The Effect of Endoscopic Fundoplication Prior to Sleeve Gastrectomy Versus Gastric Bypass on Reflux Symptoms in Bariatric Patients With Gastroesophageal Reflux Disease

Gastroesophageal Reflux Disease or GERD is a common condition that produces discomfort and can result in serious sequelae from frequent esophageal acid exposure, including Barrett's esophagus, erosive esophagitis, esophageal adenocarcinoma, voice changes, and asthma exacerbation. The prevalence of GERD in adults continues to increase in conjunction with the increase in obesity. Because obesity and GERD are clearly linked, an individual with obesity is four times more likely to develop esophageal carcinoma than in an individual with a normal BMI. Additionally, the incidence of GERD is proportional to rising BMI ranging from 23 to 50%. Weight loss is associated with decreased GERD symptoms. Bariatric surgery has proven to be effective in reducing BMI, which subsequently often reduces GERD. The laparoscopic sleeve gastrectomy is an effective weight loss tool; however, recent literature suggests a correlation of de novo or worsening reflux symptoms in bariatric patients within one year postoperatively, independent of weight loss. A study conducted by Tai,et al,.2013 found that the prevalence of GERD symptoms increased significantly from 12.1% to 47% after LSG. Additionally, of the 58 patients in the study who were asymptomatic prior to surgery, 44.8% developed GERD symptoms after LSG. Other studies have found that among patients with no preoperative GERD, 86% developed symptoms postoperatively.

The Laparoscopic Roux-en-Y gastric bypass has been touted as the gold standard to treat both obesity and GERD; however, this procedure has a higher morbidity rate. While LSG has relatively low rates of re-operations, the LRYGB carries significant lifetime risk for multiple operative procedures due to adhesive bowel obstruction, internal hernia, non-healing ulcers and intussusception. Furthermore, nutrient malabsorption following LRYGB can result in irreversible neurological complications, and accelerated, ongoing decline in bone mineral density.. Options for surgical correction of GERD are limited following bariatric surgery. However, options for anti-reflux procedures prior to undergoing bariatric surgery are viable, and may include Transoral Fundoplication.

Transoral fundoplication is an anti-reflux procedure which has proven to achieve long-lasting relief of gastroesophageal reflux symptoms, and eliminate, or reduce the use of proton pump inhibitors. Daily dependence on PPI's were eliminated in 75-80% of cases for up to six years in a 2014 study conducted by Testoni et al.. Although a TF procedure is not an option post bariatric surgery due to technical issues, it is available prior to LSG. With these surgeries working in tandem, patients may attain the benefits of both, as they are reciprocal in nature: TF provides anti-reflux barriers and LSG enables patients to lose weight, which ultimately decreases GER symptoms.

We propose that performing a TF procedure prior to a sleeve gastrectomy will result in a decrease in GERD symptoms similar to that of a LRYGB. In addition to evaluating symptoms, we will perform endoscopy screening post bariatric surgery at one, three, five and 10 years or more often as indicated , to assess for asymptomatic GERD and its sequelae..

Population to be Reviewed