A 45-year-old morbidly obese female with past medical history significant for hypertension presents for evaluation of burning epigastric and substernal pain that has recurred almost daily for the past four months. She says these symptoms are worse when she lies down and after meals. She denies difficulty swallowing. The patient has been taking Nexium, a proton pump inhibitor (PPI), regularly over the past 12 weeks, resulting in partial resolution of her symptoms. Her history is significant for frequent early morning wheezing and hoarseness that have been present for the past few months. On examination, she is obese with a central fat distribution. She is found to be 5 feet, 3 inches and weighs 280 pounds. Her body mass index (BMI) is 47 kg/m2. She is interested in discussing the best appropriate treatment plan.
Obesity is increasing in epidemic proportions, and qualifies as one of the leading medical conditions among Americans. The adverse health effects associated with obesity may reduce patient quality of life and longevity. The treatment goals of any patient with morbid obesity should be focused on weight loss as well as on the reduction of comorbidities.
Surgical weight-loss options, such as the Laparoscopic Roux-En-Y Gastric Bypass and Laparoscopic Vertical Sleeve Gastrectomy, should be considered in patients who have unsuccessfully attempted supervised weight-loss programs by diet, exercise or medications, and fulfill minimum weight criteria that include BMI of 35 to 39.9 kg/m2 with obesity-related comorbidity, or BMI of greater-than 40 kg/m2 without comorbidity.
Patients with long-standing gastroesophageal reflux disease (GERD) may develop complications such as peptic strictures or Barrett’s esophagus – which is associated with an increased risk for developing esophageal adenocarcinoma. These patients are also at greater risk for extraesophageal complications due to pharyngeal reflux and silent aspiration (including laryngitis, reactive airway disease, recurrent pneumonia and pulmonary fibrosis).
Normal physiologic mechanisms are important in preventing abnormal GE reflux. Abnormalities in the resting pressure, intra-abdominal length or number of relaxations of the lower esophageal sphincter (LES) can contribute to abnormal reflux. There is a correlation between obesity and GERD.
The first phase of therapy for symptomatic GERD involves lifestyle modifications aimed at factors that have been shown to increase symptoms and acid exposure in the esophagus. Triggers include spicy foods, fatty foods, drinks that contain caffeine or alcohol, and certain medicines. Medical therapy includes motility agents, which increase acid clearance, H2-receptor antagonists and proton-pump inhibitors. For the uncomplicated patient with GERD, surgical therapy should not be recommended over PPI therapy. However, patients who are refractory to medications should be considered for anti-reflux operations such as fundoplication and weight-loss surgery.
Reflux disease warrants special consideration in the recommendation of operative bariatric choices for patients. Patients with GERD will have significantly greater improvement in symptoms after gastric bypass than after the sleeve gastrectomy or gastric adjustable banding operations. Patients who undergo gastric bypass also have higher symptomatic relief than those who undergo other anti-reflux procedures such as fundoplication for GERD. Those who are referred for surgical fundoplication with a BMI of greater than 35 should be offered the option of having a gastric bypass as an alternative to a laparoscopic fundoplication. Gastric bypass will treat the patient’s reflux symptoms as well as improve their physical and medical issues related to severe obesity.
Elizabeth Dovec, M.D., serves as a bariatric surgeon at Greater Baltimore Medical Center’s Comprehensive Obesity Management Program. Dr. Dovec may be reached at 443-849-3779 or firstname.lastname@example.org.
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