GERD After Sleeve GastrectomyWhat are the Treatment Options?

Stacy A. Brethauer, MD

Bariatric and Metabolic Institute

Disclosures

• Medtronic Consultant, Speaker

• Ethicon Consultant, Research

Possible Mechanisms

• Increased GERD after LSG– Higher intragastric pressure– Phreno-esophageal ligament disruption– Sling fiber resection– Decreased LES pressure– Decreased gastric compliance– Neofundus formation– Missed Hiatal Hernia

• Decreased GERD after LSG– Weight loss, reduced abdominal pressure– Accelerated gastric emptying– Resection, decreased parietal cell mass– Increased LES pressure

Evidence of Increased GERD after LSG

BMI 36 to 26

Pre- and Post-operative Reflux

Variable %

Preoperative GERD 25%

Preoperative radiographic evidence of reflux

4%

Postoperativeradiographic evidence of reflux

39%

Worsening GERD after LSG

23%

Satisfied with weight loss

100%

Would choose LSG again 100%

GERD complaints at 6 yearspostoperatively

Preoperative Postoperative

Stand alone LSG (30)

%EWL 53%

GERD 3.3% 23%

Vomiting 0% 18%

Stand along LSG and LSG + DS (41)

%EWL 57%

GERD 0% 26%

Vomiting 0% 21%

• GERD Prevalence Decreased

– 7 studies

– 12-60 month follow-up

• GERD Prevalence Increased

– 4 studies

– 12-24 month follow-up

• Low quality data

• No consensus

• 1,380 Surgeons

• 46,133 LSG’s

• Postoperative GERD 7.9 ± 8.2% (0-30%)

Options

• Stretta

• Muse

• LINX

• Endostim

• Revision/Conversion

Stretta

Durability of Stretta Radiofrequency Treatment for GERD:Results of an 8-Year Follow-Up

Luca Dughera,1 Gianluca Rotondano,2 Maria De Cento,3 Paola Cassolino,4 and Fabio Cisarò5

0

10

20

30

40

50

60

70

Baseline

Heartburn score GERD HQRL

26 patients 4 years 8 years

∘

∘

∗

∗

∗

∗

∗

∗∗ P < 0.001 ∘P < 0.003

SF-36 mental SF-36 physical

Baseline0

10

20

30

40

50

60

70

80

90

100

P < 0.0001

26 patients 4 years 8 years

∗∗

Durability of Stretta Radiofrequency Treatment for GERD:Results of an 8-Year Follow-Up

Luca Dughera,1 Gianluca Rotondano,2 Maria De Cento,3 Paola Cassolino,4 and Fabio Cisarò5

Treatment of refractory gastroesophageal reflux disease with radiofrequency energy (Stretta) in

patients after Roux-en-Y gastric bypass Mattar SG, Qureshi F, Taylor D, Schauer PR

Surg Endosc. 2006 Jun;20(6):850-4

• 7 patients 20 mos post RYGB

• 5 clinically improved with decreases esophageal acid exposure

• 1 did not improve

• 1 LTFU

MUSEMedigus

MUSE

Long-term follow-up results of endoscopic treatmentof gastroesophageal reflux disease with the MUSETM endoscopic

stapling deviceHong Joo Kim1, Chang-Il Kwon2, William R Kessler3, Don J Selzer4, Gail McNulty3, Amol Bapaye5, Luigi Bonavina6, Glen A. Lehman

Surg Endosc 2015

• 37 patients with 4 year follow-up

Long-term follow-up results of endoscopic treatmentof gastroesophageal reflux disease with the MUSETM endoscopic

stapling deviceHong Joo Kim1, Chang-Il Kwon2, William R Kessler3, Don J Selzer4, Gail McNulty3, Amol Bapaye5, Luigi Bonavina6, Glen A. Lehman

Surg Endosc 2015

No Data in Bariatric Patients

LYNX

Gastroesophageal Reflux Management with the LINX® Systemfor Gastroesophageal Reflux Disease Following Laparoscopic

Sleeve GastrectomyKenneth Desart1 & Georgios Rossidis1 & Michael Michel1 & Tamara Lux1 &

Kfir Ben-David2J Gastrointest Surg (2015) 19:1782–1786

Gastroesophageal Reflux Management with the LINX® Systemfor Gastroesophageal Reflux Disease Following Laparoscopic

Sleeve GastrectomyKenneth Desart1 & Georgios Rossidis1 & Michael Michel1 & Tamara Lux1 &

Kfir Ben-David2J Gastrointest Surg (2015) 19:1782–1786

Endostim

Alejandro Nieponice, Yves Borbély, Leonardo Rodriguez, Henning G Schulz, Camilo Ortiz, Michael Talbot, David Martin, Nicole Bouvy

Surg Endosc. 2016; 30:S263.

• 12 Patients• 5mA, 220uSec pulse in twelve 30 minute sessions daily• All (12/12) were on at least daily double-dose PPIs• Median esophageal pH at baseline was 16.4% which improved to

1.3% at last follow-up at least 6 month post-implant (n=6; p=0.01).• All patients improved esophageal acid exposure, 83% (5/6) patients

had normalized acid exposure and 1/6 patient had >40% improvement

• Median GERD-HRQL scores at baseline was 25 (IQR 18-31) which improved to 4 (IQR 3-10) at last follow-up (n=6; p= 0.015).

• No SAEs related to the device or procedure were reported. • No dysphagia or other GI side effects were reported.

Surgical Options

• Re-sleeve

• Conversion to RYGB

• Pouch reduction

Thank You