Weight-reduction surgery effective, but may worsen acid reflux

The two most popular types of weight-reduction surgery are almost equally effective at shedding pounds, reversing diabetes and possibly improving survival.

But for people who also suffer from the heartburn and choking acid of gastroesophageal reflux disease, the most popular form of bariatric surgery can make their symptoms even worse, according to two new studies in the Journal of the American Medical Association.

Both studies are among the few that have followed patients for 5 years. They looked at sleeve gastrectomy, the newer and more-popular operation, where surgeons remove part of the stomach - particularly the top - to narrow it, and Roux-en-Y gastric bypass, in which the stomach is replaced with a small pouch and the upper part of the small intestine is bypassed.

In recent years, doctors have been favoring the newer sleeve procedure because it is easier to perform. But there has been no clear evidence that it is as good or better.

The new data suggest that “both procedures are excellent options for surgeons and patients to consider in the treatment of obesity,” said Dr. David Arterburn of the University of Washington in Seattle and Dr. Anirban Gupta of the Washington Permanente Medical Group, also in Seattle, in an editorial in the Journal.

“Although bariatric surgery may improve mortality, the effect is small, whereas the effect on remission of type 2 diabetes is substantial,” said Dr. Edward Livingston, a deputy editor for JAMA. “The benefits of weight loss surgery on other obesity-related comorbidities are less clear.”

The studies are part of a package of reports on weight loss published at a time when the obesity epidemic is getting worse and attempts to reverse the trend are being met with limited success.

Weight-loss surgery is an option for the most severely obese, when the body-mass index (a ratio of weight to height) is 40 or higher, or above 35 in people with serious weight-related problems. For someone who is 5‘5” (165 cm), that would equate to a weight of at least 240 pounds (109 kg) in the first instance and 210 pounds (95 kg) in the second.

The first study, known as SM-BOSS, looked at 217 Swiss patients and found that people who got the sleeve procedure lost 25.0 percent of their excess weight while volunteers who got the more radical operation lost 28.6 percent, a difference that was not statistically significant. Improvements in diabetes, high blood pressure and cholesterol levels were similar in the two groups.

But 31.8 percent of the people who received the sleeve procedure saw their acid reflux symptoms increase compared to just 6.3 percent of those getting the older bypass procedure, said the team, led by Dr. Ralph Peterli of St. Claraspital in Basel, Switzerland. Symptoms improved in 25.0 percent with sleeve surgery versus 60.4 percent with gastric bypass.

Reoperations were more common with bypass.

“We have always paid attention to gastroesophageal reflux (GERD) when advising patients as to which operation they should get,” Dr. Peterli told Reuters Health by email. “As a result of the study, we tell them that every third patient not suffering from GERD before surgery may end up experiencing some degree of it in the long run.”

The second study, called SLEEVEPASS, involved 240 obese people in Finland. It found that the sleeve surgery wasn’t quite as effective as bypass. Those patients dropped 49 percent of their excess weight compared to 57 percent with gastric bypass.

Gastric bypass also produced less need for high blood pressure medicines by the 5-year mark. Both surgeries produced comparable improvements in diabetes and cholesterol.

“Both sleeve gastrectomy and gastric bypass were effective in weight loss and resolution of obesity related comorbidities,” chief author Dr. Paulina Salminen of Turku University Hospital told Reuters Health in an email. “Based on our results, it is still too early to state a clinical paradigm for choosing the most optimal bariatric procedure for each individual patient, but hopefully this could be achieved by combining data with other trials.”

But reflux could be a big factor in deciding on the type of surgery because 51 percent of people with severe obesity have the stomach condition. Sleeve surgery made reflux symptoms worse in 31.8 percent of patients, compared to just 6.3 percent of those who had Roux-en-Y bypass.

“This is a major factor that needs to be taken into account, as gastric bypass should be the primary option for patients with moderate or severe reflux,” Dr. Salminen said.

After 4.3 years, death rates were 2.3 percent for obese people who didn’t have the surgery, versus 1.3 percent for those who did.

One unanswered question, said Drs. Arterburn and Gupta, revolves around understanding whether patients who don’t lose enough weight should undergo another operation. Patients who undergo the sleeve procedure are at a greater risk for insufficient weight loss.