fixation
“ Biphasic” “ Neo-fundus” DS does not resolve GERD
Anatomic and physiologic factors affecting GERD
Decreased gastric emptying
Lower LES pressure
Blunting angle of His
Decreased gastric compliance and volume
Increased gastric pressure
Accelerated gastric emptyingWeight lossReduced acid productionRemoval of fundus (source of relaxation waves to lower esophageal sphincter)Reduced wall tension (LaPlace’s law)
Increased GERD Decreased GERD
What to do?
Early GERD - evaluate anatomy: stenosis, angulation - medical management: PPI, prokinetic - myotomy? stents?
Late GERD - medical management - conversion to GBP