Management of gastro-oesophageal reflux in obese patients

Background: Obesity and gastro-oesophageal reflux disease (GORD) are two of the most significant health care problems facing our community – they are linked physiologically and epidemiologically. Laparoscopic adjustable gastric banding (LAGB) has rapidly emerged as a safe and effective procedure (for obesity) that significantly improves GORD symptoms. There is very limited understanding of the mechanism by which LAGB reduces GORD. This lack of understanding is significantly constraining use of LAGB as an anti-reflux procedure and surgeons urgently need better data to guide the choice of surgical interventions for obese patients with GORD. This need is compounded by a far higher complication and failure rate of fundoplication (the gold standard anti-reflux procedure) in obese patients. Goal: To better understand the anti-reflux mechanism of LAGB and its impact on gastro-intestinal quality of life, thereby better informing clinicians of the optimal surgical management of obese patients with GORD. Aims: 1) To determine the association of oesophageal reflux events with transient lower oesophageal sphincter relaxations in LAGB patients 2) To determine the effect of LAGB on oesophageal reflux events in response to reflux provoking stimuli 3) To compare the effects of LAGB and surgical fundoplication on GORD symptoms and gastro-intestinal quality of life Methods: Study 1: Eight LAGB patients with a stable weight loss and volume within the LAGB will undergo a study using a combined high resolution manometry and pH recorder. Transient lower oesophageal sphincter relaxations will be recorded and correlated with oesophageal reflux events. A reflux provoking high caloric intra-gastric infusion will be administered. As a comparison group 8 patients who have undergone surgical fundoplication will undergo the same evaluation as will 8 obese controls with GORD. Study 2: Twenty pre-op LAGB patients and twenty surgical fundoplication patients will be evaluated pre-operatively and six months post-operatively. Reflux scores and gastro-intestinal quality of life scores will be recorded. Title: Upper GI symptoms, satiety and gastro-intestinal quality of life following adjustable gastric banding Department: Surgery (Alfred hospital) Supervisors: Professor Wendy Brown, Mr Paul Burton, Contact: paul.burton@monash.edu Follow-up is critical to the success of laparoscopic adjustable gastric banding (LAGB). Few data are available to guide this and expected norms of satiety, adverse symptoms, and outcomes have not been defined – limiting the capacity of clinicians to specify expected long term outcomes and effects. Additionally, the effects of the procedure on gastro-intestinal (GI) quality of life have not been evaluated. Although conventional measures of quality of life improve; whether these change are truly inclusive of the adverse gastro-intestinal effects of LAGB are unknown. Overall, there are few intermediate (>5 year) data on outcomes other than weight loss, following LAGB. Methods: In a cohort of 400 LAGB patients, Baseline data (2007) is available on assessed satiety, adverse upper gastrointestinal (dysphagia, reflux, and epigastric pain), and outcomes (overall satisfaction, weight loss, and quality of life (SF-36)). This project will: 1) Evaluate different measures of gastro-intestinal quality of life in patients who have undergone gastric band surgery 2) Follow up changes over >5 years in terms of satiety, outcomes and quality of life and determine the effects of the procedure on these measures and how they change over time. Significance: Patients are generally highly satisfied with the outcome of LAGB and achieve substantial weight loss. Data from this study will significantly improve clinicians’ ability to care for patients by defining expected normal ranges at different time points. In addition far more detailed knowledge on the gastro-intestinal effects of the procedure will be provided. Correlation of different measures to weight loss and complication will be available, allowing determination of the predictors of these important end points.