OBES SURG (2012) 22:764–772 DOI 10.1007/s11695-011-0531-x CLINICAL RESEARCH Laparoscopic Treatment of Obese Patients with Gastroesophageal Reflux Disease and Barrett’s Esophagus: a Prospective Study Italo Braghetto & Owen Korn & Attila Csendes & Luis Gutiérrez & Héctor Valladares & Max Chacon Published online: 4 March 2012 # Springer Science+Business Media, LLC 2012 Abstract Background Short-segment Barrett’s esophagus (SSBE) or long-segment Barrett’s esophagus (LSBE) is the consequence of chronic gastroesophageal reflux disease (GERD), which is frequently associated with obesity. Obesity is a significant risk factor for the development of GERD symptoms, erosive esophagitis, Barrett’s esophagus, and esophageal adenocarcinoma. Morbidly obese patients who submitted to gastric bypass have an incidence of GERD as high as 50% to 100% and Barrett’s esophagus reaches up to 9% of patients. Methods In this prospective study, we evaluate the postoperative results after three different procedures— calibrated fundoplication+posterior gastropexy (CFPG), fundoplication+vagotomy+distal gastrectomy+Roux-enY gastrojejunostomy (FVDGRYGJ), and laparoscopic resectional Roux-en-Y gastric bypass (LRRYGBP)— among obese patients. Results In patients with SSBE who submitted to CFPG, the persistence of reflux symptoms and endoscopic erosive esophagitis was observed in 15% and 20.2% of them, respectively. Patients with LSBE were submitted to FVDGRYGJ or LRRYGBP which significantly improved their symptoms and erosive esophagitis. No modifications of I. Braghetto (*) : O. Korn : A. Csendes : L. Gutiérrez : H. Valladares Department of Surgery, University of Chile, Santos Dumont 999, Santiago, Chile e-mail: ibraghet@redclinicauchile.cl M. Chacon Department of Informatics Engineering, University of Santiago de Chile, Av, Ecuador 3659, Santiago, Chile LESP were observed in patients who submitted to LRRYGBP before or after the operation. Acid reflux diminished after the three types of surgery were employed. Patients who submitted to LRRYGBP presented a significant reduction of BMI from 41.5±4.3 to 25.7±1.3 kg/m2 after 12 months. Conclusions Among patients with LSBE, FVDGRYGJ presents very good results in terms of improving GERD and Barrett’s esophagus, but the reduction of weight is limited. LRRYGBP improves GERD disease and Barrett’s esophagus with proven reduction in body weight and BMI, thus becoming the procedure of choice for obese patients. Keywords Barrett’s esophagus . Obese patients . Laparoscopy . Fundoplication . Gastric bypass Introduction Short-segment Barrett’s esophagus (SSBE) or long-segment Barrett’s esophagus (LSBE) are the consequences of chronic gastroesophageal reflux disease (GERD), frequently associated with obesity [1–7]. The incidence of GERD in a non-obese population is 15% to 20% and in Barrett’s esophagus is 1.2%. Obesity is a significant risk factor for the development of GERD symptoms, erosive esophagitis, and esophageal adenocarcinoma. The reported incidence of reflux symptoms among obese patients ranged from 22% to 70%, while erosive esophagitis is very variable, ranging from 7% to 30%. Barrett’s esophagus in an obese population is three times more frequent and the odds ratio for long-segment Barrett’s esophagus is 4.3 and for Barrett’s adenocarcinoma is 16.2. In morbidly obese patients who submitted to gastric bypass, the incidence of GERD is as high as 50% to 100%, and Barrett’s esophagus reaches up to 9% of patients [8]. Therefore, surgical treatment for obese patients must be selected OBES SURG (2012) 22:764–772 765 LSBE, submitted to FVDGRYGJ, and 21 patients submitted to LRRYGBP. The demographic characteristics of patients and the surgical procedure performed are shown in Table 1. Patients with BMI greater than 35 who submitted to LRRYGBP constitute a different group with statistically significant differences in body weight and BMI compared with the other two patient groups. according to the clinical characteristics of the patient and the procedure chosen must accomplish the double purpose of treating GERD and improving obesity. For SSBE, surgeons recommend to perform only fundoplication based on the low morbi-mortality, obtaining good results in a long-term follow-up in terms of regression of intestinal metaplasia (IM) and no progression to dysplasia or adenocarcinoma as we have shown recently [9]. However, the controversy persists because worse results have been observed among patients with LSBE and its complications (ulcer or stricture) after this procedure, and many of these patients must receive continuous PPI medication. That is the reason why our group, during the open era of surgery, proposed to add to fundoplication an acid suppression and duodenal diversion procedure in order to improve the clinical results by avoiding acid and bile reflux [10–15]. We are now performing the same procedure by laparoscopic approach. For obese patients with BE, laparoscopic Roux-en-Y Gastric Bypass (LRYGBP) has been suggested as an excellent anti-reflux operation, proven by the disappearance of symptoms and the healing of endoscopic esophagitis or peptic ulcer in all patients, which is followed by an important regression of intestinal metaplasia to cardiac mucosa. [1–5, 16–23] In this prospective study, we evaluate the postoperative results among obese patients with BMI greater than 30 kg/m2 after three different procedures: calibrated fundoplication+posterior gastropexy (CFPG), fundoplication+vagotomy+distal gastrectomy+Roux-en-Y gastrojejunostomy (FVDGRYGJ), and laparoscopic resectional Roux-en-Y gastric bypass (LRRYGBP). Definitions Reflux symptoms: presence of heartburn or regurgitation more than once weekly Erosive esophagitis: according to Los Angeles’s classification, presence of esophageal erosions during endoscopy Intestinal metaplasia: presence of columnar epithelium with goblets cells at histological examination, located distal to the squamo-columnar junction Regression: disappearance of IM with multiple biopsies demonstrating the presence of cardiac or fundic mucosa Progression: biopsies demonstrating IM and focus of low-grade dysplasia Hypotensive lower esophageal sphincter (LES): LES pressure <11.9 mmHg Abnormal acid reflux: if 24-h pH monitoring shows the percentage of time of intraesophageal pH<4 greater than 4% or DeMeester Score>14.1 Short-segment Barrett’s esophagus: 10–30 mm, length of columnar epithelium in the distal esophagus Long-segment Barrett’s esophagus: 31–99 mm, length of columnar epithelium Patients and Methods Methods One hundred thirty-nine patients, who were divided in three groups, were included in this prospective study: 79 patients with SSBE submitted to CFPG, 39 patients with (a) Clinical questionnaire—A careful clinical assessment was performed in each patient before and 3–5 years Table 1 Demographic characteristics and surgery performed (n=139) Number of patients, n Sex M F Age (years) Weight (kg) BMI (kg/m2) Surgery SSBE (a) LSBE (b) 79 39 32 22 47 16 41.3 45.7 89.6±9.6z 95.3±11.3 33.9±2.9 36.5±3.4 CF+PG FVDGRYGJ LSBE (c) p, a vs b p, a vs c p, b vs c 21 12 9 53.2 115.5±22.9 0.6265 0.0001 0.0001 43.7±4.2 0.6473 0.0001 0.0001zzzzzz LRRYGBP SSBE short-segment Barrett’s esophagus, LSBE long-segment Barrett’s esophagus, BMI body mass index, CFPG calibrated fundoplication+ posterior gastropexy, FVDGRYGJ fundoplication+vagotomy–distal gastrectomy+Roux-en-Y gastrojejunostomy, LRRYGBP laparoscopic resectional Roux-en-Y gastric bypass 766 (b) (c) (d) (e) OBES SURG (2012) 22:764–772 after surgery, asking about the presence of heartburn, regurgitation, dysphagia, chest pain, or other extraesophageal reflux symptoms. Endoscopic/ histologic study—An endoscopic examination was performed on all patients before and after the operation using an Olympus Excera 2CV-180 endoscope. Multiple circumferential samples (at least eight), at 2 cm each, were obtained for histological study. Manometric studies—The resting pressure of the lower esophageal sphincter was measured and a case with pressure less than 12 mmHg was considered as a hypotensive sphincter. The details of this evaluation have been previously published. [10] It was performed in all patients before surgery and in 116 patients after surgery. 24-h intraesophageal pH studies—Using a Digitrapper (Synectics, Sweden) system, six different parameters were evaluated, but the most useful and practical is the total percentage of time during which the intraesophageal pH remains below 4, our normal value being less than 4% during a 24-h period (55 min) and the DeMeester’s score less than 14. This test was carried out in all patients before and after surgery. The complete details of this procedure have been published elsewhere. [11–13] This test was performed in all patients before surgery and in 116 patients after surgery. Follow-up—After surgery, patients were controlled following the same preoperative protocol evaluating symptoms, endoscopic, radiologic, and esophageal functional tests, in order to determine the clinical and objective results. As a prospective and close study, 100% of patients were controlled by the participant surgeons during 3–5 years after surgery. They were controlled annually for clinical questionnaire and endoscopy/histology in order to detect reflux symptoms or esophagitis; manometry and 2-h pH monitoring were also performed in order to evaluate LES function and the presence of postoperative acid reflux. Therefore, patients had three to five endoscopic and clinical controls after surgery. Surgical Procedures Statistical Analysis The paired and unpaired Student’st-test was applied for continuous data, whereas z-test was applied for binary data in order to compare proportions. A p value under 0.05 was considered as significant. The patient is placed in a French position (with legs in an abduction position). Then, pneumoperitoneum is performed with a Verres needle working at 15 mmHg of intra-abdominal pressure. Five trocars were employed for liver retraction, optic system, assistants, and surgeon instruments. The following surgical techniques were employed: (a) Fundoplication with cardial calibration, crura closure, and posterior gastropexy were performed according to the laparoscopic technique that we described previously [22]. After the removal of the fatty tissue around the angle of His, we divide the first ascending branch of the left gastric artery at the lesser curvature and continue the dissection around the cardia in order to clear completely the esophagogastric junction, also dividing one or two short gastric vessels via the right posterior approach. This way, the abdominal esophagus is surrounded and completely exposed. The hiatus is closed with two to three non-absorbable stitches. For anti-reflux surgery, the first two stitches with 2/0 nonabsorbable seromuscular sutures are placed in the anterior wall of the stomach on the lesser curvature 1– 2 cm distal and perpendicular to the anatomic border of the cardia, without including the esophagus. These seromuscular stitches include the sling fibers and the inferior clasp fibers at the lesser curvature of the esophagogastric junction and correspond to the calibration of the cardia itself. The stomach was then rotated to expose the posterior wall of the esophagus and gastric fundus and three to four additional stitches were symmetrically placed in the corresponding point of the anterior wall and posterior wall of the stomach in order to perform in this fashion a 3-cm-long 360° fundoplication wrapping of the distal esophagus. An intraluminal 36 French bougie plus the nasogastric tube (F14) was used in order to avoid extreme narrowing of distal esophagus or cardia. The more proximal stitch was also fixed to the diaphragmatic pillars closure. (b) Fundoplication plus selective vagotomy, antrectomy with Roux-en-Y gastrojejunostomy: Laparoscopic fundoplication, selective vagotomy and antrectomy with Roux-en-Y gastrojejunostomy, was performed by five-trocars approach. After the completion of the antireflux procedure, using Ligasure® device (Covidien, CO, USA), we proceeded to perform the division of distal gastric vascularization along the greater curvature, the division of the gastro-hepatic ligament and Latarjet’s branches of the vagus nerves. Thereafter, we divided and closed the duodenal stump employing Endo GIA 60-mm Duet stapler (Covidien, Norwalk, CT, USA). The distal gastrectomy resecting 60% of the stomach was completed by applying two cartridges of Endo GIA device. Then, after the division with Ligasure® of one vascular jejunal arcade, a Roux-en-Y OBES SURG (2012) 22:764–772 60-cm antecolic long limb was ascended for the end-toside gastrojejunostomy with 45-mm Endo GIA blue cartridges. Finally, a side-to-side jejuno-jejunal anastomosis was performed with a white 45-mm Endo GIA device. (c) Laparoscopic resectional Roux-en-Y gastric bypass: The greater curvature was exposed, using a Ligasure® device (Covidien, CO, USA). The gastroepiploic gastric branches were 2 cm beyond the pylorus until the His angle, cutting the short and posterior gastric fundic vessels. A division of the adhesions of the posterior antral wall to the anterior pancreatic surface was performed in order to expose the posterior wall of the duodenal bulb. The gastrohepatic ligament was opened at the avascular membrane, and identification and division of the right gastric artery with Ligasure®, (Covidien, CO, USA) were performed. Division of the duodenum with a Duet-Endo GIA blue cartridge (Covidien, Norwalk, CT, USA), introduced by the 15-mm port located at the right quadrant, was performed. Division of the fatty tissue, vessels, and Latarjet’s nerve of the lesser curvature was performed in this fashion, exposing the gastric wall just in front of the cardiotuberositarian vessels, 3 cm below the cardia. Then, a 45-mm Endo GIA stapler and a 4.8mm stapler (blue cartridge) were introduced by the same port located at the right quadrant in order to start the division of the stomach 3 cm below the cardia. Gastric trans-section was completed with two to three additional 60-mm blue cartridge. An additional Endo GIA stapler was addressed to the His angle in order to perform the gastric pouch guided by a gastric tube, and a 36 French was introduced by the anesthesiologist, leaving a gastric pouch of 30–50-ml capacity, measured by the instillation of methylene blue through the tube. The great omentum was retracted in order to localize the Treitz’s angle. The biliary loop was identified, which was elevated to the gastric stump in order to approximate it and to perform side-to-side gastrojejunostomy with a 45-mm blue or white cartridge Endo GIA. Reinforcement of the stapler line and closure of the orifice of the entrance of the instrument was done with Monocril® 000 sutures (Ethicon, Cincinnati, OH, USA). Afterwards, we performed side-to-side jejunojejunal anastomosis 170 cm distally with white cartridge 45-mm Endo GIA in the same fashion [23]. The main surgical differences between the FVDGRYGJ and LRRYGBP are: (a) Addition of fundoplication in the former procedure. (b) Greater resection of the stomach (95%), leaving a small gastric pouch of 30-ml capacity after LRRYGBP, while the resection of distal stomach was approximately of 60% after FVDGRYGJ. 767 (c) The length of the alimentary Roux-en-Y limb is 60– 70 cm after FVDGRYGJ, while after LRRYGBP is near to 130–150 cm. Results In this paper, we compared the results of three different surgical procedures for obese patients with Barrett’s esophagus: (a) fundoplication alone which represents the shortest and most simple operation, (b) fundoplication plus vagotomy and partial distal gastrectomy with Roux-en-Y gastrojejunostomy (acid suppression/duodenal diversion procedure) which represents a more complex procedure because it is a combination of two procedures, and (c) resectional Roux-en-Y gastric bypass which involves only one operation. In patients with SSBE who submitted to fundoplication, the persistence of reflux symptoms and endoscopic erosive esophagitis was respectively observed in 15% and 20.2%. In patients with LSBE who submitted to fundoplication+vagotomy+distal gastrectomy and Roux-en-Y gastrojejunostomy, reflux symptoms and erosive esophagitis persisted in one patient (2.6%). All patients with LSBE who submitted to LRRYGBP improved their symptoms, while erosive esophagitis, ulcers, or strictures also healed in all of them (p<0.003) (Table 2). Therefore, LSBE patients undergoing FVDGRYGJ and LRRYGBP had a better postoperative behavior in terms of symptoms and endoscopic findings compared to patients with SSBE who underwent fundoplication, with statistically significant differences (Table 2). Table 3 shows the evolution of IM at the distal esophagus after surgery. In patients with SSBE who submitted to CFPG and in patients with LSBE who submitted to FVDGRYGJ, intestinal metaplasia regressed to cardiac mucosa in 51.9% and 51.3% of cases (p=0.9471 and 0.4302, respectively) at a mean of 2 years after surgery (range, 16–42 months). After LRRYGBP, only eight patients (38.1%) remained with IM, showing no significant statistical differences with respect to the other two patient groups. Four cases (5.1%) which submitted to CFPG and one patient who submitted to FVDGRYGJ (2.6%) were converted to acid suppression/ duodenal diversion procedure plus argon plasma ablation as a complementary treatment for persistence of erosive esophagitis and Barrett’s metaplasia. No progression to dysplastic changes was observed. Regarding manometric findings in patients with SSBE who submitted to CFPG (Table 4), postoperative hypotensive LES was observed in 13.9%, while in patients with LSBE who submitted to FVDGRYGJ hypotensive LES was observed in 12.8% of patients (p=0.7669). After LRRYGBP, 100% of patients (p =0.000) presented hypotensive LES because no anti-reflux procedure was added during this procedure. 768 OBES SURG (2012) 22:764–772 Table 2 Clinical results Type of surgery SSBE LSBE CFPG (a) FVDGRYGJ (b) LRRYGBP (c) Reflux symptomsa SSBE short-segment Barrett’s esophagus, LSBE long-segment Barrett’s esophagus, CFPG calibrated fundoplication+ posterior gastropexy, FVDGRYGJ fundoplication+ vagotomy–distal gastrectomy+ Roux-en-Y gastrojejunostomy, LRRYGBP laparoscopic resectional Roux-en-Y gastric bypass a a vs b—p=0.0393, a vs c— p=0.0418, b vs c—p=0.4593 b a vs b—p=0.01) a vs c (p=0.0244) b vs c (p=0.4593) Preop, n (%) 79 (100) 39 (100) 21 (100) Postop, n (%) Endoscopy 12 (15.2) 1 (2.6) 0 Erosive esophagitisb Preop, n (%) Postop, n (%) Esophageal ulcer 79 (100) 39 (100) 21 (100) 16 (20.2) 1 (2.6) 0 Preop, n (%) 0 4 (10.2) 6 (28.6) Postop, n (%) 0 0 0 0 0 4 (10.2) 0 2 (9.5) 0 Esophageal stricture Preop, n (%) Postop, n (%) Regarding 24-h pH monitoring, a high proportion of patients with hypotensive LES who were submitted to CFPG had abnormal postoperative acid reflux (24%). On the contrary, after FVDGRYGJ, despite the presence of hypotensive LES, a very low percentage of patients (2.6%) presented abnormal acid reflux. In patients who submitted to LRRYGBP, 9.5% presented positive reflux. Table 5 shows the preoperative and postoperative manometric and 24-h pH monitoring findings. After CFPG or FVDGRGGJ, a significant increase in LES pressure was observed (p=0.0000). However, no modifications of LESP were observed in patients with LRRYGBP after the operation, presenting hypotensive LES compared to the other procedures (p<0.0001). Acid reflux diminished after the three types of surgery employed, especially in patients who submitted to FVDGRYGJ and LRRYGBP according to 24-h pH monitoring. The postoperative complications are shown in Table 6. Cardial calibration with fundoplication and posterior gastro- pexy presented low rates of postoperative complications compared to the other two techniques. Postoperative dysphagia was seen after fundoplication alone in four cases and in one case after fundoplication combined with partial distal gastrectomy. Postoperative diarrhea and dumping were observed exclusively after FVDGRYGJ. One patient presented a late duodenal stump leak and another patient presented early hemoperitoneum due to trocar bleeding. Both patients had to be reoperated. Gastric bleeding occurred in one patient and was treated with endoscopic injecto-therapy. Regarding postoperative complications, there were no differences between FVDGRYGJ and LRRYGBP (10.3% versus 9.5%). All patients who submitted to three surgical techniques presented weight loss and BMI reduction after a 1-year followup (Table 7). The mean body weight decrease 12 months after CFPG was 14.3 kg, ranging from 5 to 15 kg, with a reduction of BMI from 33.2±10.1 to 28.1±1.7 kg/m2, whereas the weight loss in patients who submitted to FVDGRYGJ was Table 3 Histological evaluation before and after the operation Type of surgery Intestinal metaplasia Preop Regression Dysplasia SSBE LSBE CFPG (n=79) FVDGRYGJ (n=39) LRRYGBP (n=21) 79 (100) 40 (51.9) 0 39 (100) 20 (51.3) 0 21 (100) 13 (61.9) 0 Submitted to argon plasma ablation and conversion to acid suppression/duodenal diversion procedure. a vs b—p=0.9471, a vs c—p=0.4302, b vs c—p=0.3576 SSBE short-segment Barrett’s esophagus, CFPG calibrated fundoplication, posterior gastropexy, LSBE long-segment Barrett esophagus, FVDGRYGJ fundoplication–vagotomy–distal gastrectomy–Roux-en-Y gastrojejunostomy, LRRYGBP laparoscopic resective Roux-en-Y gastric bypass OBES SURG (2012) 22:764–772 769 Table 4 Manometry and 24-h pH monitoring Surgery, n SSBE LSBE CFPG, 79 (a) FVDGRYGJ, 39 (b) LRRYGBP, 21 (c) 79 (100) 11 (13.9) 39 (100) 5 (12.8) 21 (100) 21 (100) 79 (100) 39 (100) 21 (100) 19 (24) 1 (2.6) 2 (9.5) Hypotensive LESa (% of cases) Preop, n (%) Postop, n (%) Abnormal acid refluxb (% of cases) Preop, n (%) Postop, n (%) SSBE short-segment Barrett’s esophagus, CFPG calibrated fundoplication, posterior gastropexy, LSBE long-segment barrett esophagus, FVDGRYGJ fundoplication–vagotomy–distal gastrectomy–Roux-en-Y gastrojejunostomy, LRRYGBP laparoscopic resective Roux-en-Y gastric bypass a a vs b—p=0.7669, a vs c—p=0.0001, b vs c—p=0.0001 b a vs b—p=0.0034, a vs c—p=0.1463, b vs c—p=0.2381 20.7 kg (range, 15 to 25 kg) and the BMI reduction was from 39.5±3.4 to 31.3±2.5 kg/m2. Patients who submitted to LRRYGBP presented a more pronounced reduction of BMI from 41.5±4.3 to 25.7±1.3 kg/m2 after 12 months, and the body weight decrease was more than 42 kg after a 1-year follow-up (p<0.0001). The percentage of excess weight loss (%EWL) was 59.5%±22.9% after CFPG, 82.9±30.4% after FVDGRYGJ, and 91.6±14.4% after LRRYGBP (Table 8). Discussion Obesity is associated with a statistically significant increase in the risk of GERD symptoms, erosive esophagitis, long-segment Barrett’s esophagus, and esophageal carcinoma, which progressively increased parallel to the increase of weight. Among morbidly obese patients, Csendes reported heartburn in 79%, Table 5 Manometric and 24-h pH monitoring values before and after surgery according to the procedure performed in obese patients with SSBE and LSBE CFPG (a) FVDGRYGJ (b) Lower esophageal sphincter pressure (mmHg) Preop, n 79 (9.3±2.7) 39 (7.9±1.4) Postop, n 60 (14.5±1.3) 37 (15.2±3.6) P value 0.0001 0.0001 24-h pH monitoring, % time, pH<4 Preop, n 79 (12.4±6.5) 39 (20.1±2.8) Postop, n 60 (2.1±1.8) 37 (3.9±0.7) P value 0.0001 0.0001 regurgitation in 66%, non-erosive reflux disease in 24%, macroscopic esophagitis in 49%, short-segment Barrett’s esophagus in 18%, and long-segment Barrett’s esophagus in 9% of cases, associated with abnormal acid reflux [2]. The reported incidence of GERD in obese patients varies from 33.5% to 73% for reflux symptoms and 6.4% to 31.4% for erosive esophagitis [1–5, 25–31]. Besides, there is enough evidence concerning the severity of pathophysiological alterations in the LES and esophageal motility in patients with obesity and Barrett’s esophagus [24–34]. Obesity is a predisposing factor for GERD because obese patients have a displaced and hypotensive LES due to increased intra-abdominal pressure. Due to this increased gastroesophageal gradient, hiatal hernia is also more frequent, and the presence of acid and bile content of refluxate material promotes more severe damage at the esophageal mucosa [7, 25–35]. Therefore, it is necessary Table 6 Postoperative complications and mortality CFPG (a) n=79 FVDGRYGJ (b) n=39 LRRYGBP (c) n=21 4 1 1 2 – – 4 (10.3%) 0 – – LRRYGBP (c) 21 (6.4±3.1) 19 (5.9±2.8) 0.3462 21 (17.9±3.8) 19 (2.8±1.5) 0.0001 SSBE short-segment Barrett’s esophagus, CFPG calibrated fundoplication, posterior gastropexy, LSBE long-segment Barrett esophagus, FVDGRYGJ fundoplication–vagotomy–distal gastrectomy–Roux-enY gastrojejunostomy, LRRYGBP laparoscopic resective Roux-en-Y gastric bypass Complications Dysphagia Duodenal leak Diarrhea/dumping Gastric bleeding Hemoperitoneum Total Mortality – – 4 (5.1%) 0 1 1 2 (9.5%) 0 SSBE short-segment Barrett’s esophagus, CFPG calibrated fundoplication, posterior gastropexy, LSBE long-segment Barrett esophagus, FVDGRYGJ fundoplication–vagotomy–distal gastrectomy–Roux-enY gastrojejunostomy, LRRYGBP laparoscopic resective Roux-en-Y gastric bypass 770 OBES SURG (2012) 22:764–772 Table 7 Body weight loss and BMI reduction in obese patients with SSBE or LSBE submitted to different surgical procedures For weight, a vs b, a vs c, and b vs c, all are p=0. 0001; for BMI, a vs b, a vs c and b vs c, all are p=0.0001 Be−Af before–after a Before vs after, all are p≤0.0001 Before surgery Differences (Be−Af) Calibrated fundoplication posterior gastropexy (a) (n=79) Weight 102.3±16.5 89.0±11.3a 14.3±4.4 5.4 ±1.6 BMI 33.2±2.8 28.1±1.7a %EWL Fundoplication—vagotomy—distal gastrectomy—Roux-en Y gastrojejunostomy (b) (n=39) 20.7±6.9 Weight 107.3±11.5 86.3±4.8a 8.4±2.9 BMI 39.5±3.4 31.3±2.4a Laparoscopic resectional Roux-en-Y gastric bypass (c) (n=21) 37.8±5.4 Weight 112±22.9 70.5±7.7a 13.4±2.1 BMI 41.5±4.3 25.7±1.3a to treat these patients with the double purpose of controlling GERD and reducing the obesity parameters. Worse results after fundoplication in LSBEs patients have been recognized in recent literature [17, 32, 33]. It is difficult to perform a good anti-reflux valve in patients with dilated cardia or hiatal hernia, and three times more anatomic failures have been published after fundoplication in LSBE patients compared to non-Barrett patients, demonstrating an abnormal acid reflux in 17% to 60% of cases [35–40]. On the contrary, among patients with LSBE, undergoing acid suppression/duodenal diversion or gastric bypass despite the presence of incompetent LES, acid secretion is significantly reduced and the exposure to acid or bile at the distal esophagus is avoided as has been extensively reported [10, 12–15, 32–35]. Some years ago, during the open era, our group suggested the acid suppression/duodenal diversion procedure as a response to the very disappointing results after fundoplication in LSBE. A large discussion was created concerning this concept, but Csendes et al. reported a large experience in these patients who submitted to this more aggressive surgery, demonstrating very successful clinical results and a significant decrease in the risk of progression of the IM to dysplasia or adenocarcinoma [41–46]. Despite the initial controversy or rejection of this idea by the majority of surgeons dedicated to this subject, in recent years, it has been accepted due to the benefits of a long-term follow-up [47]. Now, in the laparoscopic era, we treat our patients with Table 8 BMI reduction and percentage of excess weight lost after surgery BMI reduction % EWL After surgery CFPG (a) FVDGRYGJ (b) LRRYGBP (c) 5.4±1.6 59.5±22.9 8.4±2.9 82.9±30.4 13.4±2.1 91.6±14.4 a vs b—p=0.000034, a vs c—p=0.0001, b vs c—p=0. 2201 Barrett’s esophagus under the same principles by laparoscopic approach and we have performed acid suppression/ duodenal diversion in a safe way with very low morbidity and no mortality [41, 47]. We have confirmed our hypothesis performing these types of procedure for patients with LSBE in whom not only acid reflux is involved but also bile reflux plays an important role in the pathogenesis of the disease and its complications. [45] This successful procedure for patients with LSBE and its complications (ulcer or stricture) is also followed by reduction of excess body weight and BMI, but it is a more complex procedure compared to LRRYGBP, involving two technical steps: fundoplication plus gastric resection with Roux-en-Y gastrojejunostomy, with the operative time being more prolonged and eventually associated with more intraoperative difficulties and postoperative complications. We have published our first experience employing LRRYGBP and we demonstrated similar results to classic laparoscopic gastric bypass (without resection of the distal segment of stomach) regarding the obesity index. This technique for obese Barrett’s patients appears easier and fast to perform compared to FVDGRYGJ. There are many papers concerning the role of LRYGP in patients with GERD reporting very successful results, but few papers have published experience in Barrett’s patients [19–21, 43, 44, 46–54]. This is the first paper reporting the results observed in obese patients with LSBE, employing fundoplication plus vagotomy, partial gastrectomy with Roux-en-Y gastrojejunostomy, or laparoscopic resectional Roux-en-Y gastric bypass without fundoplication. The latter technique is safe, with a very low rate of complications, and for us it will be the operation of choice for obese patients with LSBE, but for non-obese patients we postulate that the operation of choice is fundoplication+vagotomy+distal gastrectomy, and classic Roux-en-Y gastrojejunostomy because gastric bypass could induce a significant weight loss as well as vitamin and mineral deficiencies. OBES SURG (2012) 22:764–772 The right operation for patients with obesity and LSBE seems to be a gastric bypass which has proven good results in term of obesity control [55]. Therefore, we conclude that in patients with SSBE, CFPG improves GERD disease with regression of intestinal metaplasia but does not induce weight loss after surgery and probably is the procedure of choice for non-obese patients as has been shown before [10]. In patients with LSBE, FVDGRYGJ presents very good results in terms of improving GERD and Barrett’s esophagus, but the reduction of weight is limited, and LRRYGBP improves GERD disease and Barrett’s esophagus with proven reduction in body weight and BMI and is the procedure of choice for obese patients. In the present study, we confirmed the results obtained during the open era and we suggest performing it by laparoscopic approach. Other authors are in agreement with these ideas, also suggesting the same procedure to be performed [54, 55]. Conflicts of Interest All contributing authors declare that they have no conflicts of interest. References 1. Hampel H, Abraham NS, El-Serag HB. 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