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The Effect of Concurrent Esophageal Pathology on Bariatric Surgical Planning
Daniel Davila Bradley*1, Brian E. Louie1, Ralph W. Aye1, Ross Mcmahon2, Judy Chen2, Alexander S. Farivar1
1Thoracic and Esophageal Surgery Clinic, Swedish Cancer Institute, Seattle, WA; 2Swedish Weight Loss Services, Swedish Medical Center, Seattle, WA
Introduction
Gastroesophageal reflux disease (GERD), hiatal hernias (HH), and esophageal dysmotility are common in patients planning bariatric surgery. There is no established paradigm guiding bariatric surgeons when esophageal disease is noted preoperatively, i.e. to perform additional esophageal workup or even change the operative plan completely. Previous research demonstrates increased complications and worse outcomes after laparoscopic adjustable gastric banding (GB) and sleeve gastrectomy (SG) if esophageal pathology is not addressed. This study reviewed how an esophageal workup affected a bariatric operative plan in patients with concurrent esophageal pathology.
Methods
From 2006 to 2013, we retrospectively reviewed 80 patients referred by the bariatric team to dedicated esophageal surgeons after noting a hiatal hernia (>3 cm) on preoperative esophagogastroduodenoscopy (EGD). All patients underwent an EGD, esophagram (UGI), high resolution manometry (HRM) and pH test.
Results
Sixty percent of patients reported reflux symptoms preoperatively, while 10% had dysphagia. The original plan was a Roux-en-Y Gastric Bypass (RYGB) in 35% patients, GB in 45%, and SG in 20% patients. Of the patients scheduled for GB, the plan was changed in 20% of patients that had symptomatic reflux with high DeMeester (>14.7) scores or dysphagia with an abnormal manometry (less than 70% peristalsis or low normal mean distal amplitude 30-50 mmHg). On the patients scheduled for SG, the plan was changed to a RYGB in 60%. Sixty percent of these patients had high DeMeester scores (>14.7) and/or abnormal manometry, and 10% had Barrett's. The remainder had large hernias (5 cm or larger). Barrett's esophagus was reported on pathology on 13% of the patients. In the non-RYGB patients, the plan was changed to a RYGB in 25% of the patients with Barrett's. All patients underwent a concurrent hiatal hernia repair. In 30% of the patients, the original plan from the bariatric team was changed based on esophageal testing findings. Mean follow up was 12 months (3-48) and 95% of the patients reported resolution of reflux after surgery.
Discussion
We recommend a thorough esophageal workup preoperatively in bariatric patients noted to have esophageal pathology. A significant number of patients may have their operative plan changed to a RYGB to prevent possible adverse outcomes including dysphagia or severe reflux. Physicians should be careful with patients exhibiting dysphagia if LAGB is planned and in patients with elevated DeMeester scores or Barrett's esophagus planning to undergo SG. Additional esophageal workup may help counsel patients to a safer and more appropriate bariatric operation.
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