Gastroesophageal reflux disease (GERD) is a prevalent condition, especially in Western countries, affecting a significant portion of the population. Laparoscopic Nissen Fundoplication (LNF) has become a standard surgical approach for treating severe GERD. While LNF is primarily aimed at alleviating reflux symptoms, its effect on body weight has been a subject of interest. This article explores the relationship between LNF and weight loss, considering factors like patient BMI and surgical outcomes.
Understanding GERD and LNF
GERD, recognized since the mid-1930s, is characterized by the frequent occurrence of heartburn and acid regurgitation. The availability of laparoscopic antireflux surgery (LARS) has broadened the options for patients seeking relief. LNF involves wrapping the upper part of the stomach (fundus) around the lower part of the esophagus, reinforcing the lower esophageal sphincter (LES) to prevent stomach acid from flowing back into the esophagus.
Obesity and GERD: A Complex Relationship
Obesity is recognized as a significant risk factor for developing GERD. The prevalence of GERD tends to increase with higher body mass index (BMI). However, the impact of obesity on the outcomes of LNF has been a topic of debate, with some studies suggesting poorer results in obese patients.
Investigating the Impact of LNF on Weight Loss
Several studies have explored the potential for weight loss following LNF. One study, conducted between July 2000 and March 2003, involved 213 patients undergoing LNF. The results indicated a significant decrease in mean BMI after LNF, with an average body weight loss of 3.9 kg. Interestingly, the BMI reduction was more pronounced in women and obese patients.
Another study retrospectively analyzed data collected prospectively from April 1994 to October 2016, focusing on the long-term efficacy of LNF in controlling reflux in relation to BMI. The study included 201 patients who underwent LNF with at least 11-year follow-up data available and preoperative weight and height data for BMI calculation. Patients were categorized into normal weight, overweight, and obese groups based on WHO classification.
Read also: Fundoplication Diet Guidelines
Study Design and Patient Selection
The retrospective study included patients who underwent LNF with at least 11 years of follow-up data and had preoperative weight and height information available for BMI calculation. Patients with a BMI greater than 35 with obesity-related comorbidities were considered candidates for bariatric surgery instead of LNF and were excluded from the study.
All patients with suspected GERD underwent comprehensive evaluations, including upper alimentary endoscopy, esophagogram, stationary esophageal high-resolution manometry, ambulatory 24-hour pH-impedance testing of the esophagus, and upper abdominal ultrasound. Indications for surgery included failed medical management, patient preference for surgery despite successful medical management, GERD complications, and extraesophageal manifestations.
Surgical Technique and Postoperative Care
All LNF procedures were performed by a single surgeon. The modified LNF involved creating a floppy 360° posterior wrap with circumferential dissection and mobilization of the esophagus without routine division of the short gastric vessels. Posterior hiatal repair was performed selectively in patients with hiatal hernias, using mesh in some cases. The use of drains was determined by the surgeon's discretion.
Postoperatively, patients were evaluated at 1 week and 3 months, and then yearly. Gastroscopy and pH metry were performed in all patients, regardless of symptoms. Data collected included patient age, type of fundoplication, operation duration, conversion to open procedure, intra- and early postoperative complications, late outcomes, and reasons for revisional surgery.
Study Results: BMI and Surgical Outcomes
The duration of the operation was significantly longer in obese patients, and the use of drains and grafts for hiatal hernia repair was less frequent in the normal BMI group. The higher number of grafts used in higher-BMI patients can be explained by the significantly higher number of hiatal hernias in overweight and obese patients. Conversion to an open surgical operation was not influenced by preoperative weight.
Read also: Nissen Fundoplication vs. Toupet for Acid Reflux
Intraoperative and early postoperative complication rates were similar across the BMI groups. Dysphagia was reported by some patients initially, but it generally resolved over time. The rate of bloating was evenly distributed among the groups.
Long-Term Outcomes and Recurrence Rates
During the 16-year mean follow-up, pH metry-proven reflux recurrence occurred in 27 patients, resulting in an overall recurrence rate of 13.4%. A notable correlation was observed between recurrence rate and BMI, with a higher failure rate in obese patients compared to normal weight and overweight individuals. Insufficiency of the fundoplication was diagnosed in four patients, who underwent reoperation.
Impact of BMI on LNF Outcomes: A Closer Look
The study revealed that increased BMI was associated with a slight increase in age, duration of symptoms, erosive nature of the disease, and Barrett's metaplasia, although these differences were not statistically significant. The rate of hiatal hernia was higher in patients with increased BMI, and the difference was statistically significant.
Consistent with previous studies, longer operating times were observed for LARS in obese subjects. The increased difficulty in performing LNF in obese patients was evident in the longer operating times, higher rate of hiatal hernia, and graft and drain usage. This difficulty led to conversion to open laparotomy in a higher percentage of obese patients compared to normal weight and overweight groups.
LNF vs. Laparoscopic Splenectomy: Investigating the Mechanism of Weight Loss
To understand the mechanism behind weight loss after LNF, a study compared the weight loss effect of LNF and laparoscopic splenectomy (LSP). LNF involves mechanical manipulation of the gastric fundus and ligation of the short gastric vessels, while LSP only involves ligation of the short gastric vessels. The study found that LNF, but not LSP, resulted in long-term weight loss, suggesting that the weight loss after LNF is related to the manipulation of the gastric fundus rather than the ligation of the short gastrics.
Read also: Weight Loss Guide Andalusia, AL
The Patient Experience: Preparing for and Recovering from LNF
Patients undergoing LNF typically undergo preoperative tests to check for esophageal narrowing and hiatal hernias. They are advised to refrain from eating or drinking after midnight on the day of surgery.
The surgery can be performed through open or laparoscopic approaches. Laparoscopic surgery involves smaller incisions and a quicker recovery time. Post-surgery, patients may experience side effects such as difficulty swallowing, discomfort at the surgical site, abdominal bloating, and nausea. Following the doctor's instructions for home care, including dietary modifications and avoiding irritating foods, can help minimize these issues.
Fundoplication and Hiatal Hernia Repair
If you have a hiatal hernia, you know how painful and difficult this condition can be. Managing hiatal hernias through dietary and lifestyle changes is the preferred treatment approach. However, some people require surgery in severe cases. While it can help reduce pain and discomfort, this type of procedure can have some short-term side effects. Weight loss after hiatal hernia surgery is one of the most common.
Weight Loss After Hiatal Hernia Surgery
Why can you expect to drop a little weight after this type of surgery? The condition directly affects your digestive system, so recovery often requires dietary modifications. Immediately after the procedure, patients may not eat or drink until a specialist verifies their ability to swallow safely. Then patients start on a liquid diet to minimize pressure and discomfort at the surgical site. It can take days to progress to soft foods and more to return to a normal diet. This way of eating is out of the norm for most patients, so it is common to gradually lose a few pounds in the meantime. In addition, the procedure may reduce the size of the stomach. This means you may feel satisfied with less food than before, which can also lead to gradual weight loss with time.
The Connection Between Hiatal Hernias and Weight Loss
Doctors often recommend a plan to safely shed extra pounds to overweight hiatal hernia patients. This is true both before and after surgery. Pre-Surgery Because surgery is a last resort for any condition, it’s important to try other less invasive interventions first. For those who are obese, weight loss can significantly improve and even resolve hiatal hernias altogether. Without the extra pressure from fatty tissue surrounding the stomach, the digestive system can rest naturally in place and function more efficiently. The result is often a reduction in painful symptoms. Even if weight loss alone is not enough to manage hiatal hernia symptoms, your doctor may still recommend it if you are overweight. Not only can it improve your overall health, but it can help reduce your risks of developing another hiatal hernia in the future.
Post-Surgery The body’s response to surgery, an expected loss of appetite, and dietary restrictions can all lead to weight loss after hiatal hernia surgery. Dropping a few pounds over the course of a few weeks is normal for most patients. Most people can expect to gain this back within the next few months as more normal eating habits resume. If your stomach lost any of its capacity during the procedure, you may lose weight and keep it off. Some patients have hiatal hernia repairs and bariatric surgery simultaneously. This combination of procedures can lead to continued weight loss over time. While all of these situations are normal, rapid weight loss after surgery is not. If you find yourself losing more than two pounds per week, talk with your doctor.
The Role of Gastric Bypass in Obese Patients with GERD
When surgical treatment of GERD is indicated in a morbidly obese patient, laparoscopic Roux-en-Y gastric bypass surgery, rather than fundoplication should be strongly considered. Gastric bypass surgery not only better address the mechanisms that lead to GERD in morbidly obese patients with high efficacy and durability, but it also addresses the obesity-related comorbidities by achieving significant and sustained weight loss. After gastric bypass surgery, patients can have durable relief of reflux symptoms, improved quality of life and reduced long-term mortality due to improvement or resolution of obesity related comorbidities. For those patients who failed previously anti-reflux surgery, laparoscopic Roux-en-Y gastric bypass has also been reported to be effective in controlling reflux symptoms.
tags: #laparoscopic #nissen #fundoplication #weight #loss