The case of the month is a 50-year-old female who had her adjustable gastric band removal a year ago for heartburn, food regurgitation and nighttime cough. The patient like so many other adjustable gastric band victims was over-restricted for so many years in hopeless attempts to promote weight loss. Pure mechanical restriction does not lead to weight loss but instead it causes esophageal dysmotility that leads to GERD. Long-term Lap Band over-restriction leads to irreversible esophageal damage. Esophageal function failure is characterized by heartburn, food regurgitation, difficulty swallowing food, recurrent vomiting and nighttime symptoms including cough. Patients may develop an aspiration pneumonia that requires hospitalization and intravenous antibiotics to treat.
The key to management of acid reflux in the setting of adjustable gastric banding is EARLY intervention and band decompression. An UGI series is recommended to evaluate the band position, gastric pouch above the band and esophageal diameter and peristalsis. Patients with tertiary contractions and esophageal dilation are unlikely to loose weight from band adjustment in the future. Band removal is recommended to these patients to prevent further esophageal damage and to prepare them for a metabolic procedure like gastric bypass surgery if they wish to loose weight. Gastric sleeve surgery is not recommended in the setting of esophageal dysmotility. Contrary to Roux en Y gastric bypass surgery, a gastric sleeve is a high-pressure system and it may exacerbate GERD related symptoms if esophageal motility is affected. I recommend staging the revision process. First, the band is removed and after 6 months an UGI and esophageal manometry are performed. If both manometry and UGI are normal then a gastric sleeve may be performed otherwise a gastric bypass is offered.
Back to our patient, her work up showed a dilated flaccid esophagus with minimal peristalsis. Contrast freely refluxed on UGI from the stomach into the esophagus when placed in the head down position. Esophageal manometry showed a weak lower esophageal sphincter, 50 % failed peristalsis, low distal contractile integral and distal wave amplitude. Any surgical intervention should achieve two aims: Alleviate dysphagia and stop reflux. Roux en Y gastric bypass surgery can do both. Gastric bypass has traditionally been used for GERD. The Roux en Y configuration is, in addition, a low-pressure system that promoted esophageal emptying. A study published in 2007 in the Annals of Thoracic Surgery showed that gastric bypass surgery is superior to esophageal resection and Nissen fundoplication for treatment of GERD in Scleroderma patients. It is associated with lower morbidity and mortality than esophageal resection. It causes less dysphagia than a Nissen and offers excellent GERD control.
I plan to perform a gastric bypass on my patient for treatment of both GERD and esophageal dysmotility related symptoms. Her symptoms will resolve and I hope with time she may recover some of her esophageal function.