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National trends in utilization and safety of gastric bypass, sleeve gastrectomy and conversion surgery in patients with GERD
BackgroundWhile some studies have reported improvement in gastro-esophageal reflux disease (GERD) symptoms after sleeve gastrectomy (SG), others have reported higher incidence of de-novo GERD, worsening of prior GERD symptoms and erosive esophagitis post SG. Furthermore, GERD unresponsive to medical management is one of the most common indications for conversion of SG to Roux-en-Y gastric bypass (RYGB). Real-world data on safety of primary SG, primary RYGB and SG to RYGB conversion for obese patients with GERD would be helpful for informing surgeons and patient procedure selection. We sought to evaluate the trends in utilization and safety of primary RYGB and primary SG for patients with GERD requiring medications, and compare the peri-operative outcomes between primary RYGB and conversion surgery from SG to RYGB for GERD using the MBSAQIP database.MethodsA comparative analysis of post-operative outcomes within 30 days was performed for primary RYGB and primary SG after 1:1 nearest neighbor propensity score matching for patient demographics and preoperative comorbidities using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) registry from 2015 to 2021. This was followed by comparison of peri-operative outcomes between conversion surgery from SG to RYGB for GERD and primary RYGB using MBSAQIP 2020–2021 data.ResultsUtilization of primary RYGB increased from 38% in 2015 to 45% in 2021, while primary SG decreased from 62% in 2015 to 55% in 2021 for bariatric patients with GERD. Post-operative outcomes including reoperation, reintervention, readmission, major complications, and death within 30 days were significantly higher for patients undergoing primary RYGB compared to primary SG. Increased readmissions and ED visits were seen with conversion surgery. However, there was no difference in rates of reoperation, reintervention, major complications, or death between primary RYGB and SG conversion to RYGB cohorts.ConclusionsThis data suggests that a strategy of performing a primary SG and subsequent SG-RYGB conversion for those with recalcitrant GERD symptoms is not riskier than a primary RYGB. Thus, it may be reasonable to perform SG in patients who are well informed of the risk of worsening GERD requiring additional surgical interventions. However, the impact of such staged approach (SG followed by conversion to RYGB) on long-term outcomes remains unknown.
Journal Article
Antireflux Mucosectomy Band (ARM-b) in Treatment of Refractory Gastroesophageal Reflux Disease After Bariatric Surgery
Laparoscopic sleeve gastrectomy has become the most commonly used bariatric surgery worldwide. However, there are a proportion of patients who present with a refractory GERD after this procedure. In these patients, when surgical conversion to RYGPB is not possible or declined, we propose to describe the results of an endoscopic antireflux mucosectomy band (ARM-b) technique in 6 LSG patients with refractory GERD. The technical feasibility was 100%; 5 out of 6 patients had a clinical response with a reduction of the GERD-HRQL score of > 50%. Two patients had adverse events: one esophageal stricture and one benign bleeding. ARM-b is feasible and potentially effective to treat patients with refractory GERD after LSG.
Journal Article
Choosing the Therapeutic Strategy in Gastroesophageal Reflux Disease in Pediatric Patients: Is it a Challenge for Clinicians?
Gastroesophageal reflux disease (GERD) affects 8-33% of individuals worldwide, independent of age or gender. Diagnosis relies on mucosal lesions or symptomatic discomfort, validated by proton pump inhibitor (PPI) response. Lyon Consensus categorizes diagnostic tests as supportive, refuting, or inconclusive. A retrospective cohort study on 78 pediatric subjects at the ‘Sfântul Ioan’ Galați Hospital (February 2018-October 2020) aimed to assess GER incidence and management principles. Data analyzed using SPSS v26 revealed urban predominance (66.7%) and varied age distribution (1 month to 18 years), with heartburn as a prevalent symptom. Treatment modalities included antacids, PPIs, H2RAs, and prokinetics. Symptom relief and therapeutic response guided management, with PPIs commonly administered. This study underscores the need for comprehensive GERD diagnosis and tailored therapeutic strategies in pediatric populations.
Journal Article
Best practice approach for redo-surgeries after sleeve gastrectomy, an expert's modified Delphi consensus
BackgroundSleeve gastrectomy (SG) is the most common metabolic and bariatric surgical (MBS) procedure worldwide. Despite the desired effect of SG on weight loss and remission of obesity-associated medical problems, there are some concerns regarding the need to do revisional/conversional surgeries after SG. This study aims to make an algorithmic clinical approach based on an expert-modified Delphi consensus regarding redo-surgeries after SG, to give bariatric and metabolic surgeons a guideline that might help for the best clinical decision.MethodsForty-six recognized bariatric and metabolic surgeons from 25 different countries participated in this Delphi consensus study in two rounds to develop a consensus on redo-surgeries after SG. An agreement/disagreement ≥ 70.0% on statements was considered to indicate a consensus.ResultsConsensus was reached for 62 of 72 statements and experts did not achieve consensus on 10 statements after two rounds of online voting. Most of the experts believed that multi-disciplinary team evaluation should be done in all redo-procedures after SG and there should be at least 12 months of medical and supportive management before performing redo-surgeries after SG for insufficient weight loss, weight regain, and gastroesophageal reflux disease (GERD). Also, experts agreed that in case of symptomatic GERD in the presence of adequate weight loss, medical treatment for at least 1 to 2 years is an acceptable option and agreed that Roux-en Y gastric bypass is an appropriate option in this situation. There was disagreement consensus on efficacy of omentopexy in rotation and efficacy of fundoplication in the presence of a dilated fundus and GERD.ConclusionRedo-surgeries after SG is still an important issue among bariatric and metabolic surgeons. The proper time and procedure selection for redo-surgery need careful considerations. Although multi-disciplinary team evaluation plays a key role to evaluate best options in these situations, an algorithmic clinical approach based on the expert's consensus as a guideline can help for the best clinical decision-making.
Journal Article
Refractory Gastroesophageal Reflux Disease: A Management Update
Gastroesophageal reflux disease (GERD) is one of the most frequent gastrointestinal disorders. Proton pump inhibitors (PPIs) are effective in healing lesions and improving symptoms in most cases, although up to 40% of GERD patients do not respond adequately to PPI therapy. Refractory GERD (rGERD) is one of the most challenging problems, given its impact on the quality of life and consumption of health care resources. The definition of rGERD is a controversial topic as it has not been unequivocally established. Indeed, some patients unresponsive to PPIs who experience symptoms potentially related to GERD may not have GERD; in this case the definition could be replaced with “reflux-like PPI-refractory symptoms.” Patients with persistent reflux-like symptoms should undergo a diagnostic workup aimed at finding objective evidence of GERD through endoscopic and pH-impedance investigations. The management strategies regarding rGERD, apart from a careful check of patient's compliance with PPIs, a possible change in the timing of their administration and the choice of a PPI with a different metabolic pathway, include other pharmacologic treatments. These include histamine-2 receptor antagonists (H2RAs), alginates, antacids and mucosal protective agents, potassium competitive acid blockers (PCABs), prokinetics, gamma aminobutyric acid-B (GABA-B) receptor agonists and metabotropic glutamate receptor-5 (mGluR5) antagonists, and pain modulators. If there is no benefit from medical therapy, but there is objective evidence of GERD, invasive antireflux options should be evaluated after having carefully explained the risks and benefits to the patient. The most widely performed invasive antireflux option remains laparoscopic antireflux surgery (LARS), even if other, less invasive, interventions have been suggested in the last few decades, including endoscopic transoral incisionless fundoplication (TIF), magnetic sphincter augmentation (LINX) or radiofrequency therapy (Stretta). Due to the different mechanisms underlying rGERD, the most effective strategy can vary, and it should be tailored to each patient. The aim of this paper is to review the different management options available to successfully deal with rGERD.
Journal Article
The effect of antral resection start point on post sleeve gastrectomy gastroesophageal reflux symptoms and weight loss outcomes
PurposeSleeve gastrectomy (SG) has gained worldwide popularity by surgeons due to acceptable results in weight loss and obesity-associated medical problems. Distance from the pylorus during antral resection in SG may be effective in decreasing the occurrence of gastroesophageal reflux disease (GERD). The aim of this study was to evaluate GERD symptoms and weight loss outcomes in two groups of SG patients with different start points of antral resection.MethodsThis is a prospective cohort study on 220 patients who underwent SG between June 2019 and July 2021, aged 18 and above, BMI ≥ 40 kg/m2, or BMI > 35 kg/m2 with at least one obesity-associated medical problem. According to the start point of antral resection the patients were divided in two groups (group A: from 2 cm of pylorus and group B: from 4 cm of pylorus). Evaluation of GERD was performed using GerdQ questionnaire at 12-month follow up.ResultsMean age and BMI of all patients were 37.6 ± 10 year and 44.8 ± 5.7 kg/m2 at the time of SG. Totally 153(69.5%) of the patients were female. De novo GERD after 12 months in the groups A and B was found in 18 (20%) and 19 (21%) patients. TWL% at 12-month follow ups, were 33.9% and 32.5% in group A and B, respectively.ConclusionAntral resection's start point has no statistically significant effect on the excess and total weight loss indices, resolution of the obesity-related medical problems and De novo GERD between 2 and 4 cm start point for antral resection during SG.
Journal Article
SAGES guidelines for the surgical treatment of gastroesophageal reflux (GERD)
BackgroundGastroesophageal Reflux Disease (GERD) is an extremely common condition with several medical and surgical treatment options. A multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians, patients, and others in decisions regarding the treatment of GERD with an emphasis on evaluating different surgical techniques.MethodsLiterature reviews were conducted for 4 key questions regarding the surgical treatment of GERD in both adults and children: surgical vs. medical treatment, robotic vs. laparoscopic fundoplication, partial vs. complete fundoplication, and division vs. preservation of short gastric vessels in adults or maximal versus minimal dissection in pediatric patients. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Recommendations for future research were also proposed.ResultsThe panel provided seven recommendations for adults and children with GERD. All recommendations were conditional due to very low, low, or moderate certainty of evidence. The panel conditionally recommended surgical treatment over medical management for adults with chronic or chronic refractory GERD. There was insufficient evidence for the panel to make a recommendation regarding surgical versus medical treatment in children. The panel suggested that once the decision to pursue surgical therapy is made, adults and children with GERD may be treated with either a robotic or a laparoscopic approach, and either partial or complete fundoplication based on surgeon–patient shared decision-making and patient values. In adults, the panel suggested either division or non-division of the short gastric vessels is appropriate, and that children should undergo minimal dissection during fundoplication.ConclusionsThese recommendations should provide guidance with regard to surgical decision-making in the treatment of GERD and highlight the importance of shared decision-making and patient values to optimize patient outcomes. Pursuing the identified research needs may improve future versions of guidelines for the treatment of GERD.
Journal Article
Sovereignty vs-a-vis survival: a critical discourse analysis of the BBC and Al-Jazeera’s reporting on the Great Ethiopian Renaissance Dam negotiations
This research looked at news reports from the BBC and Al-Jazeera websites on the US-led negotiations on the Grand Ethiopian Renaissance Dam (GERD). Its objective is to investigate the ways the news stories of the BBC and Al-Jazeera covered the GERD issue. Two news stories were purposely selected from each medium just to show how ideology was embodied in the news texts. Critical Discourse Analysis (CDA) was used as a theoretical framework and research methodology. The findings indicate that news stories of the BBC and Al-Jazeera constructed GERD as a source of conflict and disagreement. Ethiopia was depicted as an aggressive social player, Sudan as passive, and Egypt as a GERD victim by the news stories of the BBC and Al-Jazeera. The GERD is also depicted as a confrontation between Ethiopian sovereignty and Egyptian survival. This depiction has ideological implications since it maintains the status quo or Egypt’s monopoly on the Nile, while demeaning Ethiopia’s and other upstream country’s rights to utilize the Nile.
Journal Article
Development as a Driver of Conflict in Grand Ethiopia Renaissance Dam Crisis
This study argues that although development can be a catalyst for a country’s economic growth and political consolidation, on the other hand, development can be harmful and can lead to unimaginable crises. Recent trends in the Grand Ethiopian Renaissance Dam (GERD) undertaken by the Ethiopian government have affected peaceful relations and conflict dynamics amongst the riparian states of the Nile River. The gap that this research tends to bridge in the existing literature is premised on the fact that development projects have the possibility of causing harm to their intended beneficiaries. The overall objective of this paper is to contribute to the body of knowledge available on the GERD project, while promoting peaceful inter-state relations. This study is a qualitative research, which was developed using published documentary sources. This research relied on information gathered from secondary sources: journals, book chapters, online newspapers, and so on. The theoretical framework used in this research is anchored on the idea of development as an impasse. This theory argues that development not only does well, it can also cause harm. A key finding of this study highlights that the GERD project has heightened tension and has resulted in the involvement of international actors such as Russia, the US, the European Union, the African Union, the Arab League, and so on, with divergent interests, which have further complicated negotiations and the path to peace. The study emphasizes the urgent need for a win-win peace approach, which will favor all eleven riparian states of the Nile River. Finally, there is a need for joint research by all riparian countries, which will recommend measures on how the Nile River can be used optimally by the riparian states
Journal Article