Surgical Treatments for Weight Management and GERD

May 26, 2022

Of course, any treatment plan should begin with the least invasive, lowest risk, treatment possible...

...and then increase as needed.

This is also advisable for weight management for obesity and GERD treatments which initially may focus on dietary modifications and lifestyle changes. But if these conservative treatment options fail then eventually surgical options may be discussed.

Multiple surgical weight loss procedures exist. The two surgical procedures most commonly performed are the sleeve gastrectomy and the Roux-en-Y.

Sleeve Gastrectomy

Roux-en-Y

While studies show these two procedures have similar long-term weight loss results, their impact on GERD are very different. One study compared different factors related to GERD in a large group of two patients: Roux-en-Y resulted in 60.4% of patients reporting gastric reflux remission and 6.3% reporting worsening symptoms. Sleeve gastrectomy by comparison only had 25% of patients reporting remission but 31.8% of the patients had worsening of symptoms (JAMA, 2018). Another study showed that in patients undergoing sleeve gastrectomy without GERD before surgery that 23% developed GERD after surgery. This is called “de novo” and is important from a medical perspective because the sleeve gastrectomy appears to have caused the GERD (Ann Surg, 2020).

A less frequently performed procedure is the laparoscopic adjustable gastric band. The gastric band is like the sleeve gastrectomy in that both are considered “restrictive” procedures. The Roux-en-Y is considered both restrictive and malabsorptive, meaning it restricts the amount that can be ingested and changes the way the body is able to absorb nutrients from things that are eaten.

The gastric band seems to have a similar postoperative impact on GERD to the sleeve gastrectomy with added possible complications due to it being an implanted surgical device. For these, among other reasons, it is not performed frequently.

There are also surgeries that do not impact obesity but are only for GERD treatment. For many years the standard surgical treatment has been a Nissen fundoplication which can be performed as an open procedure, laparoscopically, or even via an endoscope and an “incisionless” procedure.

Looking at the drawing of the stomach below may help understand what happens in this procedure. The fundus of the stomach is wrapped around the back side of the esophagus and then secured around the area of the lower esophageal sphincter (LES) by suturing the fundus together in the front, so the lower esophagus is then anchored below the level of the diaphragm.

This surgery can also be a treatment option for hiatal hernia. A fundoplication can also be partial, meaning it does not completely wrap around the esophagus. This procedure is performed to reinforce the LES so it can perform its function better. Unfortunately, in morbidly obese individuals this procedure can be difficult to perform, and post-surgical complications can be increased. For this reason the Roux-en-y is typically recommended to treat GERD in morbidly obese individuals rather than a fundoplication.

Over a decade ago a new procedure became available called magnetic sphincter augmentation (MSA) using the LINX Reflux Management System. This is a minimally invasive, laparoscopic procedure performed under general anesthesia. The LINX is a small implant made of interlinked titanium beads with magnetic cores that is placed around the LES on the outside of the esophagus helping the LES work better. One study compared patients undergoing MSA to taking a proton pump inhibitor medication twice daily found 89% reported relief of symptoms after MSA versus only 10% reporting relief with twice daily medication (Gastrointestinal Endoscopy, 2019).

There are multiple other surgical procedures, (e.g. Stretta procedure, Bard EndoCinch Procedure) which can be performed for GERD but due to risk versus benefit profiles are not as commonly used. The important thing is to always discuss treatment options with your provider to find what is the best option for you and voice any questions or concerns you have about your health or treatment plan.

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