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Treatment of GERD in Obese Patients

Treatment of GERD in Obese Patients. David W Rattner, MD. What is Obesity?. A life-long, progressive, life-threatening, genetically-related, multi-factorial, and costly, disease of excess fat storage and multiple co-morbidities. Group BMI Normal 19-25 Overweight* 25-30 Obesity > 30

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Treatment of GERD in Obese Patients

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

  2. What is Obesity? A life-long, progressive, life-threatening, genetically-related, multi-factorial, and costly, disease of excess fat storage and multiple co-morbidities. Group BMI Normal 19-25 Overweight* 25-30 Obesity > 30 Class I 30-35 Class II 35-40 Class III > 40 We can further quantify obesity by the Body Mass Index (BMI) = Weight (kg) / Height2(m)2

  3. 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). • increased prevalence of esophageal motor disorders • diminished lower esophageal sphincter (LES) pressure • Hiatal Hernia • Increased intragastric pressure.

  4. Body Weight and Disease Gallstones Diabetes Elevated cholesterol Hypertension Venous thrombosis Mortality Relative Risk 20 25 30 35 40 45 Body Mass Index

  5. Impact of Obesity on Antireflux Surgery Surgical Endoscopy. 15(9):986-9, 2001

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

  7. Obesity is not a contraindication to laparoscopic Nissen fundoplication • 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 fundoplication • Clinical outcomes were scored by patients with a Likert scale

  8. BMI 35 with GERD • Fix GERD only?? • Fix GERD and other co-morbidities!! • Varela JE et al • Surgery 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. • 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.

  9. Which operation for Obese Patient with GERD? • Lap Band • Sleeve Gastrectomy • VBGP with Nissen? • Duodenal Switch • Roux en Y

  10. Try to Avoid This! Hard Re-do Fundoplication Hard Lap RYGBP

  11. Laparoscopic RYGB - Gastric Pouch Creation Small pouch eliminates volume Vagi transected Acid production moved away from esophagus

  12. Case History: 42 year old RN • History of Obesity since age 20. • Yo-yo dieting for over 20 years. • Co-morbidities: • Sleep Apnea • GERD • Blood pressure • Back Pain • Urinary Incontinence • Gallstones • 283lbs 5’5” BMI 49

  13. Case Outcome • 44 year old R.N. • Weight 147lbs 5’5” BMI 24 • 100% EBW lost • Co-morbidities: • Sleep Apnea -cured • High Blood pressure – cured • Back Pain-cured • Urinary Incontinence-cured • Gallstones-cured • GERD-cured • Recently Married xx

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

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