Esophageal Problems after Gastric Banding MISS 2011 Salt Lake City, UT Christine Ren Fielding, MD Associate Professor, Surgery NYU School of Medicine

Esophageal problems Esophageal reflux Esophagitis heartburn Esophagitis Ulcers, Barrett’s Esophageal dysmotility Esophageal dilation

Effect of LAGB on GERD Conflicting data in literature about effect of LAGB reflux Often GERD resolves after LAGB Often GERD appears several years after LAGB Depends on whether a hiatal hernia was identified and repaired

24 pH in pts with normal preop Gamagaris et al. Lap-band impact on the function of the esophagus. Obes Surg. 2008;18:1268

24 pH in pts with abnormal preop Gamagaris et al. Lap-band impact on the function of the esophagus. Obes Surg. 2008;18:1268

Effect of LAGB on GERD Acid reflux vs Food reflux Heartburn Time of occurrence (day, night) Will determine treatment PPI Behavior modification

Nocturnal Reflux Volume reflux, regurgitation, cough, aspiration If occurs when lies down right after oral intake = “normal” If occurs when lies down > 1 hour after oral intake = “abnormal” Poor esophageal clearing

Esophageal motility in pts with normal preop manometry Gamagaris et al. Lap-band impact on the function of the esophagus. Obes Surg. 2008;18:1268

Esophageal motility in pts with abnormal preop manometry Gamagaris et al. Lap-band impact on the function of the esophagus. Obes Surg. 2008;18:1268

Esophageal Motility Responsive to hormones Cortisol Day/night variability Thyroid Estrogen/Progesterone Menstrual cycle/pregnancy variability Epinephrine Stress variability Most common symptom: dysphagia/regurgitation Recurrent regurgitation/vomiting increase acid exposure of distal esophageal mucosa

Esophageal dilation Esophageal obstruction due to band too tight Smooth esophageal mucosa Peristalsis seen Reverse immediately with band loosening Not uncommon to see in the morning Often asymptomatic

Esophageal Dilation Acute vs Chronic Achalasia vs Pseudo-achalasia Obstructed vs Dysmotile Esophagram Esophageal diameter Esophageal mucosa Manometry Typically reversible when band loosened

Case Study 19 yo male, BMI 50, no co-morbidities Routine preop esophagram Dilated esophagus with poor motility, small hiatal hernia EGD Small hiatal hernia, erosive esophagitis Manometry No peristalsis, decreased LES pressure

Case Study PPI x 6 weeks Repeat esophagram and manometry Conclusion Normal Conclusion Esophagitis can diminish esophageal motililty

Esophageal motility and GERD Hiatal hernia pts vs w/o HH have Higher extent of reflux Lower frequency of reflux events More severe esophagitis Prolonged acid clearance Lower amplitude of peristalsis at 5 cm prox to LES Same LES pressure Conclusion: GER patients with hiatal hernia have  amount of reflux and more severe esophagitis which results in more severely impaired esophageal peristalsis as compared to pt w/o hernia Kasapadis et al. Dig Dis Sci, 1995;40:2724

Esophageal motility after Nissen Wetscher GJ et al. Am J Surgery, 1999;177:189 Peristalsis increases after anti-reflux surgery

Esophageal dilation: Case 2 46 yo female, BMI 48 Preop esophagram- normal EGD- 2 cm hiatal hernia March 2004 Lapband 10 No hernia visualized at surgery March 2006 Reflux Esophagram: large pouch EGD: erosive esophagitis, residual food Resolved with band loosening and PPI

Esophageal dilation: Case 2 October 2007 Aspiration pneumonia Esophagram shows:

Esophageal dilation: Case 2 Band loosened Started on PPI Repeat esophagram shows:

Esophageal dilation: Case 2 Patient underwent surgical repair of hiatal hernia Resolution of reflux, off PPI, resume weight loss

Esophageal Dilation: Case 2 45 year old female 3 years s/p LAP-BAND® 9.75 Down 60 lbs, happy Worsening nocturnal reflux She takes a MVI each morning Esophagram shows:

Esophageal Dilation: Case 2

Esophageal dilation: Case 2 All fluid removed (2.3 cc) EGD- erosions in distal esophagus Start PPI qd, carafate bid (not with PPI) x 1-3 months All symptoms resolved immediately Warn pts of esophageal spasm (24-48 hrs) Repeat esophogram shows:

Esophageal Dilation: Case 2

Esophageal Dilation: Case 2 Conclusion Esophagitis can diminish esophageal motililty Pill esophagitis can be caused by Vitamins Medications NSAIDs Antibiotics KCL Large pills

Pill Esophagitis All meds/vitamins should be liquid or chewable Meds the size of tic tac or smaller should Be taken one at a time Never early in the morning Never just before lying down Meds larger than tic tac Open capsule/crush and put into applesauce Beware of extended release capsules Best to take just prior to eating or with a large fluid ‘chaser’ Consider empiric acid supp if pt takes many meds

Conclusion Esophageal problems consist of esophagitis, dilation and dysmotility Correlate patient symptoms with esophagram Nocturnal reflux, cough or aspiration can be suspicious of esophageal dysmotility which can lead to esophageal dilation Chronic esophageal dilation is due to esophagitis, should be treated with PPI, short-term band loosening, and confirmed with repeat e-gram Esophagitis is caused by hiatal hernia, chronic vomiting or by medication