WLS and Gastroesophageal Reflux Disease (GERD)

June 20, 2016

Obesity surgery has as its main objective the loss of weight and resolution of co-morbidities. Currently, weight loss surgery is one of the best tools we have  to achieve both.

Obesity and Gastroesophageal Reflux Disease (GERD)

There is a direct association between obesity and Gastroesophageal Reflux Disease (GERD). In the last few years, according to US NHANES surveys, this incidence has increased  from 15% to 40%. This direct relation is influenced by :

• Eating habits, foods rich in fat and carbohydrates reduce the  upper esophageal sphincter
• An increase in abdominal pressure due to high-fat volume
• Association between smoking and obesity
• H Pylori

There have been different opinions on whether obesity surgery increases the incidence of reflux or if reflux decreases after surgery and weight loss.

We can divide the behavior into four separate clinical groups.

1. Patients with GERD before surgery without a hiatal hernia
2. Patients without GERD before surgery without a hiatal hernia
3. Patients with hiatal hernia and GERD after surgery
4. Patients without a hiatal hernia and GERD after surgery

Analyzing the symptoms clinically before weight loss surgery is important due to the fact that there is an increase in GERD after surgery  even without the presence of a hiatal hernia at the time of surgery. The recurrence of  GERD is also common with patients that have a hiatal hernia repaired at the time of surgery, the reflux ceases during the initial stages,this can come back due to changes in eating habits and weight regain.

There exists a direct association between GERD and weight loss surgery, due to the fact that restrictive surgeries, like the Vertical Sleeve Gastrectomy (VSG), affect  the natural mechanisms the body has to prevent reflux.

The  increase in intragastric  pressure also increases the possibility of GERD, in cases where patients feel reflux related to food that is being eaten, it usually is because large bites are taken and these get caught in the interior of the esophagus  causing pain, esophageal discomfort, and GERD-like symptoms.

GERD and Eating Habits

GERD is a complex condition and in reality after surgery, in our experience, 18% of post-operative Sleeve patients have symptoms of reflux and over 95% of these are resolved with a change in eating habits, PPIs or Carafate, the other 5% require prokinetics, intense PPI therapy or even surgery.

Initially, treating a post-surgery patient with GERD symptoms, is clinical, we need to ask ourselves:

When do the symptoms appear during the day?

• Early in the morning?
• Throughout the day?
• After meals?
• After I having irritating foods?
• Does it  diminish with anything?

Does it diminish with anything?

• Medication, change in foods or topical therapy?

Is it associated with external factors, like smoking, stress or alcohol? Has there been weight regain since the reflux started?

Is it associated with eating habits?

• Am I eating too fast?
• Am I forcing my stomach to take more food?
• Am I chewing properly?

After this assessment is done, we start with a moderate dosage of PPIs and changes in eating habits,  reducing irritants, eating five small meals a day, avoiding meals before going to bed and avoiding  liquids before going to bed , over 70% of patients get better with these changes  alone.

If reflux continues, we perform a barium swallow x-ray, both standing and lying down, to check for reflux or regurgitation after meals. After this, we perform an endoscopy and take a biopsy to check for H Pylori. If positive, we start treatment since there is a large incidence of H Pylori and difficult to control reflux.

If at the time of the biopsy patient has a change such as  dysplasia in the esophagus, the immediate treatment is to convert the Sleeve to the RNY Gastric Bypass to prevent future complications.

If you have issues with GERD, discuss your symptoms with your bariatric surgeon to determine the best course of treatment for you.

ABOUT THE AUTHOR Dr. Edgar Campos is a clinical bariatric doctor and nutritionist with over 10 years of experience with pre-op and post-op bariatric patients. He also supports patients with non-surgical options for weight loss such as the balloon procedure and nutritional guidance. Dr. Campos  practices medicine at Mexicali Bariatric Center as the medical advisor and bariatric doctor.  He is an 8-year post-op gastric sleeve patient himself. Read more articles from Dr. Edgar Campos!

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