Laparoscopic Nissen fundoplication with gastric plication as a potential treatment of morbidly obese patients with GERD, first experience and results. Obes Surg. 2014;24:1447-1452. [PMID: 24610517 DOI: 10.1007/s11695-014-1223-0]

Potential therapies for obesity management: Exploring novel frontiers

Humans are becoming less active in the current age of technological advancement, which leads to poor health. Many factors, including unregulated diet, lack of exercise, environmental pollution and genetic factors are contributing to an increase in overweight. Obesity is a chronic condition that disturbs the physical health of a person, resulting in various other complications including cardiac, respiratory, and psychosocial issues. According to WHO, the current trend of obesity has shown a sharp increase in recent years. Methods ranging from as simple as regulating the diet to as complex as surgery are available. There are many approved drugs to treat the obesity majority of them works as suppressing the appetite and making the patient satisfy. Some of other agents works by insulinotropic activity. However, these agents need to be taken for longer period of time thus are associated with significant adverse drug reactions. Thus, the motive of this study is to understand obesity and the various methods available to manage it using the recent pharmacological and non-pharmacological approaches.

Sleeve gastrectomy with one anastomosis bipartition versus one anastomosis gastric bypass: A pilot study

BACKGROUND

One anastomosis gastric bypass (OAGB) is a new recognized metabolic surgery, but the problem that we cannot screen the excluded stomach is a troubling issue in China. The emergence of sleeve gastrectomy plus one anastomosis bipartition (SG + OAB) makes us see a hope to solve this problem.

OBJECTIVES

By comparing the efficacy of the two surgical methods, to evaluate whether SG + OAB surgery can solve the dilemma faced by OAGB that the excluded stomach cannot be screened.

METHODS

A retrospective study to compare the patients who underwent OAGB and SG + OAB was conducted. The main outcome measures were (1) operation risk, (2) weight loss, and (3) diabetes remission at 6 months.

RESULTS

This study was conducted in the bariatric/metabolic surgical center. From November 2021 to February 2022, a total of 30 patients with obesity who received SG + OAB surgery were recruited. Another matched 60 patients undergoing OAGB were recruited as control group. There was no difference in preoperative age (32.15 ± 9.02 vs. 34.47 ± 7.22; p = .224), female ratio (83% vs. 85%; p = .837), and BMI (36.18 ± 5.30 vs. 34.68 ± 5.58; p = .217) between the two groups. OAGB had a shorter mean operation time (121.67 ± 20.41 vs. 143.50 ± 25.07 min; p < .001) and a lower intraoperative blood loss (21.92 ± 12.35 vs. 32.43 ± 22.01 mL; p = .005), but a longer postoperative flatus passage (2.13 ± 0.43 vs. 1.87 ± 0.43 days; p = .007) compared with the SG + OAB group. Two patients (6.7%) developed major surgical complication in SG + OAB group but no major complication developed in OAGB group. At 6 months after surgery, SG + OAB had a higher %total weight loss than OAGB (31.05 ± 3.12 vs. 28.14 ± 5.43%; p = .015), but diabetes remission rate was similarly high in both groups.

CONCLUSIONS

SG + OAB operation had a non-inferior or even better weight loss than OAGB, with a similar glycemic control efficacy. However, the high complication rate of SG + OAB is the major drawback that needs attention.

Anti-reflux surgery vs. bariatric surgery as anti-GERD and hiatal hernia treatment in obese patient. New surgical proposals

The persistence of obesity favors the failure of the Fundoplication (FP) in the treatment of Gastroesophageal Reflux (GER). However, the weight loss obtained with the performance of a Gastric Bypass (GBP) allows a good resolution of symptoms, without increasing the incidence of postoperative complications. All of this leads us to consider that while FP is the indication in patients with BMI < 30, in those patients with BMI > 35, GBP appears to be the procedure of choice. But there is still no position in the case of patients with a BMI between 30 and 35, although we must take into account that an increase in GER recurrence has been described after FP in patients with a BMI > 30. Although Sleeve Gastrectomy (SG) is one of the most frequently used bariatric procedures in recent years, its association with a high rate of postoperative GER has led several authors to propose its performance associated with an anti-reflux procedure in patients with GER symptoms. Likewise, if the existence of an Hiatal Hernia is verified, it must be treated by hiatoplasty, both during the performance of a GBP and a SG. This simultaneous treatment is not associated with an increase in complications.

GASTRIC PLICATION ASSOCIATED WITH FUNDOPLICATION IN INDIVIDUALS WITH CLASS I OBESITY AND GASTROESOPHAGEAL REFLUX DISEASE: WEIGHT LOSS OUTCOMES, REFLUX-RELATED SYMPTOMS, ENDOSCOPIC AND pH MONITORING FINDINGS

BACKGROUND

The association of gastric plication with fundoplication is a reliable option for the treatment of individuals with obesity associated with gastroesophageal reflux disease.

AIMS

To describe weight loss, endoscopic, and gastroesophageal reflux disease-related outcomes of gastric plication with fundoplication in individuals with mild obesity.

METHODS

A retrospective cohort study was carried out, enrolling individuals who underwent gastric plication with fundoplication at a tertiary private hospital from 2015-2019. Data regarding perioperative and weight loss outcomes, endoscopic and 24-hour pH monitoring findings, and gastroesophageal reflux disease-related symptoms were analyzed.

RESULTS

Of 98 individuals, 90.2% were female. The median age was 40.4 years (IQR 32.1-47.8). The median body mass index decreased from 32 kg/m2 (IQR 30,5-34) to 29.5 kg/m2 (IQR 26.7-33.9) at 1-2 years (p<0.05); and to 27.4 kg/m2 (IQR 24.1-30.6) at 2-4 years (p=0.059). The median percentage of total weight loss at 1-2 years was 7.8% (IQR -4.1-14.7) and at 2-4 years, it was 16.4% (IQR 4.3-24.1). Both esophageal and extra-esophageal symptoms showed a significant reduction (p<0.05). A significant decrease in the occurrence of esophagitis was observed (p<0.01). The median DeMeester score decreased from 30 (IQR 15.1-48.4) to 1.9 (IQR 0.93-5.4) (p<0.0001).

CONCLUSIONS

The gastric plication with fundoplication proved to be an effective and safe technique, leading to a significant and sustained weight loss in addition to endoscopic and clinical improvement of gastroesophageal reflux disease.

Innovative Bariatric Procedures and Ethics in Bariatric Surgery: the IFSO Position Statement

With the rise in obesity and bariatric procedures worldwide, there has been a surge in new and innovative procedures that has been increasingly offered to patients. In this position statement, IFSO highlights the importance of surgical ethics in innovation and when offering new procedures. Furthermore, the task force reviewed the current literature to describe which procedures can be offered as mainstream outside research protocols versus those that are still investigational and need further data.

Roux-en-Y Gastro-jejunostomy for Complex Leak After the "Nissen" Variant of Sleeve Gastrectomy

BACKGROUND

Recently, improvised variants of sleeve gastrectomy SG were reported as alternative bariatric options in patients suffering from both morbid obesity and GERD, including mainly additional anterior or posterior fundoplication over a partially sleeved stomach.

METHODS

We present the case of a 29-year-old male patient with a body mass index (BMI) of 46.2 kg/m2 underwent laparoscopic SG with concomitant posterior fundoplication: Nissen-SG (N-SG). At postoperative day (POD) 4, he presented with epigastric pain, nausea, and 40 °C fever. The abdomen was tender with signs of peritonitis. Explorative laparotomy displayed a massive gastric leak with generalized peritonitis. Peritoneal lavage was performed. the patient was transferred to our department for the management of persistent SGL.

RESULTS

Initial management comprised total parenteral nutrition and wide-spectrum intravenous antibiotics. Three weeks later, the patient underwent laparoscopic exploration. As shown in the video, at least two leaks were individualized, including one, anterior, catheterized by the pigtails, and the other one, posterior, impossible to reach endoscopically (Fig. 1). A residual abscess, located between the left crus, the pancreas, and the upper edge of the spleen, was evacuated. Eventually, Roux-en-Y gastro-jejunostomy was performed CONCLUSION: The adjunction of a posterior fundoplication may have contributed to the multiple and complex occurrence of SGL. Having an ill-vascularized redundant fundus may have increased ischemia of the GE junction. Moreover, it is more difficult to perform endoscopic treatment in a plicated and sleeved stomach as well.

Unusual complication after laparoscopic Nissen fundoplication

We describe a rare complication of Laparoscopic Nissen Fundoplication in the presence of a Gastric greater curvature Plication (LNFGP). An overweight 64-year-old woman was admitted for severe abdominal pain, dysphagia and fever 2 weeks after a Nissen fundoplication. She had pneumoperitoneum on scanner. At laparoscopy, we found a generalized peritonitis secondary to a perforated Nissen wrap in the presence of a gastric greater curvature plication. Gastric bypass and sleeve gastrectomy can be irrelevant in case of moderately and severely obese patients with gastroesophageal reflux disease. Four studies have investigated the risks and rewards of the LNFGP as an alternative. Only one case of leakage has been reported. We present another severe complication: the pylorus stenosis caused by a plication performed too close to the pylorus, causing gastric dilatation in the presence of the wrap, leading to wrap perforation.

Twenty years' experience of laparoscopic 1-anastomosis gastric bypass: surgical risk and long-term results

BACKGROUND

Laparoscopic 1- (single-) anastomosis gastric bypass (OAGB) was developed as a simplified technique of Roux-en-Y gastric bypass (RYGB), but super long-term data are lacking.

OBJECTIVES

To evaluate the risks and long-term results of OAGB over a period of 20 years.

SETTING

Tertiary teaching hospital.

METHODS

A total of 2223 patients underwent OAGB from 2001 to 2020; the mean age was 35.3 ± 11.4 years (range, 14-71 yr), 70.2% were female, and the mean body mass index was 40.2 ± 11.9 kg/m². All data were kept in a prospective bariatric database. Patients were divided into 4 groups, based on the 5-year period in which their surgery was performed, and a retrospective analysis was conducted.

RESULTS

The means for operating time, intraoperative blood loss, and length of hospital stay after OAGB were 131.9 ± 40.1 minutes, 38.5 ± 30.7 mL, and 4.5 ± 4.0 days, respectively. There were 27 patients (1.2%) with 30-day postoperative major complications overall, but the group rate decreased to .4% in the last 5-year period. At postoperative years 5, 10, and 15, the percentages of total weight loss were 31.9%, 29.6%, and 29.5%, respectively, and the percentages of excess weight loss were 77.2%, 68.4%, and 65.5%, respectively. Among 739 patients (33.2%) with type 2 diabetes (T2D), the rates of complete remission (glycated hemoglobin < 60%) at 5, 10, and 15 years were 67.3%, 73.8%, and 66.7%, respectively. The weight loss and antimetabolic effects were similar in each 5-year period, but a significant malnutrition effect was observed. A total of 113 (5.1%) patients needed revision surgery at follow-up, due to malnutrition (n = 51), weight regain (n = 24), acid or bile reflux (n = 22), marginal ulcer (n = 8), ileus (n = 3), and other causes (n = 5). At 15 years, the overall revision rate was 11.9% (27/226), and 80% of the patients were very satisfied with their procedures.

CONCLUSION

Our results showed that OAGB is a safe and durable primary bariatric procedure, with sustained weight loss and a high resolution of T2D up to 20 years post surgery in Taiwan, although malnutrition is a major side effect.

Gastroesophageal Reflux and Laparoscopic Sleeve Gastrectomy: Results of the First International Consensus Conference

BACKGROUND

Gastroesophageal reflux disease (GERD) is probably the main drawback of laparoscopic sleeve gastrectomy (LSG). Herein, we critically discuss the issue and report the results of the first international consensus conference held in Montpellier, France, during June 2019.

METHODS

Fifty international bariatric experts from 25 countries convened for 2 days for interactive discussions, and to formulate the most relevant questions by electronically submitting 55 preliminary questions to panelists. Following the meeting, a final drafted questionnaire comprised of 41 questions was sent to all experts via e-mail.

RESULTS

Forty-six experts responded (92%). Esophago-gastro-duodenoscopy was considered mandatory before (92%) and after (78%) surgery. No consensus was achieved as to time intervals after surgery and the role of specialized tests for GERD. Higher degrees of erosive esophagitis (94%) and Barrett's esophagus (96%) were viewed as contra-indications for LSG. Roux-en-Y gastric bypass was recommended in postoperative patients with uncontrolled GERD and insufficient (84%) or sufficient (76%) weight loss and Barrett's esophagus (78%). Hiatal hernia (HH) repair was deemed necessary even in asymptomatic patients without GERD (80% for large and 67% for small HH). LSG with fundoplication in patients with GERD was considered by 77.3% of panelists.

CONCLUSIONS

The importance of pre- and postoperative endoscopy has been emphasized. The role of specialized tests for GERD and the exact surveillance programs need to be further defined. LSG is viewed as contra-indicated in higher degrees of endoscopic and clinical GERD. LSG with anti-reflux fundoplication emerges as a new valid option in patients with GERD.

Chronic Fistula Post Laparoscopic Nissen Sleeve Gastrectomy: Conversion to Roux-en-Y Gastric Bypass

BACKGROUND

Sleeve gastrectomy (SG) is the most frequently performed bariatric intervention worldwide, and obese patients have a higher risk of developing reflux symptoms compared with the general population [1, 2]. One of the controversies of SG is to perform it in patients with gastroesophageal reflux disease (GERD). Some studies have shown that SG may exacerbate GERD symptoms or even increase the risk of "de novo" postoperative GERD [3, 4]. Laparoscopic Nissen fundoplication is an effective treatment for patients with severe GERD. In order to avoid the Roux-en-Y gastric bypass (RYGB), some authors combined the SG with the Nissen fundoplication in morbid obese patients with GERD [5]. As after SG, postoperative gastric fistula may occur after Nissen SG. Persistent fistula after Nissen SG may be treated by conversion to RYGB.

METHODS

We present the case of a 35-year-old woman with long-standing morbid obesity, who presented to our institution seeking management options for her postoperative fistula. In August 2018, she underwent a laparoscopic Nissen SG in another institution. Her initial weight was 107 kg, height 172 cm, and body mass index (BMI) 36.27 kg/m². At the 7th postoperative day, she complained of severe abdominal pain and fever. A computed tomography (CT) scan was performed showing a massive supra-mesocolic pneumoperitoneum. An explorative laparoscopy was performed with evidence of a generalized peritonitis without identification of the orifice of the leak. Peritoneal lavage of the abdominal cavity was done and the patient was transferred to our institution. An upper gastrointestinal endoscopy was performed with evidence of a fistula on the gastric longitudinal staple line (8 mm in diameter), and a stenosis of about 15 mm on the distal gastric tube. A double pig-tail was placed. After 14 days, the patient underwent a gastric pneumatic dilatation of the stenosis placed at the antro-fundic region, without complications. Three months later, the fistula was persistent; therefore, after a careful nutritional and psychological evaluation and discussion with the patient, we decided to perform a conversion to a RYGB. The valve of the Nissen fundoplication was identified and divided using a stapler. The orifice of the fistula was identified. Resection of this valve, including the orifice of the fistula and the gastric tube, was done using a blue-load stapler ECHELON FLEX™ GST (Ethicon Endo-Surgery, USA) while creating the new gastric pouch. Then, we performed a Roux-en-Y gastric bypass with a 150-cm alimentary limb and a 50-cm biliary limb. The Petersen and the mesenteric defects were closed.

RESULTS

The blood loss was less than 100 cc and the operative time was 240 min. The postoperative period was smooth and uneventful; the patient was started on liquid diet on the second postoperative day and discharged at day 8. At 1 month postoperatively, the patient has lost 16 kg and the %EWL was 36.53%, %TWL 14.95% with a BMI of 30.84 kg/m². At 6 months postoperatively, the patient lost 24 kg, with a BMI at 26 kg/m². She does not complain of GERD, no vomiting, no abdominal pain, and no diarrhea.

CONCLUSIONS

In cases of fistulas after Nissen SG, the surgery becomes more tedious and difficult. Conversion to RYGB seems a feasible and effective option to treat chronic fistula after Nissen SG.

Modified laparoscopic sleeve gastrectomy with Rossetti antireflux fundoplication: results after 220 procedures with 24-month follow-up

BACKGROUND

Gastroesophageal reflux disease (GERD), including erosive esophagitis, is highly prevalent in the obese population. Laparoscopic sleeve gastrectomy (LSG) is one of the most frequently performed bariatric procedures. The relationship between LSG and GERD has gained increasing attention. This retrospective study aimed to assess the effectiveness of combined LSG and modified Rossetti antireflux fundoplication for the treatment of GERD on morbidly obese patients after bariatric surgery.

OBJECTIVES

To assess the effectiveness, on morbid obese patients, of combined SG and Rossetti fundoplication for the treatment of GERD in obese patients.

SETTING

Public Hospital, Italy.

METHODS

From January 2015 to May 2018, 220 obese patients (167 female; 53 male) underwent LSG and modified Rossetti antireflux fundoplication procedure, performed by 4 different expert bariatric surgeons. Data have been collected in an Excel file and processed by XLStat to perform statistical analyses. We analyzed short-term complications and medium-term results with 24-month follow-up in terms of weight loss, remission of co-morbidities, and resolution of GERD.

RESULTS

Mean BMI was 42.58 ± 5.93 kg/m² (range, 31.70-63.16). Patients suffering from GERD before surgery were 137 of 220 (62.3%). No intraoperative complications or conversion were reported. Regular postoperative course was recorded in 90% of patients (198 of 220 patients). Gastric perforation has always occurred on the fundoplicated portion of the stomach. This perforation, which is different from the well-known post-LSG gastric fistula, may be because of incorrect gastric fundus manipulation. Rate of reoperation was 14 of 220 (6.4%). A good sense of repletion without episodes of vomiting, nausea, or dysphagia was reported in 95% of the analyzed patients. Of patients, 98.5% did not suffer from reflux symptoms and did not take proton pump inhibitors. A decrease in BMI and percent of total weight loss at follow-up were comparable with LSG. Endoscopic follow-up is still ongoing. Improvement in esophagitis was observed in 63 of 65 (96.92%) patients and all 4 patients shows improvement in Barrett's esophagus.

CONCLUSIONS

LSG and modified Rossetti antireflux fundoplication procedure is a tolerated and feasible procedure in obese patients, with good postoperative weight loss results and improvement in GERD.

Surgical strategy for gastroesophageal reflux disease in patients with obesity

Gastroesophageal reflux disease (GERD) and obesity have become serious problems affecting global health. The surgical treatment strategy for GERD patients with obesity is still a difficult point. In particular, obesity exacerbates the occurrence of GERD, and simple anti-reflux surgery has limited efficacy in obese patients. Currently, bariatric surgery is a good choice for the treatment of such patients, and Roux-en-Y gastric bypass is the best choice. Revisional surgery remains to be standardized for serious complications in postoperative patients. In addition, the new anti-reflux bariatric surgery that has been emerging in recent years is expected to be an effective alternative treatment for GERD patients with obesity.

Nissen Fundoplication–Preserving Laparoscopic Sleeve Gastrectomy

Gastroesophageal reflux disease (GERD) is significantly more prevalent in obese patients. Nissen fundoplication alleviates symptoms in those refractory to dietary changes and optimal medical management. The need for concomitant treatment of GERD and obesity is becoming more prevalent. The objective of this study was to determine whether Nissen-preserving laparoscopic sleeve gastrectomy (SG) is a safe and effective weight loss option for patients with pre-existing Nissen fundoplication. The study was conducted at the Hospital Corporation of America, Memorial Health, Savannah, Georgia, academic institution. We retrospectively reviewed five patients who underwent laparoscopic Nissen-preserving SG between 2011 and 2017. We compared pre- and postoperative subjective GERD symptoms, occurrence of any immediate postoperative complications, change in BMI, and excess weight loss. Of the five patients, four were female and one was male. The mean age was 50.6 years. The mean preoperative BMI was 44.8 ± 5.4, one-month postoperative BMI was 41.2 ± 6.1 (P < 0.001), and six-month postoperative BMI was 37.5 ± 8.1 (P < 0.009), with mean excess weight loss at six months of 33.9 ± 23 per cent. There were no immediate postoperative complications. Subjective GERD symptoms were unchanged in two patients and improved in the other three. We demonstrate the early feasibility of Nissen-preserving SG for surgical weight loss in patients with existing Nissen fundoplication. Although our results are early, we feel encouraged by mean excess weight loss to date and control of GERD symptoms.

PRE AND POSTOPERATIVE PH MONITORING AND WEIGHT LOSS ANALYSIS IN PATIENTS UNDERGOING GASTRIC PLICATION IN ASSOCIATION WITH FUNDOPLICATION

BACKGROUND

Obese patients with gastroesophageal reflux disease with pathological pH monitoring result may benefit from surgical treatment which is based on the fundoplication technique in association with laparoscopic gastric plication. The Nissen surgery is the gold standard for surgical treatment of gastroesophageal reflux disease, whereas laparoscopic gastric plication is a restrictive surgery that consists of the invagination of the greater curvature, resulting in weight loss.

AIM

To compare pre and postoperative pHmetry results and to evaluate weight loss in patients submitted to gastroplasty with fundoplication.

METHOD

Sixteen patients with class I body mass index with symptoms of gastroesophageal reflux with changes of stomach pH and/or erosive esophagitis seen in endoscopy were selected The evaluation of the weight and 24-h pH monitoring was performed preoperatively and postoperatively. The weight, body mass index, percentage of excess weight loss and DeMeester score of patients that underwent the surgery were evaluated pre and postoperatively.

RESULTS

Regarding pH monitoring, the average preoperative DeMeester index was 28.7, which was followed by a significant postoperative average reduction to 2.8 (p<0,001). Regarding the weight reduction, the average of weight loss was 13.6 kg and body mass index of 5.3 kg/m2 (p<0.001). Furthermore, the average percentage of excess weight loss was 53.9% (standard deviation=26.2).

CONCLUSION

The combination of Nissen surgery and gastric plication is a viable procedure and appears to be an acceptable option for the treatment of gastroesophageal reflux disease in obese patients, especially patients with obesity class I.

Recent advancements in bariatric/metabolic surgery

Obesity and type 2 diabetes mellitus (T2DM) are currently two pan‐endemic health problems worldwide and are associated with considerable increase in morbidity and mortality. Both diseases are closely related and very difficult to control by current medical treatment, including diet, drug therapy and behavioral modification. Bariatric surgery has proven successful in treating not just obesity but also in significantly decreasing overall obesity‐associated morbidities as well as improving quality of life in severely obese patients (body mass index [BMI] >35 kg/m²). A rapid increase in bariatric surgery started in the 2000s when the laparoscopic surgical technique was introduced into this field. Many new procedures had been developed and changed the face of modern bariatric surgery. Recently, bariatric surgery played as gastrointestinal metabolic surgery has been proposed as a new treatment modality for obesity‐related T2DM for patients with BMI >35 kg/m². Strong evidence has demonstrated that bariatric/metabolic surgery is an effective and durable treatment for obese T2DM patients. Bariatric/metabolic surgery is now becoming an important surgical division. The present article examines and discusses recent advancements in bariatric/metabolic surgery and covers four major fields: (i) the rapid increase in numbers and better safety; (ii) new procedures with better outcomes; (iii) from bariatric to metabolic surgery; and (iv) understanding the mechanisms and personalized treatment.

SLEEVE GASTRECTOMY AND FUNDOPLICATION AS A SINGLE PROCEDURE IN PATIENTS WITH OBESITY AND GASTROESOPHAGEAL REFLUX

BACKGROUND

Bariatric surgery in Chile has seen an exponential increase in recent years, especially in sleeve gastrectomy. Its use is currently discussed in patients suffering from gastroesophageal reflux disease. Different options have been considered for the management of these patients but up to now laparoscopic Roux-en-Y gastric bypass seems to be the best option. Sleeve gastrectomy plus concomitant fundoplication or hiatal hernia repair also has been suggested in patients having reflux or small hiatal hernia.

AIM

To present a cohort of obese patients with gatroesophageal reflux undergoing this procedure, which seeks to provide the benefits of both laparoscopic gastric sleeve (LSG) and antireflux surgery focused on the evaluation of presence of reflux and BMI after surgery, and to compare the result observed in this cohort with a previous group of obese patients without reflux submitted to sleeve gastrectomy alone.

METHODS

Retrospective case series in 15 patients who underwent this surgery between the years 2003 and 2012. Clinical records were analyzed and values ​​of 24 hr pH monitoring, esophageal manometry and clinical outcome were recorded. Results were compared to a previous series of patients who underwent LSG. No statistical analyses were made.

RESULTS

Group A consisted of 15 patients submitted to LSG plus fundoplication. 93% (n=14) were female. Mean age was 46.2 years. Mean preoperative body mass index (BMI) was 33.9. All patients had altered pH monitoring and manometry preoperatively. There was one minor complication corresponding to a seroma. There was no perioperative mortality. Group B consisted of 23 obese patients who underwent LSG. These patients developed de novo reflux, hypotensive LES and esophagitis after the surgery. Group A patients showed improvement in esophageal pH monitoring and manometry at three months. During long-term follow-up, six underwent revision surgery, four for weight regain, one regained weight associated with symptomatic reflux, and one underwent re-intervention for reflux.

CONCLUSIONS

Good results are observed in the short-term follow up in both reflux resolution and weight loss. Nevertheless, results at long term are discouraging, with 53.3% of the patients requiring revision surgery during follow-up.

Technique of Hill's Gastropexy Combined with Sleeve Gastrectomy for Patients with Morbid Obesity and Gastroesophageal Reflux Disease or Hiatal Hernia

BACKGROUND

Observational studies based on quality-of-life and endoscopy relate sleeve gastrectomy (SG) to gastroesophageal reflux disease (GERD), while some functional studies have demonstrated a decrease in esophageal exposure to gastric acid after SG. Currently, it is recommended to treat hiatal hernia along with the SG. However, as the sleeve gastrectomy involves the resection of the fundus, it is not possible to add a traditional fundoplication to the closure of the hiatus.

METHODS

Based on the classic works of Hill et al., and more recent studies by Swänstrom and Aye, our group has incorporated a modified Hill's gastropexy to the sleeve gastrectomy for patients with pathologic GERD and/or huge hiatal hernia submitted to weight loss surgery.

RESULTS

A 28-year-old male patient, 43 kg/m(2) BMI, with a small hiatal hernia and pathologic GERD was scheduled for sleeve gastrectomy. After complete fundus and left crus dissection, the phrenoesophageal membrane was opened and the distal esophagus dissected. The hiatus was closed with interrupted sutures. The sleeve was completed over a 42-French bougie. The preaortic fascia was dissected at the root of the crura and three interrupted sutures placed approximating the gastroesophageal junction to the aforementioned fascia. At 6 months from the operation, weight loss has been satisfactory and the patient does not complaint GERD. Barium swallow demonstrates absence of gastroesophageal reflux, pHmetry and manometry have normalized, and endoscopy shows no esophagitis.

CONCLUSIONS

Gastropexy to the preaortic fascia is a possible antireflux technique to combine with SG.

Sleeve gastrectomy and anti-reflux procedures

BACKGROUND

Obesity is an epidemic in the USA that continues to grow, becoming a leading cause of premature avoidable death. Bariatric surgery has become an effective solution for obesity and its comorbidities, and one of the most commonly utilized procedures, the sleeve gastrectomy, can lead to an increase in gastroesophageal reflux following the operation. While these data are controversial, sometimes operative intervention can be necessary to provide durable relief for this problem.

METHODS

We performed an extensive literature review examining the different methods of anti-reflux procedures that are available both before and after a sleeve gastrectomy.

RESULTS

We reviewed several different types of anti-reflux procedures, including those that supplement the lower esophageal sphincter anatomy, such as magnetic sphincter augmentation and radiofrequency ablation procedures. Re-operation was also discussed as a possible treatment of reflux in sleeve gastrectomy, especially if the original sleeve becomes dilated or if a conversion to a Roux-en-Y gastric bypass or biliopancreatic diversion is deemed necessary. Sleeve gastrectomy with concomitant anti-reflux procedure was also reviewed, including the anti-reflux gastroplasty, hiatal hernia repair, and limited fundoplication.

CONCLUSION

A number of techniques can be used to mitigate the severity of reflux, either by maintaining the normal anatomic structures that limit reflux or by supplementing these structures with a plication or gastroplasty. Individuals with existing severe reflux should not be considered for a sleeve gastrectomy. New techniques that incorporate plication at the time of the index sleeve gastrectomy show some improvement, but these are in small series that will need to be further evaluated. The only proven method of treating intractable reflux after sleeve gastrectomy is conversion to a Roux-en-Y gastric bypass.

Impact of obesity treatment on gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a frequently encountered disorder. Obesity is an important risk factor for GERD, and there are several pathophysiologic mechanisms linking the two conditions. For obese patients with GERD, much of the treatment effort is focused on weight loss and its consistent benefit to symptoms, while there is a relative lack of evidence regarding outcomes after novel or even standard medical therapy is offered to this population. Physicians are hesitant to recommend operative anti-reflux therapy to obese patients due to the potentially higher risks and decreased efficacy, and these patients instead are often considered for bariatric surgery. Bariatric surgical approaches are broadening, and each technique has emerging evidence regarding its effect on both the risk and outcome of GERD. Furthermore, combined anti-reflux and bariatric options are now being offered to obese patients with GERD. However, currently Roux-en-Y gastric bypass remains the most effective surgical treatment option in this population, due to its consistent benefits in both weight loss and GERD itself. This article aims to review the impact of both conservative and aggressive approaches of obesity treatment on GERD.

Stomach intestinal pylorus sparing surgery (SIPS) with laparoscopic fundoplication (LF): a new approach to gastroesophageal reflux disease (GERD) in the setting of morbid obesity

The increase in the prevalence of obesity and gastroesophageal reflux disease (GERD) has paralleled one another. Laparoscopic fundoplication (LF) (Nissen or Toupet) is a minimally invasive form of anti-reflux surgery. The duodenal switch is a highly effective weight loss surgery with a proven record of long term weight loss success. However, fundoplication alone does not give satisfactory results when used for GERD in morbidly obese patients. Here we present a novel approach combining stomach intestinal pylorus sparing surgery (SIPS) with LF for morbidly obese patients with GERD. The data from patients who underwent the SIPS procedure along with LF in past year was retrospectively analyzed. The variables collected were age, sex, height, weight, intra-operative and post-operative complications, length of stay, operative time, and estimated blood loss. All revisions were excluded. Descriptive statistics such as mean and standard deviation were used to analyze the data. The total sample size of the study was 5 patients, with a mean age of 59.6 ± 16.4 years, a mean weight of 292.1 ± 73.6 lbs., and a mean body mass index (BMI) of 43.4 ± 6.3. Weight loss patterns were the same as those without LF. All the 5 patients had resolution or improvement in their GERD symptoms within 6 months. SIPS with LF provides substantial and sustained weight loss and GERD resolution. Long term follow ups and further study on this novel surgical technique is recommended.