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Laparoscopic adjustable gastric banded plication for weight loss: The pros and cons

Obesity is a worldwide endemic, defined as a body mass index (BMI) of at least 30 kg/m, with increasing prevalence in recent years with a significant impact on major medical conditions, including metabolic syndrome (MS), acute myocardial infarction, hypertension, sleep apnea, nonalcoholic fatty liver disease, and type II diabetes mellitus. Obesity has been demonstrated to be associated with esophageal diseases such as gastroesophageal reflux disease (GERD) and esophageal motility disorders. Hypotensive lower esophageal sphincter (LES) has been demonstrated in patients with morbid obesity. Despite no obviously linear association between BMI and the development of GERD, greater BMI is in favor of acid reflux. Theoretically, increased abdominal fat is a major pathophysiological factor that increases intragastric pressure and gastroesophageal pressure gradients to increase transient LES relaxations,5–7 which easily exposes esophageal mucosa to acidic refluxate and consequently leads to the development of GERD. Bariatric surgery, resulting in weight loss, is divided into two different categories, restrictive and restrictive-malabsorptive types. Purely restrictive surgery is represented by the laparoscopic adjustable gastric banding (LABG) and the laparoscopic sleeve gastrectomy, which aim to limit total amount of food the stomach can hold and delay gastric emptying. Restrictivemalabsorptive surgery is represented by the Roux-en-Y gastric bypass, which leads to both reduction in the size of the stomach and selective malabsorption as an additional weight loss benefit. Finally, LAGB with gastric plication (LAGBP) is a new restrictive procedure that combines adjustable gastric banding with gastric plication, which has been proved to be a relatively safe and effective bariatric procedure. In this issue of Advanced in Digestive Medicine, Tseng et al have first reported the change in the prevalence of erosive esophagitis (EE) in obese patients undergoing LAGBP with an approximately follow up of 1 year. They retrospectively reviewed medical records of obese patients undergoing LAGBP who had upper gastrointestinal (GI) endoscopy both preoperatively and at least 12 months postoperatively in association with their clinical characteristics, such as BMI, waist circumference (WC), and MS. Not surprisingly, although their patients had a significant improvement in all clinical characteristics (BMI, WC, and MS) 12 months after the surgery, they did find that the prevalence of EE significantly increased from 20% to 45% and also observed a de novo increase in EE at a prevalence of 44%. They concluded that the prevalence of EE significantly increased in obese patients after LAGBP. Finally, they recommended the necessity of upper GI endoscopy preoperatively, and perhaps postoperatively, in patients intending on undergoing LAGBP to minimize the risk of developing EE after the bariatric procedure. Although no studies have been reported the unintended impact of LAGBP on GERD, earlier studies with LABG could shed some light by demonstrating that there is a significant increase in GERD following such a procedure either in patients with preoperative GERD symptoms or those without any of GERD symptoms. However, other studies reported contradictory results because of various durations of follow up after LABG. Moreover, several motility alterations have been reported, including ineffective esophageal motility, aperistalsis, and incomplete LES relaxation in patients undergoing LABG. The mechanisms contributing to GERD after LABG or LAGBP is potentially due to the fact that the progressive filling of the band overtime may contribute to stasis in the pouch, and relative obstruction of the band can cause acid regurgitation. Furthermore, LAGBP or LABG also results in esophageal dysfunction and other complications, such as band slippage and erosions. One of the major limitations of this study is that there is weak evidence regarding how and when the diagnosis of GERD is made. Without optimal diagnosis of GERD, the current data need to be interpreted carefully, especially for their clinical implication. In this study, no reflux testing was performed to achieve a comprehensive diagnosis of GERD as most GERD patients appear to have normal upper endoscopy. Therefore, the results may be underestimated as only patients with EE were documented, although EE may represent a subset of patients with GERD. Furthermore, because of the retrospective design in this study, it is probably impossible to evaluate the true prevalence of EE or GERD in all subjects before and perhaps 1 year after LAGBP in order to test their hypothesis of the change in the prevalence of EE 1 year after this procedure. Finally, it may be of great interest to explore any of the clinical characteristics, as well as physiological parameters, using novel esophageal testing Received: 14 March 2019 Accepted: 24 March 2019