Esophageal Problems after Gastric Banding

Christine Ren Fielding, MD

Associate Professor, Surgery

NYU School of Medicine

MISS 2011Salt Lake City, UT

Esophageal problems

• Esophageal reflux– heartburn

• Esophagitis– Ulcers, Barrett’s

• Esophageal dysmotility

• Esophageal dilation

Effect of LAGB on GERD

• Conflicting data in literature about effect of LAGB reflux

• Often GERD resolves after LAGB

• Often GERD appears several years after LAGB

• Depends on whether a hiatal hernia was identified and repaired

Effect of LAGB on GERD

• Acid reflux vs Food refluxH

eartburn

Time of occurrence (day, night)

• Will determine treatmentP

PI

Behavior modification

Nocturnal Reflux

• Volume reflux, regurgitation, cough, aspiration

• If occurs when lies down right after oral intake = “normal”

• If occurs when lies down > 1 hour after oral intake = “abnormal”– Poor esophageal clearing

Esophageal Motility

• Responsive to hormones– Cortisol

• Day/night variability

– Thyroid– Estrogen/Progesterone

• Menstrual cycle/pregnancy variability

– Epinephrine • Stress variability

• Most common symptom: dysphagia/regurgitation– Recurrent regurgitation/vomiting increase acid exposure

of distal esophageal mucosa

Esophageal dilation

Esophageal obstruction due to band too tight

Smooth esophageal mucosa

Peristalsis seen

Reverse immediately with band loosening

Not uncommon to see in the morning

Often asymptomatic

Esophageal Dilation

• Acute vs Chronic• Achalasia vs Pseudo-achalasia

– Obstructed vs Dysmotile

• Esophagram– Esophageal diameter

– Esophageal mucosa

• Manometry• Typically reversible when band loosened

Case Study

• 19 yo male, BMI 50, no co-morbidities

• Routine preop esophagram– Dilated esophagus with poor motility, small

hiatal hernia

• EGD– Small hiatal hernia, erosive esophagitis

• Manometry– No peristalsis, decreased LES pressure

Case Study

• PPI x 6 weeks

• Repeat esophagram and manometry– Normal

• Conclusion– Esophagitis can diminish esophageal motililty

Esophageal motility and GERD

• Hiatal hernia pts vs w/o HH have – Higher extent of reflux– Lower frequency of reflux events– More severe esophagitis– Prolonged acid clearance– Lower amplitude of peristalsis at 5 cm prox to LES– Same LES pressure

• Conclusion: GER patients with hiatal hernia have amount of reflux and more severe esophagitis which results in more severely impaired esophageal peristalsis as compared to pt w/o hernia

Kasapadis et al. Dig Dis Sci, 1995;40:2724

Esophageal motility after Nissen

• Wetscher GJ et al. Am J Surgery, 1999;177:189

• Peristalsis increases after anti-reflux surgery

Esophageal dilation: Case 2

• 46 yo female, BMI 48– Preop esophagram- normal– EGD- 2 cm hiatal hernia

• March 2004 Lapband 10– No hernia visualized at surgery

• March 2006– Reflux– Esophagram: large pouch– EGD: erosive esophagitis, residual food– Resolved with band loosening and PPI

Esophageal dilation: Case 2

• October 2007– Aspiration

pneumonia– Esophagram shows:

Esophageal dilation: Case 2

• Band loosened• Started on PPI• Repeat esophagram

shows:

Esophageal dilation: Case 2

• Patient underwent surgical repair of hiatal hernia

• Resolution of reflux, off PPI, resume weight loss

Esophageal Dilation: Case 2

• 45 year old female

• 3 years s/p LAP-BAND® 9.75

• Down 60 lbs, happy

• Worsening nocturnal reflux

• She takes a MVI each morning

• Esophagram shows:

Esophageal Dilation: Case 2

Esophageal dilation: Case 2

• All fluid removed (2.3 cc)

• EGD- erosions in distal esophagus

• Start PPI qd, carafate bid (not with PPI) x 1-3 months

• All symptoms resolved immediately

• Warn pts of esophageal spasm (24-48 hrs)

• Repeat esophogram shows:

Esophageal Dilation: Case 2

Esophageal Dilation: Case 2

• Conclusion– Esophagitis can diminish esophageal motililty– Pill esophagitis can be caused by

• Vitamins

• Medications

– NSAIDs

– Antibiotics

– KCL

– Large pills

Pill Esophagitis

• All meds/vitamins should be liquid or chewable• Meds the size of tic tac or smaller should

– Be taken one at a time

– Never early in the morning

– Never just before lying down

• Meds larger than tic tac– Open capsule/crush and put into applesauce

– Beware of extended release capsules

• Best to take just prior to eating or with a large fluid ‘chaser’

• Consider empiric acid supp if pt takes many meds

Conclusion

• Esophageal problems consist of esophagitis, dilation and dysmotility

• Correlate patient symptoms with esophagram• Nocturnal reflux, cough or aspiration can be suspicious

of esophageal dysmotility which can lead to esophageal dilation

• Chronic esophageal dilation is due to esophagitis, should be treated with PPI, short-term band loosening, and confirmed with repeat e-gram

• Esophagitis is caused by hiatal hernia, chronic vomiting or by medication