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W. Scott Melvin, M.D., F.A.C.S.It’s no secret that obesity is at epidemic levels, with one-third of the American population diagnosed with the condition1. In addition to other more obvious life-co-morbidities such as heart disease and diabetes, gastro esophageal reflux disease (GERD) is present in a much higher percentage of the morbidly obese population, at an average rate of 60 – 70 percent, versus 10 – 20 percent of the average population2.

Bariatric surgery is widely accepted as an important weight loss strategy for the morbidly obese patient. According to the American Society for Metabolic and Bariatric Surgery (ASMBS), 173,000 bariatric procedures were performed in 20133. This figure encompasses the Roux en Y Bypass procedure, sleeve gastrectomy, gastric banding and duodenal switch.

For some patients, the surgery itself, along with the subsequent weight loss and diet modifications following bariatric surgery, can resolve GERD symptoms that were present prior to surgery. But for others, particularly those undergoing sleeve gastrectomies, GERD continues even after a successful amount of weight is lost following surgery.

A 2014 study in JAMA Surgery analyzed the presence of GERD in sleeve patients pre- and post-operatively. The study showed that 84 percent of patients with pre-existing GERD continued to experience GERD post-sleeve, and 8.6 percent who did not demonstrate pre-operative GERD, developed GERD post-operatively4.

The ASMBS also reports that the number of sleeve gastrectomies are on the rise, from 18 percent of all weight loss surgery done in 2011 to 42 percent in 2013. Sleeve procedures have certain advantages for the bariatric patient, including a reduced stomach capacity with the ability to retain somewhat normal stomach function, preservation of the pylorus, and avoidance of an anastomosis used in intestinal bypass or a foreign implant used in gastric banding procedures.

Additionally, the sleeve procedure eliminates the portion of the stomach that produces the hormone that stimulates hunger. Sleeve gastrectomy is typically done laparosopically and is an effective first stage procedure, allowing conversion to bypass or duodenal switch if additional weight loss is needed.

Despite the many advantages of the gastric sleeve procedure, the tube-like smaller stomach structure may play a role in the incidence of de novo GERD post-procedure. W. Scott Melvin, M.D., F.A.C.S., vice chairman and chief of the Division of General Surgery and the director of Advanced Gastrointestinal Surgery at the Department of Surgery, Montefiore, is concerned with the prevalence of chronic GERD in bariatric patients.

For most GERD patients, as well as those with GERD post-sleeve, he says, the first line of treatment is proton pump inhibitors (PPIs). However, many patients do not have complete resolution of symptoms with medication alone. For the sleeve patient with GERD, an option may be a surgical conversion from gastric sleeve to gastric bypass. But for many patients who have had successful sleeve procedures, a conversion to bypass may seem unpalatable.

According to Dr. Melvin, Stretta Therapy may be a viable treatment for bariatric patients with chronic GERD, especially those following gastric sleeve. Stretta is a procedure that uses non-ablative radiofrequency (NARF) energy to remodel the musculature of the LES and gastric cardia. The treatment strengthens and restores the barrier function of the muscle and significantly reduces the frequency of reflux-triggering transient sphincter relaxations. Worth noting for bariatric patients, non-surgical Stretta is performed through the mouth, so it does not interfere with previous anatomical alterations. Stretta is also performed on an outpatient basis, usually under conscious sedation.

“This type of GERD patient is a challenge to treat successfully, and the data supports that the Stretta procedure may be a good solution for many of them,” Dr. Melvin said. “The Mattar et al 2006 study on Stretta in Roux En Y patients showed After Stretta, five out of seven patients had complete resolution of their symptoms, with normalization of pH studies.’”

In light of the growing interest in identifying treatment options for bariatric patients with chronic GERD, Dr. Melvin confirmed that Montefiore would be leading a multi-center study to further investigate Stretta in sleeve patients. “We will be taking the opportunity in the coming months to investigate Stretta in gastric sleeve patients through a multi-center study,” Dr. Melvin noted. “The current data shows that Stretta is safe and effective in the treatment of GERD and this study will help understand how Stretta works in the growing population of gastric sleeve patients with GERD.”

1 Ogden CL, Carroll MD, Kit BK, Flegal KM, Prevalence of Childhood and Adult Obesity in the United States, 2011-2012. JAMA. 2014; 311(8):806-814. doi:10.1001/jama.2014.732.

2Richter JE. Advances in Gerd: Current developments in the management of acid-related GI disorders. Gastroenterol Hepatol (N Y). 2010 Feb; 6(2): 76–79.

3 American Society for Metabolic and Bariatric Surgery. Estimate of Bariatric Surgery Numbers Found at: https://asmbs.org/resources/estimate-of-bariatric-surgery-numbers Accessed on March 6, 2015.

4 DuPree CE, Blair K, Steele SR, Martin MJ. Laparoscopic Sleeve Gastrectomy in Patients With Preexisting Gastroesophageal Reflux Disease: A National Analysis. JAMA Surg. 2014;149(4):328-334. doi:10.1001/jamasurg.2013.4323.

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