Expert: John Pilcher, MD - 1/25/2010

Question
Hi.  My mother is a 60 year old black female that is 5 feet tall and weighs 265.  She has severe osteoarthritis in both knees and has had for 6 or more years.  She has very little range of motion in her knees, and she doesn't really attempt to bend at the knee due to the pain and because she is flexible enough to bend and touch the floor from the waist.  She takes 2 aleve 2 times a day to take the edge off the pain daily, and occasionally uses a cane.  She occasionally also uses the motorized carts in stores. She also has type 2 diabetes (oral medications only) and high blood pressure (2 diuretics %26 1 calcium channel blocker).

She has had 3 abdominal sx - one for removal of an ovary and tube - due to a ovarian cyst and another for a c-section. She has a hx of an esophageal ring which was treated with an endoscopic procedure where they 'popped' the excess the skin, but was told that it might come back.  She has periodic GERD type symptoms when eating spicy food and if she eats too fast (excessive belching) mostly.  

Anyway, 6 years ago when she saw the knee specialist, he said that he recommended gastric by-pass, before a knee replacement sx. I don't believe he knew of her GI hx. Question 1 - would Gastric Bypass and Lap-band be counter-indicated since she has the GI problems?  

She can and does lose weight when she does Chair-dancing and things, but the last attempts she made resulted in severe cramping of the quads.  

I hope the data wasn't too much.  Thank you so much for taking the time to answer my question.

Christine (a fellow expert on this site)  

Answer
Christine,
Thanks for writing and no, the data was not too extensive.  :)

You are correct that the presence of reflux and a history of esophageal ring can affect choices around a bariatric surgical procedure.  In my opinion, a history of esophageal issues is a contra-indication for Band surgery, since the Band does not reduce reflux and the Band does put a mild steady strain on the esophagus.

On the other hand, the gastric bypass is a very good procedure in a situation like that you've described for your Mom.  Since the gastric bypass separates the acid-producing part of the stomach from the esophagus where the acid can cause damage, the gastric bypass helps with reflux almost immediately.  Also, the gastric bypass does not cause any resistance to emptying from the esophagus so it is a good choice in the context of a prior esophageal ring.

In your research, you may also run across the gastric sleeve.  This is a good operation overall but it has uncertain benefit in the context of reflux so I would tend not to recommend it in your Mom's case.

In summary, I think it would be very reasonable for her to visit with an experienced bariatric surgeon in her area, and I expect that surgeon will agree that gastric bypass is a reasonable consideration.  Bariatric surgical Centers of Excellence may be found at:
http://www.surgicalreview.org/locate.aspx

Best wishes!

Dr JP