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GBP and reflux

Effectiveness of gastric bypass on reflux symptoms overestimated

Risk factors for post-operative reflux include high dose of pre-operative anti‐reflux medication, older age and female

Although gastro‐oesophageal reflux symptoms do show a dramatic decline after gastric bypass surgery approximately half of patients required continuous anti‐reflux medication after surgery, according to researchers from Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden. The study group therefore summarised that the treatment efficacy of gastric bypass on reflux could have been overestimated.

In the study, ‘Gastric bypass surgery in the treatment of gastro‐oesophageal reflux symptoms’, published in Alimentary Pharmacology & Therapeutics, the investigators assessed the long‐term risk of remaining/recurring reflux symptoms after gastric bypass as they stated that the current evidence was lacking due to small study samples sizes and inadequate follow-up. In addition, they sought to identify factors influencing the treatment success.

The main outcome of the study was remaining/recurring reflux defined by the dispensing of proton pump inhibitors (PPI) or H2RA after gastric bypass. A six‐month cut‐off was used to identify participants requiring long‐term anti‐reflux medication (while excluding other indications for use of such medication). The authors also considered seven covariates that might influence the efficacy of gastric bypass in the treatment of GERD (age, sex, comorbidity, calendar period of gastric bypass, dose of preoperative anti‐reflux medication, previous anti‐reflux surgery or bariatric surgery and open laparotomy or laparoscopic approach of the gastric bypass).

Outcomes

In total, 2,454 patients (2,005 women; 81.7%) who had gastric bypass surgery were included in the study, the mean age at surgery was 46.1 years (range 18.0‐75.0 years), median follow‐up was 4.6 years (interquartile range 3.1‐6.3 years). Within 30 days of gastric bypass, 65 (2.6%) participants underwent re‐operation and one (0.04%) patient died, four (0.2%) participants died within 90 days of surgery and 63 (2.6%) died during the entire follow‐up. The authors noted that complications requiring re‐operation were relatively common, particularly in men.

The authors reported that the average use of anti‐reflux medication during the year before gastric bypass was 442 daily doses, which decreased by 39% to 272 daily doses in the first year after surgery. The corresponding daily doses were 237 and 227, in the second and third year after surgery, respectively. There was a mean decrease of only ten daily doses per year until ten years after surgery.

During the first-year post-surgery, reflux symptoms remained/recurred in 55.8% of the participants and in 48.8% during the second year - the occurrence of reflux remained at approximately 50% at ten years after surgery. Of those without reflux in the first year of gastric bypass, 15% had reflux recurrence in the second year and 8% in the second to fifth year of surgery. A total of 67.6% had reflux requiring long‐term anti‐reflux medication for at least one year within five years of surgery.

Regarding risk factors for recurrent reflux, the authors reported that:

  • Participants aged >50 years had a slightly increased risk of postoperative reflux symptoms vs. patients aged <40 years
  • Female sex was associated with an increased risk of reflux vs. males
  • Higher comorbidity scores were also associated with an increased risk of postoperative reflux
  • The risk of reflux was relatively stable over time comparing those operated in 2013‐2015 vs. 2006‐2010
  • The strongest risk factor for postoperative reflux was a high‐cumulative dose of anti‐reflux medication before gastric bypass - patients with more severe preoperative reflux are less likely to be relieved of reflux symptoms by means of gastric bypass
  • The risk of reflux was similarly for laparoscopic vs open surgery
  • The risk factors older age and comorbidity (particularly diabetes) are associated with an increased likelihood of failed weight loss after gastric bypass, which might introduce a higher risk of recurring reflux

“In conclusion, this large and population‐based cohort study with long and complete follow‐up indicates that gastric bypass is an effective and long‐lasting treatment of GERD in only approximately 50% of patients with severe obesity,” the authors determined. “This is a lower success rate than in previous studies, indicating that the treatment effect may have been overstated. Physicians and patients should be aware of the limited effect of gastric bypass on reflux in patients with severe obesity, particularly in those with risk factors for post-operative reflux, that is, high dose of pre-operative anti‐reflux medication, older age, female sex and comorbidity.”

To access this paper, please click here

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