The incidence of reflux in obese people is approximately 40-50%. The most common complaint due to reflux in obese patients is chest pain (87%). This is followed by complaints of wheezing (40%), sudden high amounts of saliva (water brush) (18%), laryngitis (17%) and aspiration (14%).
The most common cause of reflux disease is The important factor is transient lower esophageal sphincter relaxation (TLESR). The main factor that causes this is the stimulation of the relevant cells, especially in the dome (fundus) part of the stomach, due to post-meal stretching. Another factor is that this valve loosens when food is swallowed. Especially in obese patients, these valve loosening episodes are experienced more frequently due to excessive increase in intragastric pressure after meals.
One of the factors that cause reflux disease is the movement disorder in the esophagus. Studies show that approximately 40% of obese patients have movement disorders in the esophagus. The most common is nonspecific movement disorder (57%). This is followed by nutcracker esophagus (26%).
The pressure of the lower esophageal valve (LES) is between 10-35 mmHg. Studies show that as body mass index (BMI) increases, the pressure of the lower esophageal valve decreases (<10mmHg). This is one of the factors that predispose to gastric reflux.
The incidence of hiatal hernia in obese patients is much higher than in the normal population. This causes reflux and associated inflammation of the esophagus (esophagitis) in this group of patients. ) increases the incidence.
In patients who have undergone gastric banding, it increases reflux if the band is applied too tightly or if its location is not adjusted well. In bands that are adjusted too tightly or placed too low, the upper stomach or esophagus will expand, which paves the way for reflux.
After sleeve gastrectomy (tube stomach surgery), reflux disease improves with 4 mechanisms:
Decrease in intra-abdominal pressure due to weight loss
Since the stomach fundus (dome) is removed, stomach acid production decreases and reflux decreases
Food leaves the stomach faster
Intragastric pressure is reduced by reducing the stomach volume.
After gastric sleeve surgery, reflux disease may increase or start (de novo) due to various reasons:
If the stomach is made too narrow, the intra-gastric pressure increases and paves the way for reflux ( This is especially felt when the lower gastric valve is closed).
Due to the operation, the loosening of the structures supporting the lower esophageal valve (LES) and disruption of the His angle reduce the pressure there and cause reflux. .
The rotation of the tubulated stomach part around itself increases reflux. (To prevent this, it is necessary to pull the front and back walls equally while separating the stomach).
Regrowth of the dome (fundus) part of the stomach due to insufficient removal also increases reflux.
Failure to notice the hiatal hernia during the pre-operative examinations or during the surgery also increases reflux after the sleeve gastrectomy.
Excessive removal of the lower part of the stomach, called the antrum, paves the way for reflux as it will delay the discharge of food.
During preoperative examinations or surgery, If a stomach hernia (hiatal hernia) is detected during surgery, reflux complaints can be greatly reduced if gastric sleeve surgery is performed along with diaphragm repair. If the part is found to have grown again, re-sleeve can be applied to the patient; However, if the stomach volume and size are found to be normal or a hiatal hernia is detected, it would be more appropriate to apply gastric bypass to this group.
The most appropriate bariatric surgery procedure for morbidly obese patients with severe reflux disease and esophagitis (inflammation of the esophagus) is laparoscopic roux. -en –y bypass (LRYGB). In morbidly obese patients with severe gastric reflux, applying gastric bypass (stomach bypass) to both correct the reflux and prevent obesity-related diseases is more advantageous than the fundoplication operation.
Laparoscopic roux-en-y bypass (LRYGB) increases both stomach volume. It reduces reflux by reducing the amount of food consumed and ensuring rapid passage of nutrients into the small intestine. Since a small volume of stomach remains in gastric bypass, the secreted stomach acid decreases; this one has reflux It provides a positive effect on patients.
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