I Have a Lap Band: Should I Be Taking Antacid Medications?
Almost all Lap Band patients who present to my office for heartburn evaluation have already been started on proton pump inhibitors, PPIs. Primary care physicians in Houston and all over Texas recommend PPIs for heartburn. Irrespective of etiology, severity, or presentation, PPI treatment is, unfortunately, first line therapy. These powerful antacid medications have many side effects including renal failure, osteoporosis, magnesium deficiency, and altered gut microbiome. Thorough evaluation and GERD staging are crucial prior to committing patients to lifelong PPI treatment. Patients with stage 1 GERD don’t need PPIs. Patient with stage 3 or stage 4 GERD need surgery. Lap Band patients in particular do not benefit from any PPI treatment. The cause of heartburn, food regurgitation and chronic cough in Lap Band patients is directly related to the band itself. Any sensible treatment needs to address the band first.
When Lap Band patients present to Houston Weight Loss Surgery Center or Houston Heartburn and Reflux center for GERD related symptom evaluation, the subcutaneous port is accessed and all fluid aspirated. An upper gastro-intestinal (UGI) contrast study is performed. If the UGI shows a dilated gastric pouch, a hiatal hernia, tertiary esophageal contractions, or esophageal dilation then the band should remained completely decompressed for at least 6 months. Meanwhile, the patient is closely monitored for GERD related symptoms. Most patients will promptly improve with fluid removal from the band. Those patients may have their bands readjusted especially if they have a normal UGI study. Patients who do not improve with band decompression usually have a hiatal hernia and significant esophageal dysmotility. An esophageal manometry is highly recommended to evaluate the degree of dysmotility and the lower esophageal sphincter. If there is evidence of weak peristalsis, low contractile amplitudes and weak lower esophageal sphincter a Roux en Y gastric bypass and hiatal hernia repair are offered. Gastric bypass surgery isolates most of the stomach from the esophagus preventing reflux and decreasing the risk of aspiration. Roux limb anatomy creates a low-pressure system promoting esophageal emptying and further safeguarding against potential aspiration. It should be mentioned that patients with normal esophageal motility and a hiatal hernia might be offered the traditional Nissen fundoplication surgery for GERD symptom control. However, most Lap Band patients gain significant amount of weight following band removal and gastric bypass is preferred over Nissen fundoplication in order to promote weight loss. Indeed, excess weight is a major contributor to GERD and Nissen surgery in morbidly obese patients is associated with lower efficacy and durability.
Overall, patient satisfaction rates are very high following Lap band removal and conversion to Gastric Bypass. I caution against converting a Lap Band to gastric sleeve in the setting of esophageal dysmotility. Gastric sleeve is assumed to be a high-pressure system. Therefore, it may exacerbate acid reflux and esophageal emptying.