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

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

3. 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

4. 24 pH in pts with normal preop
Gamagaris et al. Lap-band impact on the function of the esophagus. Obes Surg. 2008;18:1268

5. 24 pH in pts with abnormal preop
Gamagaris et al. Lap-band impact on the function of the esophagus. Obes Surg. 2008;18:1268

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

7. 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

8. 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

9. 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

10. 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

11. 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

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

13. 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

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

15. 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

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

17. 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

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

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

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

21. 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:

22. Esophageal Dilation: Case 2

23. 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:

24. Esophageal Dilation: Case 2

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

26. 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

27. 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