(B, a young patient who was 165 kgs, before surgery)

The same applies to ‘morbid obesity’. We call this ‘Clinically Severe Obesity’ now. Allegedly because the term ‘morbid’ is negatively prejudiced against the obese. Some time soon, they will replace the term ‘obese’ and call it ‘adiposely challenged’ or something, I have no doubt!

All said and done, what does it change? Does it change the fact that obesity kills more people than most other diseases today? If you want to know why obesity is not considered being healthy, have a look at this list of diseases associated with it. The term we use is ‘co-morbidity’.

(from Gen Surg News)

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So let us now assume that you are awaiting bariatric surgery and have reflux symptoms. So how does your reflux have an implication on your surgery? Will bariatric surgery (after all, we are operating on the stomach) make your reflux worse or better?

Let us take this procedure by procedure:

The Band: The band produces a mechanical obstruction right below the junction of the food pipe and the stomach. While this produces a barrier for the downward descent of food and accounts for the restriction in food intake after its placement, it does just the reverse for acid reflux. In other words, it tends to make reflux symptoms worse. Not to waste too many words on this, the Band is out if you have reflux.

The Gastric Bypass: This is the ultimate anti-reflux operation. It has a nearly 100 percent success in banishing reflux. After all, the pouch is separated from the stomach, where most of the acid is produced. What more, the small gut (jejunum) that is connected to the pouch acts to drain the acid away from the food pipe downwards. The special “Roux-en-Y” way in which we attach the jejunum to the pouch is the key to banishing reflux disease.

Sleeve Gastrectomy: Sleeve gastrectomy converts the stomach into a straight tube. In addition, it removes the part of the stomach from where muscle fibers go as a sling to loop around the LES (Lower Esophageal Sphincter). So it is possible that this operation weakens the sphincter and enhances reflux. In fact, clinically, most patients tend to have some degree of reflux after the sleeve, but this is self-limited and resolves soon. Once weight loss is begins, reflux also tends to reduce and go away.

In patients with a lax esophageal hiatus (the gap in the diaphragm through which the food pipe enters the abdomen) or with hiatus hernia, the sleeve can be done along with a repair of the hiatus (a procedure known as cruroplasty). This is also an accepted modality of treating reflux in the bariatric patient.

So the sleeve is a good bariatric procedure with a fairly good tolerance for the patient with some degree of pre-existing reflux symptoms.

The Duodenal Switch: This operation does not do much more than the sleeve for reflux. Indeed, the sleeve gastrectomy is the first part of the DS operation.

To sum up, if you are looking at bariatric surgery and you have symptoms and evidence of reflux esophagitis, then you should NOT consider the Band. If reflux is making your life miserable, then a bypass will be the best operation for you. If you don’t want the bypass for any reason, by all means consider the sleeve procedure.

In Part Three, we will examine the rest of the reflux story.

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While a detailed discussion on the why’s and how’s of acid reflux are outside our syllabus in today’s class, it is important to just get an idea of the basic reasons why gastric acid gets up (against the tide) into the food pipe (esophagus).

The normal junction between the esophagus and the stomach is marked by a whorl of muscle fibers of the two organs that functionally works as a valve. This valve, called the LES (Lower Esophageal Sphincter) allows food to pass from the food pipe into the stomach, but not the other way. If it weren’t for this, we would keep burping up food into the mouth like infants. Now that wouldn’t impress our girl friends, would it?

(diagrammatic representation of the area of our interest. Pic source: www.chw.org)

In certain circumstances, the function of the LES is impaired, and the net result in the reverse entry of gastric acid into the food pipe (a place that is not adapted to acid pH). This happens if you eat too much, or oily/spicy/processed food, drink too much coffee or alcohol, or if you smoke. I am not even scratching the surface here.

In cases where the pressure within the abdomen is very high (as in advanced pregnancy or severe obesity) the excess pressure on the stomach overcomes the resistance of the lower esophageal sphincter and causes reflux. The food pipe gets inflamed as a result of the acid attack (reflux esophagitis).

In many instances there is a condition called hiatus hernia that causes severe reflux. This condition occurs when the junction between the food pipe and the stomach slides up into the chest cavity, as a result of which the positive intra-abdominal pressure pushes up the acid from the stomach into the esophagus, which is located in a negative (low) pressure zone inside the chest cavity.

With this background, we need to understand that most obese patients, specially those being considered for bariatric surgery, are chronic sufferers of reflux. However, it is important to understand that many upper abdominal or digestive symptoms (like pain after eating, vomiting, “gas”, for example) are due to associated gallstone disease.

Obviously, each of this is deserving of treatment on its own merit.

When we see patients, we evaluate the patient’s symptoms and consider reflux as a clinical diagnosis. The diagnosis is documented by other studies like upper GI endoscopy, barium study and esophageal manometry.

An ultrasound is always done to exclude gallstone diseases and to see the state of the liver. Fatty liver is almost always a given in the bariatric patient before surgery.

Now that we know what reflux is, how it occurs in the obese patient and how we detect it, we need to know what to do about it.

That will be Part Two.

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