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Crawford C, Cook M, Selzer D, Iliakova M, Brengman M. American Society for Metabolic and Bariatric Surgery position statement on describing and coding paraesophageal hernia repair with concurrent bariatric surgery. Surg Obes Relat Dis 2024; 20:795-797. [PMID: 38969592 DOI: 10.1016/j.soard.2024.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Accepted: 05/30/2024] [Indexed: 07/07/2024]
Affiliation(s)
| | - Michael Cook
- Department of Surgery, LSU Health Sciences Center, New Orleans, Louisiana
| | - Don Selzer
- Department of Surgery, Indiana University Health, Carmel, Indiana
| | - Maria Iliakova
- Department of Surgery, Innovation Surgical, New York City, New York
| | - Matthew Brengman
- Department of Surgery, Parham Doctors' Hospital, Richmond, Virginia
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Rapolti DI, Monrabal Lezama M, Manueli Laos EG, Schlottmann F, Masrur MA. Management of Gastroesophageal Reflux Disease after Sleeve Gastrectomy: Effectiveness of Medical, Endoscopic, and Surgical Therapies. J Laparoendosc Adv Surg Tech A 2024; 34:581-602. [PMID: 38568115 DOI: 10.1089/lap.2024.0111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2024] Open
Abstract
Introduction: Sleeve gastrectomy (SG) has become the most frequently performed bariatric operation in the United States. One of the main disadvantages of this procedure is the risk of developing gastroesophageal reflux disease (GERD) after the operation. We aimed to analyze different approaches for the treatment of GERD after SG. Methods: A literature review was performed to identify all possible treatment options for post-SG GERD. All the studies were assessed for full eligibility by manual assessment of their aims, methodology, results, and conclusions. Records were individually reviewed by the authors comparing outcomes and complications between procedures. Results: Although some studies have shown improvement or even resolution of GERD symptoms after SG, most patients develop or worsen symptoms. Lifestyle modifications along with medical therapy should be started on patients with GERD after SG. For those who are refractory to medication, endoscopic and surgical therapies can be offered. Conversion to Roux-en-Y gastric bypass (RYGB) is consistently effective in treatment of GERD and is the ideal therapy in patients with associated insufficient weight loss. Endoscopic and alternative surgical procedures are also available and have shown acceptable short-term outcomes. Conclusions: Several treatment options exist for the treatment of GERD after SG. Although conversion to RYGB remains the most effective therapy, other emerging endoscopic and surgical procedures could avoid the potential morbidity of this procedure and should be further evaluated. An evidence-based algorithm for the management of GERD after SG is proposed to guide decision making.
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Affiliation(s)
- Diana I Rapolti
- Department of Surgery, University of Illinois, Chicago, Illinois, USA
| | | | | | - Francisco Schlottmann
- Department of Surgery, University of Illinois, Chicago, Illinois, USA
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | - Mario A Masrur
- Department of Surgery, University of Illinois, Chicago, Illinois, USA
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Zhang K, Sun S, Yan B. A New Surgical Approach for Obese Patients with Hiatal Hernia. Obes Surg 2024; 34:1956-1957. [PMID: 38499941 DOI: 10.1007/s11695-024-07167-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 03/04/2024] [Accepted: 03/12/2024] [Indexed: 03/20/2024]
Affiliation(s)
- Kun Zhang
- Cell Therapy Center, Central Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Shaochuan Sun
- Department of Gastrointestinal Surgery, Central Hospital Affiliated to Shandong First Medical University, 105 Jiefang Road, Jinan, 250013, Shandong Province, China
| | - Bing Yan
- Department of Gastrointestinal Surgery, Central Hospital Affiliated to Shandong First Medical University, 105 Jiefang Road, Jinan, 250013, Shandong Province, China.
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Philippe H, Steven G, Iulia S, Geoffrey J, Mickaël G, Etienne VV. Laparoscopic Toupet-Sleeve gastrectomy in morbid obese patients with preoperative gastro-esophageal reflux: a 4-year follow-up cohort study. Acta Chir Belg 2024:1-8. [PMID: 38363708 DOI: 10.1080/00015458.2024.2320504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 02/14/2024] [Indexed: 02/18/2024]
Abstract
AIM To assess the 4-year outcomes after Toupet-Sleeve (TS) gastrectomy in morbid obese patients with concomitant preoperative gastro-esophageal reflux disease (GERD). MATERIAL AND METHODS The study group consisted of 19 consecutive patients operated on between August 2017 and February 2019. There were 5 men and 14 women with a mean body mass index (BMI) of 43 ± 5 kg/m2 and a mean age of 42 ± 15 years. A retrospective analysis of database and telephone interview of patients who defaulted clinic follow-up was conducted. The main study end-points were weight loss and success of surgery, defined as no need for conversion and %EWL > 50%. Resolution of GERD was a secondary end-point. RESULTS No patient was lost for follow-up. Nadir weight loss was reached after a follow-up of one year: mean BMI was 32 ± 5 kg/m2, %EWL 61 ± 21% and %TWL 24 ± 7%. Thereafter, we observed a progressive weight regain over time. With a mean follow-up of 51 ± 6 months, mean BMI was 36 ± 8 kg/m2, %EWL 43 ± 35% and %TWL 16 ± 12%. Two patients were converted to another bariatric procedure because of dysphagia and fundus dilatation or because of insufficient weight loss. The overall surgical success rate was 32% (6/19). Resolution of GERD without any PPI treatment was noted in 88% (15/17) of the non-converted patients. CONCLUSION In our experience, with a 4-year follow-up, TS is associated with a significant risk of conversion, a moderate weight loss and a poor surgical success rate.
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Affiliation(s)
| | - Granjean Steven
- Digestive Surgery, CH Wapi, site Notre-Dame, Tournai, Belgium
| | | | | | - Gerard Mickaël
- Digestive Surgery, Clinique Saint-Jean, Bruxelles, Belgium
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Abdelbaki TN. Bikini-line Hiatal Hernia Repair (BLHHR) During Sleeve Gastrectomy. Obes Surg 2023; 33:3879-3888. [PMID: 37857940 PMCID: PMC10687131 DOI: 10.1007/s11695-023-06881-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 09/29/2023] [Accepted: 10/04/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND To preserve the aesthetic benefits achieved with Bikini line sleeve gastrectomy (BLSG), we have devised a novel approach for simultaneous hiatal hernia repair (HHR), known as bikini-line hiatal hernia repair (BLHHR). This manuscript presents our initial experience with BLHHR and assesses its feasibility and outcomes. METHODS A prospective preliminary study was conducted on patients who underwent BLHHR between September 2020 and October 2022. Patient demographics, preoperative assessments, operative details, postoperative outcomes, and aesthetic evaluations were recorded. Feasibility and safety were assessed. RESULTS Among 891 BLSG patients, 89 (9.9%) underwent BLHHR. The mean distances between the xiphoid process and the umbilicus, symphysis pubis, and anterior superior iliac spine (ASIS) were 28.8 ± 2.2, 33.9 ± 3.1, and 31.2 ± 1.8 cm, respectively. Optimal visualization and accessibility of the gastroesophageal junction (GEJ) were achieved without compromising HHR repair or sleeve gastrectomy. The mean operative time was 76.5 ± 11 min, longer than the 58 ± 10 min required for BLSG alone. Patient scar satisfaction ranged from 87.5 to 97.9%, and the mean pain score was 2.9 ± 0.8. No major complications were reported. At 6 months, %EWL (percentage of excess weight loss) was 53.3 ± 13.7%, GERD (gastroesophageal reflux disease) remission was achieved in 62.8% of patients and comorbidities were improved. CONCLUSION BLHHR was potentially feasible and safe. Outcomes related to patient scar satisfaction, weight loss, improvement of associated comorbidities, and GERD symptoms were not compromised. The aesthetic benefits achieved by BLSG were maintained.
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Affiliation(s)
- Tamer N Abdelbaki
- General Surgery Department, Alexandria University Faculty of Medicine, Midan Khartoum, Alexandria, Egypt.
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Kumar A, Madhav JV, Singla V, Monga S, Aggarwal S. Concomitant Hiatal Hernia Repair With Sleeve Gastrectomy: Impact on Gastroesophageal Reflux? Surg Laparosc Endosc Percutan Tech 2023; 33:435-439. [PMID: 37671614 DOI: 10.1097/sle.0000000000001216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 07/18/2023] [Indexed: 09/07/2023]
Abstract
BACKGROUND Hiatal hernia (HH), whenever encountered during sleeve gastrectomy (SG), needs to be addressed because of its strong association with gastroesophageal reflux disease (GERD). However, the mid-term to long-term effects of hiatal hernia repair (HHR) on GERD remain unclear. METHODS This was a cross-sectional observational analysis of patients who underwent SG + HHR and had completed at least 1 year of follow-up. The preoperative data were retrieved from a prospectively maintained database. Of the 590 patients who underwent SG, 63 patients (10.7%) with concomitant HHR were assessed for the use of proton pump inhibitors (PPIs) and symptoms of GERD using the GERD-Q questionnaire. RESULTS Of the 63 patients, 11 were lost to follow-up, and one underwent Roux-en-Y gastric bypass for HH recurrence and severe reflux. The remaining 51 patients were assessed at a mean follow-up of 3.7±2.0 years. Of these, 51% (26/51) patients had preoperative reflux symptoms. On follow-up, 69.2% (18/26) had complete resolution with significant improvement in their GERD-Q scores (9.8±3.1 to 6.5±2.1; P =0.001), while 76.2% (16/21) of patients were off the PPIs. The incidence of de novo GERD was found in 20% (5/25) of the patients. CONCLUSIONS In patients of morbid obesity with HH, concomitant HHR with SG leads to improvement of the reflux symptoms in more than two-thirds of the patients, besides alleviating the use of PPIs.
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Affiliation(s)
- Arun Kumar
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
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Hauters P, van Vyve E, Stefanescu I, Gielen CE, Nachtergaele S, Mahaudens M. A case-control comparative study between Toupet-Sleeve and conventional sleeve gastrectomy in patients with preoperative gastroesophageal reflux. Acta Chir Belg 2023; 123:19-25. [PMID: 33926366 DOI: 10.1080/00015458.2021.1922189] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION The aim of that study was to compare outcomes after Toupet-Sleeve (T-Sleeve) and sleeve gastrectomy (SG) as primary bariatric procedures in obese patients presenting with preoperative gastro-esophageal reflux disease (GERD). MATERIAL AND METHODS The outcomes of 19 consecutive patients operated between 2017 and 2019 by T-Sleeve were compared to the outcomes of 38 patients operated in 2014 by SG. The two groups were matched by age, sex, ASA classification, BMI, food habits and severity of esophagitis. Postoperative weight loss and evolution of GERD symptoms were the study end-points. RESULTS The preoperative BMI was 43 ± 5 in the T-Sleeve and 42 ± 5 in the SG group (NS). All the procedures were completed by laparoscopy. The operative time was higher in the T-Sleeve group: 89 ± 18 vs. 68 ± 12 min. (p < 0.001). A lower weight loss was observed in the T-Sleeve group. Respectively 1 and 2 years after surgery, the mean BMI were: 32 ± 6 and 34 ± 6 in the T-Sleeve vs. 28 ± 5 (p < 0.006) and 30 ± 6 (p < 0.05) in the SG group and the mean %EWL were: 61 ± 23 and 54 ± 26% in the T-Sleeve vs. 86 ± 25 (p < 0.002) and 75 ± 28% (p < 0.03) in the SG group. Better control of GERD was noted in the T-Sleeve group: the number of patients with complete resolution of GERD symptoms was 17 (89%) vs. 13 (34%) in the SG group (p < 0.001). CONCLUSION T-Sleeve was an effective procedure for GERD treatment but, the weight loss was significantly much lower than after conventional SG. Studies with longer follow-up are mandatory to validate the T-Sleeve procedure.
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Affiliation(s)
- Philippe Hauters
- Department of Digestive Surgery, Centre Hospitalier de Wallonie Picarde, Tournai, Belgium
| | - Etienne van Vyve
- Department of Digestive Surgery, Centre Hospitalier de Wallonie Picarde, Bruxelles, Belgium
| | - Iulia Stefanescu
- Department of Digestive Surgery, Centre Hospitalier de Wallonie Picarde, Tournai, Belgium
| | - Charles-Edouard Gielen
- Department of Digestive Surgery, Centre Hospitalier de Wallonie Picarde, Bruxelles, Belgium
| | - Sylvie Nachtergaele
- Department of Digestive Surgery, Centre Hospitalier de Wallonie Picarde, Tournai, Belgium
| | - Manon Mahaudens
- Department of Digestive Surgery, Centre Hospitalier de Wallonie Picarde, Tournai, Belgium
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Comment on: Impact of concurrent hiatal hernia repair during laparoscopic sleeve gastrectomy on patient-reported gastroesophageal reflux symptoms: a state-wide analysis. Surg Obes Relat Dis 2023; 19:666-667. [PMID: 36854644 DOI: 10.1016/j.soard.2023.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 01/15/2023] [Indexed: 01/21/2023]
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Hutopila I, Ciocoiu M, Paunescu L, Copaescu C. Reconstruction of the phreno-esophageal ligament (R-PEL) prevents the intrathoracic migration (ITM) after concomitant sleeve gastrectomy and hiatal hernia repair. Surg Endosc 2023; 37:3747-3759. [PMID: 36658283 PMCID: PMC10156812 DOI: 10.1007/s00464-022-09829-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 12/12/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND Laparoscopic Sleeve Gastrectomy (LSG) is the most attractive bariatric procedure, but the postoperative intrathoracic gastric migration (ITM) and "de novo" GERD are major concerns. The main objective of our study was to evaluate the efficiency of the concomitant HHR with or without partial reconstruction of phreno-esophageal ligament (R-PEL) to prevent ITM after LSG. The secondary objectives focused on procedure's metabolic and GERD-related outcomes. PATIENTS AND METHOD Consecutive patients who underwent primary LSG and concomitant HHR were included in a single-center prospective study. According to the HHR surgical technique, two groups were analyzed and compared: Group A included patients receiving crura approximation only and Group B patients with R-PEL. The patients' evolution of co-morbidities, GERD symptoms, radiologic, and endoscopic details were prospectively analyzed. RESULTS Two hundred seventy-three patients undergoing concurrent HHR and LSG were included in the study (Group A and B, 146 and 127 patients) The mean age and BMI were 42.6 ± 11.3 and 43.4 ± 6.8 kg/m2. The 12-month postoperative ITM was radiologically found in more than half of the patients in Group A, while in group B, the GEJ's position appeared normal in 91.3% of the patients, meaning that R-PEL reduced 7 times the rate of ITM. The percentage of no-improvement and "de novo" severe esophagitis (Los Angeles C) was 4 times higher in group A 3.4% vs. 0.8% with statistical significance, and correlated to ITM. The GERD symptoms were less frequent in Group B vs Group A, 21.3% vs 37%, with statistical significance. No Barrett's esophagus and no complication were recorded in any of the patients. CONCLUSION Concurrent LSG and HHR by crura approximation only has a very high rate of ITM in the first postoperative year (over 50%). R-PEL is an innovative technique which proved to be very efficient in preventing the ITM after HHR.
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Affiliation(s)
- I Hutopila
- Department of Bariatric and Metabolic Surgery, Ponderas Academic Hospital, Bucharest, Romania.,Titu Maiorescu University Doctoral School of Medicine, Bucharest, Romania
| | - M Ciocoiu
- Department of Radiology, Ponderas Academic Hospital, Bucharest, Romania
| | - L Paunescu
- Department of Radiology, Ponderas Academic Hospital, Bucharest, Romania
| | - C Copaescu
- Department of Bariatric and Metabolic Surgery, Ponderas Academic Hospital, Bucharest, Romania. .,Carol Davila University of Medicine and Pharmacy, Bucharest, Romania. .,Ponderas Academic Hospital, Nicolae Caramfil Street, No. 85 A, Bucharest, Romania.
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Hany M, Torensma B, Zidan A, Agayby ASS, Ibrahim M, Shafie ME, Sayed IE. Comparison of Sleeve Volume Between Banded and Non-banded Sleeve Gastrectomy: Midterm Effect on Weight and Food Tolerance-a Retrospective Study. Obes Surg 2023; 33:406-417. [PMID: 36508154 PMCID: PMC9889434 DOI: 10.1007/s11695-022-06404-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 11/24/2022] [Accepted: 11/30/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Sleeve dilatation after laparoscopic sleeve gastrectomy (LSG) causes weight regain (WR). Banded sleeve gastrectomy (BSG) was proposed to prevent dilatation and reduce WR. METHODS A retrospective cohort study on patients who underwent BSG and LSG and completed 4 years of follow-up from 2016 to 2021 was included. Body mass index (BMI), percentage of excess weight loss (%EWL), percentage of total weight loss (%TWL), and FT scores were calculated at 1, 2, 3, and 4 years. The sleeve volume was estimated at 6 months, 1 year, and 4 years. Multi-variate analysis was conducted to assess correlations between covariates. WR was calculated as weight gain > 10%, > 10 kg above the nadir, or BMI increase of ≥ 5 kg/m 2 above the nadir. RESULTS This study included LSG 1279 patients and BSG 132 patients. Mean %EWL at 1 year was 83.87 ± 17.25% in LSG vs. 85.71 ± 7.92% in BSG and was 83.47 ± 18.87% in LSG and 85.54 ± 7.48% in BSG at 4 years. Both had significant weight loss over time (p. < 0.001) with no significant main effect of surgery (p.0.438). Mean sleeve volume at 6 months was 102.32 ± 9.88 ± 10.28 ml in LSG vs. 101.89 ± 10.019 ml in BSG and at 4 years was 580.25 ± 112.25 ml in LSG vs. 157.94 ± 12.54 ml in BSG (p. < 0.001). WR occurred in 136 (10.6%) and 4 (3.1%) (p.0.002) in LSG and BSG patients, 90 (7%) vs. zero (0%) (p.0.002) and 31 (2.4%) vs. zero (0%) (p.0.07) using the > 10%, > 10 kg increase above the nadir and the ≥ 5 kg/m 2 BMI increases above the nadir formulas, respectively. CONCLUSION BSG had significantly lower sleeve volume, significantly lower WR, and significantly lower FT scores than LSG after 4 years from surgery; however, volume changes were not correlated with weight loss.
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Affiliation(s)
- Mohamed Hany
- grid.7155.60000 0001 2260 6941Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, Alexandria, 21561 Egypt ,Consultant of Bariatric Surgery at Madina Women’s Hospital (IFSO Center of Excellence), Alexandria, Egypt
| | - Bart Torensma
- grid.10419.3d0000000089452978Clinical Epidemiologist, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Ahmed Zidan
- grid.7155.60000 0001 2260 6941Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, Alexandria, 21561 Egypt
| | - Ann Samy Shafiq Agayby
- grid.7155.60000 0001 2260 6941Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, Alexandria, 21561 Egypt
| | - Mohamed Ibrahim
- grid.7155.60000 0001 2260 6941Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, Alexandria, 21561 Egypt
| | - Mohamed El Shafie
- grid.7155.60000 0001 2260 6941Department of Radiology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Iman El Sayed
- grid.7155.60000 0001 2260 6941Biomedical Informatics and Medical Statistics Department, Medical Research Institute, Alexandria University, Alexandria, Egypt
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da Silva JTD, Santa-Cruz F, Cavalcanti JMS, Padilha MV, Coutinho LR, Siqueira LT, Ferraz ÁAB. Incidence of Abnormalities of the Gastric Tube Following Sleeve Gastrectomy and Its Role on Esophagitis Progression. Obes Surg 2023; 33:263-267. [PMID: 36460942 DOI: 10.1007/s11695-022-06375-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 11/20/2022] [Accepted: 11/27/2022] [Indexed: 12/04/2022]
Abstract
PURPOSE The purpose of this study is to determine the incidence of gastric tube abnormalities after SG and its relationship with esophagitis progression. METHODS Retrospective study which included 459 patients in the postoperative period of SG who underwent an esophagogastroduodenoscopy in both pre- and postoperative periods. The main studied variables were presence of gastric tube abnormalities (dilation, neofundus, twist, and hiatal hernia) and esophagitis progression. RESULTS Among the 459 patients who underwent SG, 393 (85.6%) were women, and 66 (14.4%) men, with mean age of 40.4 years. Mean preoperative BMI was 39.70 kg/m2. In total, 20.3% of the sample presented progression of esophagitis after surgery. Among the whole sample, 130 (28.3%) presented with an abnormality of the remnant gastric tube. The most common alteration was gastric dilation, which occurred in 16.1% of the patients, followed by gastric twist (10.7%), neofundus (7.4%), and hiatal hernia (0.2%). Patients who presented with any abnormality of the gastric tube were significantly prone to presenting esophagitis progression (p = 0.013). When analyzing each morphological abnormality isolated, there was no statistically significant correlation. CONCLUSION Abnormalities of the gastric tube are not uncommon after SG and seems to contribute partially to the relevant rates of GERD and esophagitis after this surgery.
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Affiliation(s)
- José-Tarcísio Dias da Silva
- Federal University of Pernambuco, Recife, PE, Brazil.,General Surgery Unit, Hospital das Clínicas (HC-UFPE/EBSERH), Federal University of Pernambuco, Recife, PE, Brazil
| | | | - Joyce Maria S Cavalcanti
- General Surgery Residency, Hospital das Clínicas (HC-UFPE/EBSERH), Federal University of Pernambuco, Recife, PE, Brazil
| | | | - Lucas R Coutinho
- Medical School, Federal University of Pernambuco, Recife, PE, Brazil
| | - Luciana T Siqueira
- General Surgery Unit, Hospital das Clínicas (HC-UFPE/EBSERH), Federal University of Pernambuco, Recife, PE, Brazil
| | - Álvaro A B Ferraz
- General Surgery Unit, Hospital das Clínicas (HC-UFPE/EBSERH), Federal University of Pernambuco, Recife, PE, Brazil. .,Gastrointestinal Surgery Unit, Hospital Esperança - Rede D'Or São Luiz, Recife, PE, Brazil.
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Factors Associated with Increased Severity of Erosive Esophagitis 1 Year After Laparoscopic Sleeve Gastrectomy. Obes Surg 2022; 32:3891-3899. [PMID: 36205881 DOI: 10.1007/s11695-022-06268-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 09/01/2022] [Accepted: 09/01/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE Weight reduction decreases gastroesophageal reflux disease (GERD), but laparoscopic sleeve gastrectomy (LSG) that damages the structure of the stomach may worsen GERD. We aimed to elucidate the factors associated with increased severity of erosive esophagitis (EE) at 1 year after LSG. MATERIALS AND METHODS Data on patients who underwent LSG between February 2007 and March 2016 were reviewed. Endoscopic findings and anthropometric data before and after surgery were recorded. The severity of EE was assessed according to the Los Angeles classification; severe EE was defined as grade C or D esophagitis. RESULTS Totally, 316 patients were enrolled. Before LSG, 96 patients (30.4%) had grade A or B EE. One year after LSG, 215 patients (68%) had EE, including 136 (43%) with grade A, 62 (19.6%) with grade B, and 17 (5.4%) with grade C or D EE. One-hundred and twenty-seven of 220 patients (57.7%) without EE before LSG developed de novo EE following LSG. The incidence of severe EE after LSG in patients without pre-operative EE, grade A EE, or grade B EE at baseline was 3.2%, 6.8%, and 50%, respectively. Independent factors for an increased severity of EE after LSG were male gender (OR = 2.55, 95% CI = 1.52-4.28) and post-operative hiatal hernia (OR = 3.17, 95% CI = 1.66-6.06). CONCLUSION The prevalence and severity of EE increased after LSG. Male gender and post-operative hiatal hernia are independent factors for an increased severity of EE after LSG. The incidence of severe EE after LSG is low for patients without pre-operative EE or grade A EE at baseline.
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Repairing small type I hiatal hernias at the time of RYGB is not necessary to achieve resolution of reflux symptoms. Surg Endosc 2022:10.1007/s00464-022-09653-5. [PMID: 36167871 DOI: 10.1007/s00464-022-09653-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 09/13/2022] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Roux-en-Y gastric bypass (RYGB) is the gold standard operation for gastroesophageal reflux disease (GERD) in patients with severe obesity, but there is variability in surgeon opinion regarding whether small type I hiatal hernias (HH) require routine repair concurrently with RYGB. We sought to examine whether leaving small type I HHs unrepaired during RYGB affected GERD outcomes. METHODS Pre-operatively our patients all receive endoscopy, and select patients with reflux symptoms receive esophagram based on attending surgeon practice and preference. We routinely repair paraesophageal hernias (PEH) concurrently with RYGB, but refrain from repairing small type I HH if, intra-operatively, the gastric fat pad and cardia are below the diaphragm with no evidence of retraction into the mediastinum. Records from 268 consecutive patients undergoing primary RYGB between January 2016 and February 2021 who completed pre-operative GERD-HRQL assessments were reviewed for presence of type I HH or PEH. Mann-Whitney U tests examined the pre-operative to post-operative change in GERD-HRQL in patients with type I HH left unrepaired at the time of RYGB (HH group) and patients with no hernia (NH group). RESULTS Pre-operatively, GERD-HRQL scores were not statistically different between HH group (median = 7, mean = 8.5, n = 100) and NH group (median = 6.5, mean = 7.2, n = 141) (p > 0.05). Post-operatively, there was no increase in GERD-HRQL scores patients whose hernias were left unrepaired. Neither group had clinically pathologic post-operative GERD-HRQL scores, with median 6 months scores of 1 for HH group (n = 68) versus 1.5 for NH group (n = 90) (p > 0.05), and median 12 months scores of 1.5 for HH group (n = 40) versus 1 for NH group (n = 56) (p > 0.05). CONCLUSION Repair of small type I HH is not necessary to achieve effective, durable resolution of reflux symptoms with RYGB. Omitting repair reduces operative time, cost, and potential risk without adverse impact on post-operative reflux symptoms.
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Ehlers AP, Bonham AJ, Ghaferi AA, Finks JF, Carlin AM, Varban OA. Impact of hiatal hernia repair technique on patient-reported gastroesophageal reflux symptoms following laparoscopic sleeve gastrectomy. Surg Endosc 2022; 36:6815-6821. [PMID: 35854122 DOI: 10.1007/s00464-021-08970-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 12/22/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Repairing a hiatal hernia at the time of laparoscopic sleeve gastrectomy (SG) can reduce or even prevent gastroesophageal reflux disease (GERD) symptoms in the post-operative period. Several different hiatal hernia repair techniques have been described but their impact on GERD symptoms after SG is unclear. METHODS Surgeons (n = 74) participating in a statewide quality collaborative were surveyed on their typical technique for repair of hiatal hernias during SG. Options included posterior repair with mesh (PRM), posterior repair (PR), and anterior repair (AR). Patients who underwent SG with concurrent hiatal hernia repair (n = 7883) were compared according to their surgeon's reported technique. Patient characteristics, baseline and 1-year GERD health-related quality of life surveys, weight loss and 30-day risk-adjusted complications were analyzed. RESULTS The most common technique reported by surgeons for hiatal hernia repair was PR (n = 64, 85.3%), followed by PRM (n = 7, 9.3%) and AR (n = 4, 5.3%). Patients who underwent SG by surgeons who perform AR had lower rates of baseline GERD diagnosis (AR 55.3%, PR 59.5%, PRM 64.8%, p < 0.01), but were more likely to experience worsening GERD symptoms at 1 year (AR 29.8%, PR 28.7%, PRM 28.2%, p < 0.0001), despite similar weight loss (AR 29.8%, PR 28.7%, PRM 28.2%, p = 0.08). Satisfaction with GERD symptoms at 1 year was high (AR 73.2%, PR 76.3%, PRM 75.7%, p = 0.43), and risk-adjusted 30-day outcomes were similar among all groups. CONCLUSIONS Patients undergoing SG with concurrent hiatal hernia repair by surgeons who typically perform an AR were more likely to report worsening GERD at 1 year despite excellent weight loss. Surgeons who typically performed an AR had nearly one-half of their patients report increased GERD severity after surgery despite similar weight loss. While GERD symptom control may be multifactorial, technical approach to hiatal hernia repair at the time of SG may play a role and a posterior repair is recommended.
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Affiliation(s)
- Anne P Ehlers
- Department of Surgery, Michigan Medicine, University of Michigan, 1500 E Medical Center Drive, SPC 5343, 2210 Taubman Center, Ann Arbor, MI, 48109, USA.
- Center for Healthcare Outcomes & Policy, Ann Arbor, MI, USA.
| | - Aaron J Bonham
- Michigan Bariatric Surgery Collaborative, Ann Arbor, MI, USA
| | - Amir A Ghaferi
- Department of Surgery, Michigan Medicine, University of Michigan, 1500 E Medical Center Drive, SPC 5343, 2210 Taubman Center, Ann Arbor, MI, 48109, USA
- Center for Healthcare Outcomes & Policy, Ann Arbor, MI, USA
- Michigan Bariatric Surgery Collaborative, Ann Arbor, MI, USA
| | - Jonathan F Finks
- Department of Surgery, Michigan Medicine, University of Michigan, 1500 E Medical Center Drive, SPC 5343, 2210 Taubman Center, Ann Arbor, MI, 48109, USA
- Michigan Bariatric Surgery Collaborative, Ann Arbor, MI, USA
| | - Arthur M Carlin
- Department of Surgery, Henry Ford Health System, Detroit, MI, USA
| | - Oliver A Varban
- Department of Surgery, Michigan Medicine, University of Michigan, 1500 E Medical Center Drive, SPC 5343, 2210 Taubman Center, Ann Arbor, MI, 48109, USA
- Michigan Bariatric Surgery Collaborative, Ann Arbor, MI, USA
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15
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Nocca D, Galtier F, Taleb S, Picot MC, Jaussent A, Silvestri M, Lefebvre P, de Jong A, Gautier T, Loureiro M, Nedelcu M. Peri-operative Morbidity of Nissen Sleeve Gastrectomy: Prospective Evaluation of a Cohort of 365 Patients, Beyond the Learning Curve. Obes Surg 2022; 32:1-7. [PMID: 35524904 DOI: 10.1007/s11695-022-06066-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 04/10/2022] [Accepted: 04/13/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE Over the last decade, an important interest was taken to prevent the reflux following sleeve. A new variant, Nissen-sleeve, was described with the purpose to prevent GERD and to decrease the occurrence of leak. The current study reports the preliminary results of a prospective trial. MATERIALS AND METHODS All consecutive patients who underwent a Nissen-Sleeve between January 2018 and September 2020 were included. Baseline characteristics including age, gender, weight, body mass index (BMI), GERD symptoms, and treatment were evaluated after 1 year. Operative time, length of stay, complication, and reoperation data were also collected. RESULTS Three hundred sixty-five consecutive patients decided to undergo Nissen-sleeve: 75% females with median age of 41.2 years (+ / - 14.1) and an average BMI of 41.6 kg/m2 (+ / - 5.4). There were 16 cases (4.4%) of early postoperative complications (< 30 days): six cases of acute wrap perforation (1.6%), intraabdominal bleeding for 5 patients (1.4%), one case of wrap dilatation (0.3%), one case of acute complete aphagia, one case of incarcerated umbilical hernia, and 2 cases (0.5%) of pulmonary atelectasis/pneumonia and one venous pulmonary embolism. We recorded the following complications: 16 patients (4.4%) mild dysphagia; 3 patients (0.8%) chronic dysphagia; and 2 cases of wrap perforation that have been diagnosed 8 and 9 months respectively, after the procedure due to the use of steroids not associated with PPI intake. The mean operative time was 83 min (46-125 min). The conversion and mortality rates were nil. CONCLUSION Following the initial learning curve and additional technical modifications, the Nissen-Sleeve appears to be a safe surgical technique with an acceptable early postoperative complication rate. CLINICAL TRIAL REGISTRATION NCT02310178.
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Affiliation(s)
- David Nocca
- CHU de Montpellier, CHU Saint Eloi 80 Av Augustin FlicheCedex 5, 34295, Montpellier, France. .,Institut de Génomique Fonctionnelle, UMR 5203 CNRS- U1191, INSERM- Univ Montpellier, Montpellier, France.
| | - Florence Galtier
- CHU de Montpellier, CHU Saint Eloi 80 Av Augustin FlicheCedex 5, 34295, Montpellier, France.,Inserm CIC 1411, Montpellier, France
| | - Sulaiman Taleb
- CHU de Montpellier, CHU Saint Eloi 80 Av Augustin FlicheCedex 5, 34295, Montpellier, France
| | - Marie-Christine Picot
- Institut de Génomique Fonctionnelle, UMR 5203 CNRS- U1191, INSERM- Univ Montpellier, Montpellier, France.,Inserm CIC 1411, Montpellier, France.,Clinical Research and Epidemiology Unit, CHU Montpellier, Univ Montpellier, Montpellier, France
| | - Audrey Jaussent
- Clinical Research and Epidemiology Unit, CHU Montpellier, Univ Montpellier, Montpellier, France
| | | | - Patrick Lefebvre
- CHU de Montpellier, CHU Saint Eloi 80 Av Augustin FlicheCedex 5, 34295, Montpellier, France
| | - Audrey de Jong
- CHU de Montpellier, CHU Saint Eloi 80 Av Augustin FlicheCedex 5, 34295, Montpellier, France
| | | | - Marcelo Loureiro
- CHU de Montpellier, CHU Saint Eloi 80 Av Augustin FlicheCedex 5, 34295, Montpellier, France.,Universidade Positivo, Curitiba, Brazil
| | - Marius Nedelcu
- ELSAN Clinique Bouchard, Marseille, France.,ELSAN Clinique Saint Michel, Toulon, France
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16
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Relationship between gastroesophageal reflux disease and laparoscopic sleeve gastrectomy: a narrative review. Wideochir Inne Tech Maloinwazyjne 2021; 16:648-655. [PMID: 34950258 PMCID: PMC8669989 DOI: 10.5114/wiitm.2021.103948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 01/18/2021] [Indexed: 11/17/2022] Open
Abstract
This paper aims to revisit the relationship between gastroesophageal reflux disease and laparoscopic sleeve gastrectomy in obese patients by reviewing the recent available literature, in the form of a narrative review. The interpretation of the current evidence is challenged by the fact that published data are contradictory and comparison between studies is difficult. Most studies investigate the presence of gastroesophageal reflux disease by assessing only the symptoms reported by patients. A few studies have objectively investigated gastroesophageal reflux disease by functional tests and endoscopic evaluation. Also, the surgical technique of laparoscopic sleeve gastrectomy plays an important role in the incidence of postoperative gastroesophageal reflux disease. In conclusion, surgeons must be aware of the existence of gastroesophageal reflux disease and, at the same time, patients should be informed regarding the possible effect of laparoscopic sleeve gastrectomy on gastroesophageal reflux disease.
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17
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Tobin EC, Knotts C, Tsai J, Austin J, Thompson S, Attia CG, Richmond BK, Monnett S. Management of the Crura During Laparoscopic Sleeve Gastrectomy. Am Surg 2021; 88:704-709. [PMID: 34772283 DOI: 10.1177/00031348211050285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
METHODS This is a retrospective cohort study that evaluated patients undergoing LSG performed by a single surgeon in a 7-year period. Data were collected via chart review. The primary endpoint was hiatal hernia presence at 5 years post-operatively. Secondary endpoints included post-procedural complications (nausea, vomiting, dysphagia, or reflux) at 30 days post-operatively. RESULTS A total of 361 patients were included in the analysis: 154 without crural closure, 164 primary crural closure, and 43 primary crural closure with mesh reinforcement. Rates of hiatal hernia occurrence at 5 years were 9.7% (no closure), 14.0% (primary closure), and 16.3% (closure with mesh reinforcement), respectively, and did not differ significantly among the 3 cohorts (P = .37). Overall rates of 30-day complications were 11.5%, 21.5%, and 28.6%, respectively (P = .015). CONCLUSION Rates of hiatal hernia after sleeve gastrectomy do not differ, regardless of management of the crura. In addition, and perhaps more significantly, avoidance of crural closure was associated with fewer 30-day complications. In fact, the highest rate of 30-day complications was seen in the group that received closure with mesh reinforcement. These data suggest that crural closure during LSG should be avoided. Further prospective study of these findings is warranted.
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Affiliation(s)
- Edward C Tobin
- 20205Charleston Area Medical Center, Charleston, WV, USA
| | - Chelsea Knotts
- 20205Charleston Area Medical Center, Charleston, WV, USA
| | - Jonathon Tsai
- 20205Charleston Area Medical Center, Charleston, WV, USA
| | - Jeffrey Austin
- 20205Charleston Area Medical Center, Charleston, WV, USA
| | - Stephanie Thompson
- Institute for Academic Medicine, Charleston Area Medical Center, Charleston, WV, USA
| | - Christina G Attia
- 12355West Virginia University/Charleston Division, Charleston, WV, USA
| | - Bryan K Richmond
- Department of Surgery, 37297West Virginia University/Charleston Division, Charleston, WV, USA
| | - Shane Monnett
- Department of Surgery, 37297West Virginia University/Charleston Division, Charleston, WV, USA
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18
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Walsh PR, Lamba M, Benias P, Lafta A, Hopkins G. Feasibility of resection and plication "RAP" technique for management of medically refractory GERD in patients with altered gastric anatomy. Endosc Int Open 2021; 9:E1549-E1555. [PMID: 34540549 PMCID: PMC8445683 DOI: 10.1055/a-1535-1279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 06/16/2021] [Indexed: 11/02/2022] Open
Abstract
Background and study aims Gastroesophageal reflux disease (GERD) is common, especially in patients after gastric surgery. Medical management of GERD is ineffective in up to 30 % patients and revisional gastric surgery for management of GERD is associated with higher morbidity. We aimed to assess the safety, feasibility, and efficacy of a novel endoscopic resection and plication (RAP) anti-reflux procedure for management of medically refractory GERD in patients with altered gastric anatomy. Patients and methods The RAP procedure involves endoscopic mucosal resection and full-thickness plication over the right posterior-medial axis extending 15 mm above and 20 to 30 mm below the squamocolumnar junction. Adverse events, technical feasibility, GERD health-related quality-of-life (GERD-HRQL) scores, and medication use were prospectively recorded. Results Twenty consecutive patients with previous gastric surgery underwent RAP between September 2018 and August 2020 with a median follow-up of 5.7 months. The median procedure duration was 66 minutes (IQR 53.8-89.5). RAP was technically successful in 19 patients. One patient developed gastric hemorrhage from suture dehiscence, which was managed endoscopically, and four patients developed esophageal stricture requiring endoscopic dilation. Following the RAP procedure, significant improvement in GERD-HRQL score was observed (mean 26.9, 95 %CI 23.36-30.55, P < 0.01). Fourteen of 19 patients reported > 50 % improvement in GERD-HRQL scores. Sixteen of 18 patients reported reduction in requirement for or cessation of antacid therapy. Conclusions Patients with refractory GERD after gastric surgery have limited therapeutic options. We have demonstrated that the RAP procedure is feasible, safe, and clinically effective at short-term follow-up. It provides a potential alternative to revisional surgery in patients with altered gastric anatomy.
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Affiliation(s)
- Patrick R. Walsh
- St. Vincent’s Private Hospital Northside, Chermside, Australia,Royal Brisbane & Women’s Hospital, Butterfield Street, Herston, Australia
| | - Mehul Lamba
- Royal Brisbane & Women’s Hospital, Butterfield Street, Herston, Australia
| | - Petros Benias
- Division of Gastroenterology, North Shore-Long Island Jewish Medical Center, Zucker school of Medicine at Hofstra/Northwell, Northwell Health System, Manhasset, New York, United States
| | - Abdulnasser Lafta
- Royal Brisbane & Women’s Hospital, Butterfield Street, Herston, Australia
| | - George Hopkins
- St. Vincent’s Private Hospital Northside, Chermside, Australia,Royal Brisbane & Women’s Hospital, Butterfield Street, Herston, Australia
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19
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Davrieux CF, Palermo M, Nedelcu M, Nocca D. Reflux After Sleeve Gastrectomy: An Update. J Laparoendosc Adv Surg Tech A 2021; 31:978-982. [PMID: 34388044 DOI: 10.1089/lap.2021.0478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background: Modifications of gastric anatomy, function, and of the esophagogastric junction secondary to sleeve gastrectomy (SG) can worsen the symptoms of gastroesophageal reflux disease (GERD). Its late diagnosis and poor treatment can lead to serious complications. In recent years, attempts have been made to optimize preoperative studies and improve surgical techniques to prevent this problem. The aim of this study was to update on the presence of GERD and their symptoms post-SG. Methods: A literature review of articles based on randomized clinical trials on the presence of GERD after SG was carried out, in a period of 10 years. Results: A result of 336 articles was obtained, of which 327 were discarded and 9 were included. The variables of GERD post-SG were analyzed according to their symptoms ("improved," "worsened," and "unchanged"), "remission," or appearance "de novo." Conclusion: GERD is a frequently associated pathology in obese patients. Several authors reported that symptoms worsen after SG, and has been diagnosed de novo. The application of exhaustive preoperative studies and a correct surgical technique could reduce its incidence.
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Affiliation(s)
- Carlos Federico Davrieux
- Department of Percutaneous Surgery, DAICIM Foundation (Teaching, Research, Assistance in Minimal Invasive Surgery), Buenos Aires, Argentina.,Department of General Surgery, Sanatorio de la Mujer, Rosario, Argentina
| | - Mariano Palermo
- Department of Percutaneous Surgery, DAICIM Foundation (Teaching, Research, Assistance in Minimal Invasive Surgery), Buenos Aires, Argentina.,School of Medicine, University of Buenos Aires, Buenos Aires, Argentina.,Department of Bariatric Surgery, Diagnomed, Buenos Aires, Argentina
| | - Marius Nedelcu
- Clinique Saint-Michel, Centre Chirurgical de l'Obesite, Toulon, France
| | - David Nocca
- Digestive Surgery Division A, CHU de Montpellier, Montpellier, France
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20
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Sudlow AC, le Roux CW, Hardwick R, Pournaras DJ. The role of staging laparoscopy in complex bariatric surgery. Clin Obes 2021; 11:e12460. [PMID: 33940659 DOI: 10.1111/cob.12460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/23/2021] [Accepted: 04/18/2021] [Indexed: 11/27/2022]
Abstract
Determining which patients will benefit from bariatric surgery is complex; however, in those who have had previous bariatric surgery or extensive abdominal surgery, this can be particularly challenging. Decisions are often made based on assumptions rather than a complete assessment of all the anatomical and physiological factors. Adopting the approach utilised in gastrointestinal surgery with a diagnostic or staging laparoscopy, it may be possible to more accurately stage disease and determine fitness bariatric surgery. Laparoscopy is relatively low risk and contributes critical information with regard to access, post-operative anatomical changes and response to anaesthetic. Additionally, it allows surgeons to accurately determine the feasibility of undertaking a procedure and facilitates a more precise discussion with patients regarding suitability for surgery. Denying patients bariatric procedures based on an incomplete assessment of risk is unfair. Scenarios in which patients have had previous surgery, particularly bariatric surgery are increasingly common with the numbers requiring revisional surgery steadily rising. Although only applicable in highly selected, very complex cases, diagnostic laparoscopy adds critical information in the preoperative assessment of patients, not only improving care but potentially widening the numbers considered eligible for bariatric surgery. Our limited experience with staging laparoscopy in patients with previous complex abdominal surgery requiring revisional surgery illustrates the potential benefit it offers in determining patient suitability for further bariatric procedures. The adoption of an established technique, applied in a novel setting offers surgeons the opportunity to more thoroughly assess potentially high risk patients as well as the ability to offer personalised care.
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Affiliation(s)
- Alexis C Sudlow
- Department of Upper GI and Bariatric/Metabolic Surgery, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - Carel W le Roux
- Department of Experimental Pathology, University College Dublin, Dublin, Ireland
| | - Richard Hardwick
- Department of Upper GI Surgery, Addenbrookes Hospital, Cambridge, UK
| | - Dimitri J Pournaras
- Department of Upper GI and Bariatric/Metabolic Surgery, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
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21
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Effect of Concomitant Laparoscopic Sleeve Gastrectomy and Hiatal Hernia Repair on Gastroesophageal Reflux Disease in Patients with Obesity: a Systematic Review and Meta-analysis. Obes Surg 2021; 31:3905-3918. [PMID: 34254259 DOI: 10.1007/s11695-021-05545-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 06/11/2021] [Accepted: 06/17/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Hiatal hernia repair (HHR) during sleeve gastrectomy (SG) is recommended when hiatal hernia (HH) is found intraoperatively. However, its effect on gastroesophageal reflux disease (GERD) remains controversial. OBJECTIVE To evaluate the effect of concomitant SG and HHR on GERD in patients with obesity. METHODS Web of Science, PubMed, Embase, the Cochrane Library, and ClinicalTrials.gov databases were searched for all studies reporting the efficacy of SG+HHR for patients with obesity and GERD up to March 2021. RESULTS A total of 18 studies totaling 937 patients met the inclusion criteria. The results of meta-analysis showed that after SG+HHR, there was a significant reduction in GERD symptoms (OR: 0.20; 95% CI: 0.10 to 0.41; P < 0.00001), improvement in esophagitis (OR: 0.12, 95% CI: 0.05 to 0.26, P < 0.001), and decrease in GERD-HRQL (MD: 19.13, 95% CI: -3.74 to 34.51; P=0.01). The incidence of GERD remission after SG+HHR was 68.0% (95% CI: 55.0-80.9%), de novo GERD was 12% (95% CI: 8-16%), and HH recurrence was 11% (95% CI: 4 to 19%). SG+HHR was superior to SG alone in GERD remission (OR: 2.97, 95% CI: 1.78 to 4.95, P < 0.0001). However, there was no significant difference in de novo GERD after SG+HHR compared with SG alone. CONCLUSIONS SG+HHR can positively affect weight loss, GERD resolution, esophagitis reduction, and GERD-HRQL improvement. SG+HHR seems to have a promising future in patients with obesity and GERD. However, further studies based on objective assessment are warranted to evaluate these results better.
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22
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Małczak P, Pisarska-Adamczyk M, Zarzycki P, Wysocki M, Major P. Hiatal Hernia Repair during Laparoscopic Sleeve Gastrectomy: Systematic Review and Meta-analysis on Gastroesophageal Reflux Disease symptoms changes. POLISH JOURNAL OF SURGERY 2021; 93:1-5. [PMID: 34552030 DOI: 10.5604/01.3001.0014.9356] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Introduction Obesity is associated with a higher prevalence of various comorbidities including gastroesophageal reflux disease. It is yet still unclear whether LSG exacerbates or alleviates GERD symptoms. Available date in the literature on LSG influence on GERD are contradictory. Material and methods Systematic review of literature comparing GERD in sleeve gastrectomy versus sleeve gastrectomy with concomtitant hiatal repair. The review was conducted in January 2021 in accordance to PRISMA guidelines. Inclusion criteria involved reporting GERD and comparison of above mentioned techniques. Primary outcome of interest were alleviation of GERD and "de-novo" GERD symptoms. Secondary outcomes were operative time and morbidity. Results Initial search yielded 831 records. After the review and full-text screening 5 studies were included in the analysis. There were no differences in terms of GERD outcomes, p=0.74 for alleviation, p=0.77 for new symptoms. Concomitant hiatal hernia repair significantly prolongs sleeve gastrectomy by 38 mins. Conclusion There are no differences in GERD between hiatal hernia repair during sleeve gastrectomy in comparison to sleeve gastrectomy alone. More high-quality studies are required to fully evaluate this subject.
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Affiliation(s)
- Piotr Małczak
- Department of Medical Didactics, Jagiellonian University Medical College, Kraków, Poland
| | | | - Piotr Zarzycki
- Department of Medical Didactics, Jagiellonian University Medical College, Kraków, Poland
| | - Michał Wysocki
- Students' Scientific Group at 2'nd Department of Surgery, Jagiellonian University Medical College, Kraków, Poland
| | - Piotr Major
- 2'nd Department of Surgery, Jagiellonian University Medical College, Kraków, Poland
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23
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Laxague F, Sadava EE, Herbella F, Schlottmann F. When should we use mesh in laparoscopic hiatal hernia repair? A systematic review. Dis Esophagus 2021; 34:6041174. [PMID: 33333552 DOI: 10.1093/dote/doaa125] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/21/2020] [Accepted: 11/06/2020] [Indexed: 12/11/2022]
Abstract
The use of mesh in laparoscopic hiatal hernia repair (LHHR) remains controversial. The aim of this systematic review was to determine the usefulness of mesh in patients with large hiatal hernia (HH), obesity, recurrent HH, and complicated HH. We performed a systematic review of the current literature regarding the outcomes of LHHR with mesh reinforcement. All articles between 2000 and 2020 describing LHHR with primary suturing, mesh reinforcement, or those comparing both techniques were included. Symptom improvement, quality of life (QoL) improvement, and recurrence rates were evaluated in patients with large HH, obesity, recurrent HH, and complicated HH. Reported outcomes of the use of mesh in patients with large HH had wide variability and heterogeneity. Morbidly obese patients with HH should undergo a weight-loss procedure. However, the benefits of HH repair with mesh are unclear in these patients. Mesh reinforcement during redo LHHR may be beneficial in terms of QoL improvement and hernia recurrence. There is scarce evidence supporting the use of mesh in patients undergoing LHHR for complicated HH. Current data are heterogeneous and have failed to find significant differences when comparing primary suturing with mesh reinforcement. Further research is needed to determine in which patients undergoing LHHR mesh placement would be beneficial.
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Affiliation(s)
- Francisco Laxague
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | - Emmanuel E Sadava
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | - Fernando Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
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24
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Sano A, Seki Y, Kasama K, Nabekura T, Kurokawa Y, Ubukata Y, Nakazawa N, Hara K, Sakai M, Sohda M, Shirabe K, Saeki H. Impact of the Hepatic Branch of the Vagus Nerve Transection in Laparoscopic Sleeve Gastrectomy for Patients with Obesity and Type 2 Diabetes Mellitus. Obes Surg 2021; 31:3926-3935. [PMID: 34081275 DOI: 10.1007/s11695-021-05510-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/23/2021] [Accepted: 05/26/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND An increase in gastroesophageal reflux disease (GERD) after laparoscopic sleeve gastrectomy (LSG) has been reported, and concomitant hiatal hernia repair (HHR) during LSG is expected to reduce the incidence of post-LSG GERD. In HHR, the hepatic branch of the vagus nerve is anatomically transected. Recent experimental animal models suggest that vagotomy may affect glycemic control and weight loss through a neuroendocrine response. OBJECTIVES To examine whether LSG with/without hepatic branch vagotomy (HV) has a clinical impact on glycemic control in patients with obesity and type 2 diabetes mellitus (T2DM). Furthermore, the impact on weight loss and post-LSG GERD were evaluated. METHODS A total of 204 Japanese patients with obesity and T2DM, who underwent LSG and completed 1-year follow-up, were retrospectively analyzed. Operative outcomes, weight loss, glycemic, and GERD-related parameters were compared between the LSG/HHR/HV group (n = 89) and the LSG group (n = 115). RESULTS There was no significant difference in the background factors in terms of anthropometric and T2DM-related parameters between the groups. The median operation times in the LSG/HHR/HV and LSG groups were 133 and 124 minutes, respectively (p = 0.236). At 1 year, the diabetes remission rate, HbA1c, fasting glucose, and C-peptide levels were all comparable between the groups. The weight loss effect was also comparable. The patients in the LSG/HHR/HV group achieved significant improvement and prevention of GERD and hiatus hernia (p < 0.001). CONCLUSION HV does not appear to have a clinical impact on glycemic control and weight loss. Concomitant HHR with LSG serves to reduce post-LSG GERD.
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Affiliation(s)
- Akihiko Sano
- Weight Loss and Metabolic Surgery Center, Yotsuya Medical Cube, 7-7 Nibancho, Chiyoda-ku, Tokyo, 102-0084, Japan.,Department of General Surgical Science, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Yosuke Seki
- Weight Loss and Metabolic Surgery Center, Yotsuya Medical Cube, 7-7 Nibancho, Chiyoda-ku, Tokyo, 102-0084, Japan.
| | - Kazunori Kasama
- Weight Loss and Metabolic Surgery Center, Yotsuya Medical Cube, 7-7 Nibancho, Chiyoda-ku, Tokyo, 102-0084, Japan
| | - Taiki Nabekura
- Weight Loss and Metabolic Surgery Center, Yotsuya Medical Cube, 7-7 Nibancho, Chiyoda-ku, Tokyo, 102-0084, Japan
| | - Yoshimochi Kurokawa
- Weight Loss and Metabolic Surgery Center, Yotsuya Medical Cube, 7-7 Nibancho, Chiyoda-ku, Tokyo, 102-0084, Japan
| | - Yasunari Ubukata
- Department of General Surgical Science, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Nobuhiro Nakazawa
- Department of General Surgical Science, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Keigo Hara
- Department of General Surgical Science, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Makoto Sakai
- Department of General Surgical Science, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Makoto Sohda
- Department of General Surgical Science, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Ken Shirabe
- Department of General Surgical Science, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Hiroshi Saeki
- Department of General Surgical Science, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
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Shahraki MS, Dehkordi MM, Heydari M, Shahmiri SS, Soheilipour M, Hajian A. Cruroplasty added to laparoscopic sleeve gastrectomy; does it decrease postoperative incidence of de-novo acid reflux?: A randomised controlled trial. Ann Med Surg (Lond) 2021; 66:102415. [PMID: 34113443 PMCID: PMC8170119 DOI: 10.1016/j.amsu.2021.102415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 05/15/2021] [Accepted: 05/16/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy(LSG) is the most popular bariatric surgery worldwide. Postoperative de-novo acid reflux is one of the major common complications of the procedure. Different additive anti-reflux surgical techniques have been tried to decrease the complication although no favorable outcome is obtained. This study was conducted to evaluate effects of concurrent cruroplasty during LSG on postoperative de-novo acid reflux incidence rate. METHODS In current participant-blinded randomised controlled trial total of 80 subjects who were candidate for LSG were enrolled from the September 2018 to the December 2019. Following matching patients by gender and age, simple randomization method was held to allocate participants to LSG alone and LSG + cruroplasty groups with equal 40 members in each. Demographic data, length of hospital stay, and operation time was registered. Presence of acid reflux was looked by using gastroesophageal reflux disease-health related quality of life(GERD-HRQL) questionnaire prior and 6 months after surgery in follow-up visit. RESULTS Finally 12/28 and 14/26 male/females with 38.5 ± 10.7 and 39.7 ± 8.2 years of age were recruited in LSG alone and LSG + cruroplasty, respectively.(p > 0.05) The length of operative time was significantly shorter in LSG alone(p < 0.01) although no obvious difference was existed in length of hospital stay between groups.(p = 0.7) Postoperative de-novo acid reflux also was not considerably lesser after cruroplasty compared with controls.(p = 0.1) The GERD-HRQL scores were not remarkable between subjects of study groups.(p > 0.05). CONCLUSION Equipping LSG with concurrent cruroplasty to diminish postoperative de-novo gastroesophageal acid reflux is not effective and not recommended in absence of other indications.
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Affiliation(s)
- Masoud Sayadi Shahraki
- Department of General Surgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohsen Mahmoudieh Dehkordi
- Department of General Surgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mahmoud Heydari
- Department of General Surgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shahab Shahabi Shahmiri
- Department of General Surgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Maryam Soheilipour
- Department of Gastroenterology and Hepatology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Abbas Hajian
- Department of General Surgery, School of Medicine, Kashan University of Medical Sciences, Kashan, Iran
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Chan DL, Chern TY, Iliopoulos J, Hennessy A, Wong SKH, Ng EKW, Talbot ML. Accuracy of High-Resolution Manometry in Hiatal Hernia Diagnosis in Primary and Revision Bariatric Surgery. Obes Surg 2021; 31:2906-2912. [PMID: 33852151 DOI: 10.1007/s11695-021-05335-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 03/02/2021] [Accepted: 03/04/2021] [Indexed: 12/26/2022]
Abstract
PURPOSE There is a complex association between obesity, hiatal hernia (HH), and reflux. There is a deficiency of literature on the accuracy of preoperative high-resolution manometry (HRM) in detecting HH before both primary and revision bariatric surgery. MATERIALS AND METHODS A retrospective analysis of a prospective database of all HRM performed before bariatric surgery from 2014 to 2019. An electronic medical records review was conducted. Sensitivity, specificity, and global diagnostic test accuracy were calculated. RESULTS Sixty-seven patients with HRM (mean age of 44.0 ± 11.3 years, body mass index 40.8 ± 6.9 kg/m2) were eligible. Intraoperative diagnosis of HH was made in 37 patients (55.2% prevalence). The HRM sensitivity was 48.7% (95% confidence interval (CI) 31.9-65.6%), specificity 90.0% (95% CI 73.5-97.9%), and accuracy was 67.2% (95% CI 54.6-78.2%). Comparing primary (28) and revision (39) surgery, the sensitivity (37.5% vs 57.1%), specificity (75.0% vs 100%), and diagnostic accuracy (54.3% vs 76.3%) were comparable, with overlapping 95% CI. Endoscopy performed in 30 patients had a sensitivity of 25.5% (95% CI 6.8-49.9%), specificity of 100% (95% CI 75.3-100%), and accuracy of 57.8% (95% CI 38.5-75.5%) and was comparable to HRM. CONCLUSION High-resolution manometry for the detection of HH before bariatric surgery has a high specificity and maintains a high accuracy in both primary and revision bariatric surgery.
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Affiliation(s)
- Daniel L Chan
- Department of Surgery, St George Hospital, Gray St, Sydney, NSW, 2217, Australia. .,School of Medicine, Western Sydney University, Sydney, NSW, 2751, Australia. .,Faculty of Medicine, The University of New South Wales, Sydney, NSW, 2052, Australia. .,Division of Upper Gastrointestinal & Metabolic Surgery, Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, SAR, China.
| | - Tien Y Chern
- Department of Surgery, St George Hospital, Gray St, Sydney, NSW, 2217, Australia.,Faculty of Medicine, The University of New South Wales, Sydney, NSW, 2052, Australia
| | - Jim Iliopoulos
- Department of Surgery, St George Hospital, Gray St, Sydney, NSW, 2217, Australia.,School of Medicine, Western Sydney University, Sydney, NSW, 2751, Australia.,Faculty of Medicine, The University of New South Wales, Sydney, NSW, 2052, Australia
| | - Annemarie Hennessy
- School of Medicine, Western Sydney University, Sydney, NSW, 2751, Australia
| | - Simon K H Wong
- Division of Upper Gastrointestinal & Metabolic Surgery, Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, SAR, China
| | - Enders K W Ng
- Division of Upper Gastrointestinal & Metabolic Surgery, Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, SAR, China
| | - Michael L Talbot
- Department of Surgery, St George Hospital, Gray St, Sydney, NSW, 2217, Australia.,School of Medicine, Western Sydney University, Sydney, NSW, 2751, Australia.,Faculty of Medicine, The University of New South Wales, Sydney, NSW, 2052, Australia
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Clapp B, Liggett E, Barrientes A, Aguirre K, Marwaha V, Tyroch A. Concomitant Hiatal Hernia Repair with Sleeve Gastrectomy: A 5-Year Analysis. JSLS 2021; 24:JSLS.2020.00066. [PMID: 33414611 PMCID: PMC7732366 DOI: 10.4293/jsls.2020.00066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background: The sleeve gastrectomy (SG) can be associated with postoperative gastroesophageal reflux and when a hiatal hernia (HH) is present, it should be fixed. Earlier studies have shown that 20% of SG have a concomitant hiatal hernia repair (SG+HHR). The aim of this project is to determine the rate of SG+HHR in a large state administrative database. Methods: The Texas Inpatient Public Use Data File (IPUDF) and Outpatient Public Use Data File (OPUDF) for the years 2013-2017 were examined for patients that underwent SG+HHR at the same time. Patient demographics, diagnosis, and charge data were also examined. A t-test was performed between groups and P was considered significant at < 0.05. Results: In the OPUDF, there were 6,193 (33.7%) patients who underwent SG+HHR out of 18,403 patients who underwent SG. Mean charges were $94,741 [standard deviation (SD) = $87,284]. Length of stay (LOS) was 2.1 (SD = 3.5) vs 2.3 days (SD = 3.3) with a shorter stay for SG+HHR vs SG alone (P < 0.001). In the IPUDF, there were 11,536 (21.1%) patients who underwent SG+HHR out of 54,545 patients who underwent SG. Mean charges were $69,006 (SD = $46,365). LOS was 1.59 days (SD = 3.7) for SG+HHR vs 1.63 days (SD = 1.6) for SG (P = .043). The rate of SG+HHR increased over the study period. Conclusions: SG+HHR is common in both the outpatient and inpatient setting. There is a yearly trend of increasing rates of SG+HHR.
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Affiliation(s)
- Benjamin Clapp
- Texas Tech Health Sciences Center Paul Foster School of Medicine, El Paso, TX
| | - Evan Liggett
- Texas Tech Health Sciences Center Paul Foster School of Medicine, El Paso, TX
| | - Ashtyn Barrientes
- Texas Tech Health Sciences Center Paul Foster School of Medicine, El Paso, TX
| | - Katherine Aguirre
- Texas Tech Health Sciences Center Paul Foster School of Medicine, El Paso, TX
| | - Vidur Marwaha
- Texas Tech Health Sciences Center Paul Foster School of Medicine, El Paso, TX
| | - Alan Tyroch
- Texas Tech Health Sciences Center Paul Foster School of Medicine, El Paso, TX
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Bonavina L. Commentary: Evaluation of Anterior Phrenoesophageal Ligament Preservation During Hiatus Hernia Repair in Laparoscopic Sleeve Gastrectomy as an Anti-Reflux Measure by Elmaleh et al.. J Laparoendosc Adv Surg Tech A 2021; 31:515-516. [PMID: 33769907 DOI: 10.1089/lap.2021.29036.lb] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Luigi Bonavina
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, University of Milan, Milano, Italy
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29
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Diagnostic Criteria for Gastro-esophageal Reflux Following Sleeve Gastrectomy. Obes Surg 2021; 31:1464-1474. [PMID: 33491160 PMCID: PMC8012318 DOI: 10.1007/s11695-020-05152-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 11/15/2020] [Accepted: 11/30/2020] [Indexed: 12/11/2022]
Abstract
Background Gastro-esophageal reflux disease (GERD) post-sleeve gastrectomy (SG) is a controversial issue and diagnostic dilemma. Strong heterogeneity exists in the assessment of reflux post-SG, and better diagnostic tools are needed to characterize symptomatic reflux. We aimed to determine the discriminant factors of symptomatic reflux and establish diagnostic thresholds for GERD following SG. Materials and Methods Patients post-SG were categorized into asymptomatic and symptomatic cohorts and completed validated symptom questionnaires. All patients underwent stationary esophageal manometry and 24-h ambulatory pH monitoring. Univariate and multivariate analyses were conducted to determine the strongest discriminant factors for GERD. Results Baseline characteristics of the asymptomatic cohort (n = 48) and symptomatic cohort (n = 76) were comparable. The median post-operative duration was 7.3 (14.1) vs 7.5 (10.7) months (p = 0.825). The symptomatic cohort was more female predominant (90.8 vs 72.9%, p = 0.008). Reflux scores were significantly higher in the symptomatic group (36.0 vs 10.5, p = 0.003). Stationary manometry parameters were similar, including hiatus hernia prevalence and impaired esophageal motility. The symptomatic cohort had significantly higher total acid exposure, especially while supine (11.3% vs 0.6%, p < 0.001). Univariate and multivariate regressions delineated reflux score and supine acid exposure as discriminant factors for symptomatic reflux. The thresholds for distinguishing symptomatic reflux are as follows: reflux score of 11.5 (sensitivity 84.0%, specificity 68.2%) and supine acid exposure of 2.65% (sensitivity 67.1%, specificity 70.8%). Conclusion A reflux score of 11.5 or more or supine acid exposure of 2.65% or more should be considered diagnostic in defining symptomatic reflux following SG.
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Lewis KH, Callaway K, Argetsinger S, Wallace J, Arterburn DE, Zhang F, Fernandez A, Ross-Degnan D, Dimick JB, Wharam JF. Concurrent hiatal hernia repair and bariatric surgery: outcomes after sleeve gastrectomy and Roux-en-Y gastric bypass. Surg Obes Relat Dis 2021; 17:72-80. [PMID: 33109444 PMCID: PMC8116048 DOI: 10.1016/j.soard.2020.08.035] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/30/2020] [Accepted: 08/24/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hiatal hernias are often repaired concurrently with bariatric surgery to reduce risk of gastroesophageal reflux disease-related complications. OBJECTIVES To examine the association between concurrent hiatal hernia repair (HHR) and bariatric outcomes. SETTING A 2010-2017 U.S. commercial insurance claims data set. METHODS We conducted a retrospective cohort study. We identified adults who underwent sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) alone or had bariatric surgery concurrently with HHR. We matched patients with and without HHR and followed patients up to 3 years for incident abdominal operative interventions, bariatric revisions/conversions, and endoscopy. Time to first event for each outcome was compared using multivariable Cox proportional hazards modeling. RESULTS We matched 1546 SG patients with HHR to 3170 SG patients without HHR, and we matched 457 RYGB patients with HHR to 1156 RYGB patients without HHR. A total of 73% had a full year of postoperative enrollment. Patients who underwent concurrent SG and HHR were more likely to have additional abdominal operations (adjusted hazard ratio [aHR], 2.1; 95% CI, 1.5-3.1) and endoscopies (aHR, 1.5; 95% CI, 1.2-1.8) but not bariatric revisions/conversions (aHR, 1.7; 95% CI, .6-4.6) by 1 year after surgery, a pattern maintained at 3 years of follow-up. Among RYGB patients, concurrent HHR was associated only with an increased risk of endoscopy (aHR, 1.4; 95% CI, 1.1-1.8)) at 1 year of follow-up, persisting at 3 years. CONCLUSIONS Concurrent SG/HHR was associated with increased risk of some subsequent operative and nonoperative interventions, a pattern that was not consistently observed for RYGB. Additional studies could examine whether changes to concurrent HHR technique could reduce risk.
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Affiliation(s)
- Kristina H Lewis
- Department of Epidemiology & Prevention, Department of Implementation Science, Division of Public Health Sciences, Wake Forest University Health Sciences, Winston-Salem, North Carolina; Department of Surgery, Wake Forest University Health Sciences, Winston-Salem, North Carolina.
| | - Katherine Callaway
- Division of Health Policy & Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
| | - Stephanie Argetsinger
- Division of Health Policy & Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
| | - Jamie Wallace
- Division of Health Policy & Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
| | - David E Arterburn
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Fang Zhang
- Division of Health Policy & Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
| | - Adolfo Fernandez
- Department of Surgery, Wake Forest University Health Sciences, Winston-Salem, North Carolina
| | - Dennis Ross-Degnan
- Division of Health Policy & Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
| | - Justin B Dimick
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - J Frank Wharam
- Division of Health Policy & Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
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Khan MZ, Yousaf H, Dahiya DS, Wani F, Kichloo A. Chest Pain: A Relatively Benign Symptom of Type IV Hiatal Hernia. Cureus 2020; 12:e11459. [PMID: 33329957 PMCID: PMC7733775 DOI: 10.7759/cureus.11459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2020] [Indexed: 12/13/2022] Open
Abstract
Hiatal hernia results from the translocation of intra-abdominal contents from their usual position into the thorax. They can be categorized into type I-IV which implies varying gradations of herniation. The symptomatology can range from just chest pain in the less severe types to respiratory and hemodynamic compromise resulting from strangulation in the advanced hernias. Our patient was an 81-year-old female with a past medical history of gastroesophageal reflux disease (GERD), deep venous thrombosis (DVT), hypertension, hyperlipidemia, coronary artery disease (CAD), and cerebrovascular accident (CVA), who presented to the emergency department (ED) with the chief complaint of chest pain. Assessment of the vitals in the ED revealed a temperature of 37.2 °C, respiratory rate of 18 breaths/minute with an oxygen saturation of 100% on room air, heart rate of 95 beats/min, and blood pressure reading of 132/110 mmHg. Due to significant concern of a possible coronary pathology leading to chest pain, the patient was given 325 mg of aspirin and one tablet of sublingual nitroglycerin. Her electrocardiogram (EKG) was unremarkable but the chest X-ray revealed a large retrocardiac hernia. The finding was corroborated after a review of the computerized tomography (CT) scan performed at the outlying facility. She was treated with omeprazole, a gastroenterologist was consulted, and an esophagogastroduodenoscopy (EGD) performed which revealed significant erosions in the distal esophagus and gastric antrum. She was deemed a high-risk surgical candidate for any intervention and thus managed conservatively with proton pump inhibitor (PPI) therapy. The case highlights the pertinent facts about hiatal hernia. Although the diagnosis of chest pain with the aforementioned comorbidities could be skewed towards coronary pathology, keeping a wide differential is important so that the right diagnosis can be made in a timely fashion and complications avoided.
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Affiliation(s)
- Muhammad Z Khan
- Internal Medicine, Central Michigan University College of Medicine, Saginaw, USA
| | - Hamza Yousaf
- Internal Medicine, Nishtar Medical University, Multan, PAK
| | - Dushyant S Dahiya
- Internal Medicine, Central Michigan University College of Medicine, Saginaw, USA
| | - Farah Wani
- Family Medicine, Samaritan Medical Center, Watertown, USA
| | - Asim Kichloo
- Internal Medicine, Central Michigan University College of Medicine, Saginaw, USA
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Lye TJY, Ng KR, Tan AWE, Syn N, Woo SM, Lim EKW, Eng AKH, Chan WH, Tan JTH, Lim CH. Small hiatal hernia and postprandial reflux after vertical sleeve gastrectomy: A multiethnic Asian cohort. PLoS One 2020; 15:e0241847. [PMID: 33156875 PMCID: PMC7647085 DOI: 10.1371/journal.pone.0241847] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 10/21/2020] [Indexed: 12/15/2022] Open
Abstract
Background Laparoscopic vertical sleeve gastrectomy (LSG) is a popular bariatric procedure performed in Asia, as obesity continues to be on the rise in our population. A major problem faced is the development of de novo gastroesophageal reflux disease (GERD) after LSG, which can be chronic and debilitating. In this study, we aim to assess the relationship between the presence of small hiatal hernia (HH) and the development of postoperative GERD, as well as to explore the correlation between GERD symptoms after LSG and timing of meals. In doing so, we hope to gain a better understanding about the type of reflux that occurs after LSG and take a step closer towards effectively managing this difficult to treat condition. Methods We retrospectively reviewed data collected from patients who underwent LSG in our hospital from Dec 2008 to Dec 2016. All patients underwent preoperative upper GI endoscopy, during which the identification of hiatal hernia takes place. Patients' information and reflux symptoms are recorded using standardized questionnaires, which are administered preoperatively, and again during postoperative follow up visits. Results Of the 255 patients, 125 patients (74%) developed de novo GERD within 6 months post-sleeve gastrectomy. The rate of de novo GERD was 57.1% in the group with HH, and 76.4% in the group without HH. Adjusted analysis showed no significant association between HH and GERD (RR = 0.682; 95% CI 0.419 to 1.111; P = 0.125). 88% of the patients who developed postoperative GERD reported postprandial symptoms occurring only after meals, and the remaining 12% of patients reported no correlation between the timing of GERD symptoms and meals. Conclusion There is no direct correlation between the presence of small hiatal hernia and GERD symptoms after LSG. Hence, the presence of a small sliding hiatal hernia should not be exclusion for sleeve gastrectomy. Electing not to perform concomitant hiatal hernia repair also does not appear to result in higher rates of postoperative or de novo GERD.
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Affiliation(s)
- Tiffany Jian Ying Lye
- Division of Surgery, Department of Upper Gastrointestinal & Bariatric Surgery, Singapore General Hospital, Singapore, Singapore
- * E-mail:
| | - Kiat Rui Ng
- Sheffield Medical School, University of Sheffield, Sheffield, United Kingdom
| | | | - Nicholas Syn
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Shi Min Woo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Eugene Kee Wee Lim
- Division of Surgery, Department of Upper Gastrointestinal & Bariatric Surgery, Singapore General Hospital, Singapore, Singapore
| | - Alvin Kim Hock Eng
- Division of Surgery, Department of Upper Gastrointestinal & Bariatric Surgery, Singapore General Hospital, Singapore, Singapore
| | - Weng Hoong Chan
- Division of Surgery, Department of Upper Gastrointestinal & Bariatric Surgery, Singapore General Hospital, Singapore, Singapore
| | - Jeremy Tian Hui Tan
- Division of Surgery, Department of Upper Gastrointestinal & Bariatric Surgery, Singapore General Hospital, Singapore, Singapore
| | - Chin Hong Lim
- Division of Surgery, Department of Upper Gastrointestinal & Bariatric Surgery, Singapore General Hospital, Singapore, Singapore
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The Role of Robotics in Bariatric Surgery. CURRENT SURGERY REPORTS 2020. [DOI: 10.1007/s40137-020-00277-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Boru CE, Termine P, Antypas P, Iossa A, Ciccioriccio CM, DE Angelis F, Micalizzi A, Silecchia G. Concomitant hiatal hernia repair during bariatric surgery: does the reinforcement make the difference? Minerva Surg 2020; 76:33-42. [PMID: 33006451 DOI: 10.23736/s2724-5691.20.08503-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Hiatal hernia repair (HHR) is still controversial during bariatric procedures, especially in case of laparoscopic sleeve gastrectomy (LSG). AIMS to report the long-term results of concomitant HHR, evaluating the safety and efficacy of posterior cruroplasty (PC), simple or reinforced with biosynthetic, absorbable Bio-A® mesh (Gore, Flagstaff, AZ, USA). Primary endpoint: PC's failure, defined as symptomatic HH recurrence, nonresponding to medical treatment and requiring revisional surgery. METHODS The prospective database of 1876 bariatric operations performed in a center of excellence between 2011-2019 was searched for concomitant HHR. Intraoperative measurement of the hiatal surface area (HSA) was performed routinely. RESULTS A total of 250 patients undergone bariatric surgery and concomitant HHR (13%). Simple PC (group A, 151 patients) was performed during 130 LSG, 5 re-sleeves and 16 gastric bypasses; mean BMI 43.4±5.8 kg/m2, HSA mean size 3.4±2 cm2. Reinforced PC (group B) was performed in 99 cases: 62 primary LSG, 22 LGB and 15 revisions of LSG; mean BMI 44.6±7.7 kg/m2, HSA mean size 6.7±2 cm2. PC's failure, with intrathoracic migration (ITM) of the LSG was encountered in 12 cases (8%) of simple vs. only 4 cases (4%) of reinforced PC (P=0.23); hence, a repeat, reinforced PC and R-en-Y gastric bypass (LRYGB) was performed laparoscopically in all cases. No mesh-related complications were registered perioperatively or after long-term follow-up (mean 50 months). One case of cardiac metaplasia without goblet cells was detected 4 years postoperatively; conversion to LRYGB, with reinforced redo of the PC was performed. The Cox hazard analysis showed that the use of more than four stitches for cruroplasty represents a negative factor on recurrence (HR=8; P<0.05). CONCLUSIONS An aggressive search for and repair of HH during any bariatric procedure seems advisable, allowing a low HH recurrence rates. Additional measures, like mesh reinforcement of crural closure with biosynthetic, absorbable mesh, seem to improve results on long term follow-up, especially in case of larger hiatal defects. In our experience, reinforcement of even smaller defects seems advisable in obese population.
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Affiliation(s)
- Cristian E Boru
- Division of General Surgery and Bariatric Center of Excellence-IFSO EC, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy -
| | - Pietro Termine
- Division of General Surgery and Bariatric Center of Excellence-IFSO EC, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy
| | - Pavlos Antypas
- Division of General Surgery and Bariatric Center of Excellence-IFSO EC, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy
| | - Angelo Iossa
- Division of General Surgery and Bariatric Center of Excellence-IFSO EC, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy
| | - Chiara M Ciccioriccio
- Division of General Surgery and Bariatric Center of Excellence-IFSO EC, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy
| | - Francesco DE Angelis
- Division of General Surgery and Bariatric Center of Excellence-IFSO EC, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy
| | - Alessandra Micalizzi
- Division of General Surgery and Bariatric Center of Excellence-IFSO EC, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy
| | - Gianfranco Silecchia
- Division of General Surgery and Bariatric Center of Excellence-IFSO EC, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy
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Boru CE, Coluzzi MG, de Angelis F, Silecchia G. Long-Term Results After Laparoscopic Sleeve Gastrectomy with Concomitant Posterior Cruroplasty: 5-Year Follow-up. J Gastrointest Surg 2020; 24:1962-1968. [PMID: 31410817 DOI: 10.1007/s11605-019-04355-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 07/30/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Hiatal hernia (HH) repair during laparoscopic sleeve gastrectomy (LSG) has been advocated to reduce the incidence of postoperative gastroesophageal reflux disease (GERD) and/or intrathoracic migration (ITM). The necessity of intraoperative repair in asymptomatic patients is still controversial. Previous, mid-term results of a prospective, comparative study evaluating posterior cruroplasty concomitant with LSG (group A 48 patients with simple vs. group B 48 reinforced with bioabsorbable mesh) confirmed the safety and effectiveness of simultaneous procedures. Present aim was to report the 60 months follow-up update, evaluating GERD and esophageal lesions' incidence and HH's recurrence. RESULTS Follow-up was completed in 87.5% of the patients. Recurrent GERD was registered in 6/38 (15.7%, group A) and in 9/46 (19.5%, group B) (p = 1.0000). Grade A esophagitis and GERD was shown in 2 patients (5.2%), respectively 2 (4.3%) of each group (p = 1.0000), and recurrent HH was confirmed subsequently by contrast study and CT scan. Neither Barrett's lesions nor de novo GERD was found in any patient. Failure of the cruroplasty with ITM was recorded in 7 patients from group A (18.4%) and 2 patients from group B (4.3%) p < 0.05; hence, a repeat posterior, reinforced cruroplasty was performed in all cases. A total of 12 patients (14.2%, 8 respective 4) were converted within 5 years for persistent/recurrent GERD, with only 1 case of de novo (group B). CONCLUSIONS Accurate patient selection and proper sleeve technique, combined with posterior cruroplasty (simple or reinforced) ensure effectiveness, with a rate of failure (HH recurrence) at 5 years of 10.7%.
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Affiliation(s)
- Cristian Eugeniu Boru
- Division of General Surgery & Bariatric Center of Excellence-IFSO EC, Department of Medico-Surgical Sciences and Biotechnologies, University La Sapienza of Rome, Via F. Faggiana, 1668, Latina, Italy.
| | - Maria Grazia Coluzzi
- Division of General Surgery & Bariatric Center of Excellence-IFSO EC, Department of Medico-Surgical Sciences and Biotechnologies, University La Sapienza of Rome, Via F. Faggiana, 1668, Latina, Italy
| | - Francesco de Angelis
- Division of General Surgery & Bariatric Center of Excellence-IFSO EC, Department of Medico-Surgical Sciences and Biotechnologies, University La Sapienza of Rome, Via F. Faggiana, 1668, Latina, Italy
| | - Gianfranco Silecchia
- Division of General Surgery & Bariatric Center of Excellence-IFSO EC, Department of Medico-Surgical Sciences and Biotechnologies, University La Sapienza of Rome, Via F. Faggiana, 1668, Latina, Italy
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Angrisani L, Santonicola A, Borrelli V, Iovino P. Sleeve gastrectomy with concomitant hiatal hernia repair in obese patients: long-term results on gastroesophageal reflux disease. Surg Obes Relat Dis 2020; 16:1171-1177. [PMID: 32593594 DOI: 10.1016/j.soard.2020.04.049] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/14/2020] [Accepted: 04/30/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hiatal hernia repair (HHR) during Sleeve Gastrectomy (SG) is recommended when the defect is intraoperatively found; however, the long term effect on gastro-esophageal reflux disease (GERD) remains controversial. OBJECTIVES This study aimed to report long-term follow-up data, at least after 7 years, of SG with concomitant HHR and the outcome on GERD symptoms. SETTING Tertiary-care referral hospital. METHODS This study retrospectively analyzed 91 obese patients submitted to SG + HHR with a minimum of 7-years follow-up. The preoperative evaluation included GERD symptoms assessment by a standardized questionnaire, proton pump inhibitor usage evaluation, an upper gastrointestinal endoscopy, and a barium-swallow esophagogram to detect the presence of HH. At long-term follow-up visit, GERD assessment was performed to evaluate remission, persistence, or new onset of typical GERD symptoms; proton pump inhibitor usage was also investigated. Patients underwent barium-swallow esophagogram and/or upper gastrointestinal endoscopy. RESULTS At long-term evaluation, 2 of 91 patients (2.2%) were lost and 1 patient underwent Roux-en-Y gastric bypass. Of patients with preoperative GERD, 60% had GERD resolution; however, 27 of 88 (30.6%) patients reported postoperative GERD symptoms. Among these patients 15 (55.5%) showed the HH recurrence detected by barium-swallow esophagogram. All patients with HH recurrence had esophagitis and 1 case had a Barrett's esophagus. In the remaining 12 patients (44.4%) with postoperative GERD without HH recurrence, the barium-swallow esophagogram showed signs of reflux in reverse Trendelenburg. CONCLUSIONS At long-term follow-up HH recurrence was consistently related to the presence of GERD symptoms and to a high rate of esophagitis and Barrett's esophagus. In all patients with GERD symptoms after SG + HHR, a HH recurrence should be suspected and an upper gastrointestinal endoscopy strongly recommended to rule out esophagitis, and especially Barrett's esophagus.
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Affiliation(s)
- Luigi Angrisani
- Department of Public Health, "Federico II" University, Naples, Italy
| | - Antonella Santonicola
- Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana," University of Salerno, Salerno, Italy.
| | - Vincenzo Borrelli
- General Surgery Unit, Istituto di Cura Città di Pavia-Gruppo San Donato, Pavia, Italy
| | - Paola Iovino
- Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana," University of Salerno, Salerno, Italy
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Iron, Vitamin B 12, Folate and Copper Deficiency After Bariatric Surgery and the Impact on Anaemia: a Systematic Review. Obes Surg 2020; 30:4542-4591. [PMID: 32785814 DOI: 10.1007/s11695-020-04872-y] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/19/2020] [Accepted: 07/22/2020] [Indexed: 12/20/2022]
Abstract
Bariatric surgery may increase the risk of iron, vitamin B12, folate and copper deficiencies, which can cause anaemia. This review aims to critique the evidence on the prevalence of these nutritional deficiencies and the impact on anaemia in the first 12 months after surgery. PRISMA and MOOSE frameworks, the NHMRC evidence hierarchy and The Academy of Nutrition and Dietetics bias tool were used to systematically critique current literature. Seventeen studies reported on deficiency prevalence with the majority being of low quality. Important confounders to serum micronutrient levels were not adequately considered. Results on the prevalence of nutritional anaemias were also lacking. Further investigation into the prevalence of iron, vitamin B12, folate and copper deficiency and its impact on anaemia in bariatric surgery is needed.
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Ahuja A, Mahawar K. Bariatric surgery in patients with gastroesophageal reflux disease and/or hiatus hernia. MINERVA CHIR 2020; 75:345-354. [PMID: 32773756 DOI: 10.23736/s0026-4733.20.08486-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Gastroesophageal reflux disease (GERD) and hiatus hernia (HH) are frequently encountered comorbidities in patients seeking bariatric and metabolic surgery (BMS) for obesity. sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and one anastomosis gastric bypass (OAGB) are the three commonest bariatric procedures performed worldwide. The purpose of this review was to analyze and compare the data on outcomes of these three procedures in patients with GERD and/or HH. EVIDENCE ACQUISITION We examined published English language scientific literature available on PubMed for data comparing SG, RYGB, and OAGB with specific focus on GERD outcomes and outcomes in those with GERD and/or HH. EVIDENCE SYNTHESIS Several authors have addressed the outcome of GERD after bariatric surgery. There have been randomized control trials and comparative studies in the literature comparing the results of these procedure. But very few studies have exclusively looked into the outcome of different procedures in patients with pre-existing GERD and/or HH. In this narrative review, we evaluate pros and cons of three commonest bariatric procedures worldwide in this subgroup of patients seeking BMS. We also suggest an algorithm on the basis of our experience and the available data in scientific literature. CONCLUSIONS Though RYGB is the best anti reflux procedure it is associated with significant higher morbidity/mortality as compared to SG and OAGB. These two procedures can be used in the majority of patients with GERD and/or HH seeking BMS with an acceptance that some patients will need conversion to RYGB in the long term.
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Affiliation(s)
- Anmol Ahuja
- Department of General and Laparoscopic Surgery, Sir Ganga Ram Hospital, New Delhi, India -
| | - Kamal Mahawar
- Bariatric Unit, Department of General Surgery, Sunderland Royal Hospital, Sunderland, UK.,Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland, UK
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Nedelcu M, Noel P, Loureiro M, Palermo M, Nedelcu A, Nocca D. Bariatric Surgery and the Mechanisms of Gastroesophageal Reflux Disease. J Laparoendosc Adv Surg Tech A 2020; 30:907-911. [DOI: 10.1089/lap.2020.0323] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Marius Nedelcu
- ELSAN, Clinique Bouchard, Marseille, France
- ELSAN, Clinique Saint Michel, Toulon, France
| | - Patrick Noel
- ELSAN, Clinique Bouchard, Marseille, France
- Emirates Specialty Hospital, Dubai, United Arab Emirates
| | - Marcelo Loureiro
- CHU de Montpellier, Montpellier, France
- Department of Bariatric Surgery, University Montpellier 1, Montpellier, France
- Department of Bariatric Surgery, Universidade Positivo, Curitiba, Brazil
| | - Mariano Palermo
- Division of Bariatric Surgery of DIAGNOMED, Affiliated Institution of the University of Buenos Aires, Buenos Aires, Argentina
| | | | - David Nocca
- CHU de Montpellier, Montpellier, France
- Department of Bariatric Surgery, University Montpellier 1, Montpellier, France
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Chan DL, Wong SKH, Lok HT, Iliopoulos J, Talbot ML, Hennessy A, Ng EKW. Accuracy of hiatal hernia diagnosis in bariatric patients: Preoperative endoscopy versus intraoperative reference. JGH OPEN 2020; 4:1074-1078. [PMID: 33319039 PMCID: PMC7731797 DOI: 10.1002/jgh3.12388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 12/18/2022]
Abstract
Background and Aim Obesity is becoming increasingly prevalent in Asia. Bariatric surgery in the region is growing in popularity to reflect increasing demand. Hiatal hernia (HH) is common among the obese population. There is a lack of evidence comparing preoperative endoscopy against intraoperative findings as a standard of reference for HH diagnosis. Methods This was a retrospective analysis of a bariatric procedure database from a single tertiary teaching hospital and high‐volume endoscopy center. Electronic medical records were reviewed. Endoscopy results were compared to intraoperative findings, and subgroup analysis of >2 cm hernias was performed. Sensitivity, specificity, predictive values, likelihood ratios, and global diagnostic test accuracy were calculated. Results A total of 434 patients were eligible for this study, of which HH was detected in 37 patients (prevalence rate 8.55%). Mean age was 41.51 ± 11.07 years, and body mass index was 39.37 ± 5.67 kg/m2. Endoscopy sensitivity was 75.68% (95% confidence interval, 58.80–88.23%) and specificity 91.44% (88.24–94.00%). Positive likelihood ratio was 8.53 (6.11–12.79) and negative likelihood ratio 0.27 (0.15–0.47). Positive predictive value was 45.16% (36.27–54.38%) and negative predictive value 97.58% (95.80–98.62%). Accuracy of endoscopy for preoperative HH diagnosis was 90.09% (86.89–92.74%). Conclusion Endoscopy can have a high diagnostic accuracy of preoperative HH diagnosis in obese Asian patients using intraoperative diagnosis as the reference standard.
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Affiliation(s)
- Daniel L Chan
- Division of Upper Gastrointestinal and Metabolic Surgery, Department of Surgery, Faculty of Medicine The Chinese University of Hong Kong Hong Kong SAR China.,School of Medicine Western Sydney University Sydney New South Wales Australia.,Faculty of Medicine The University of New South Wales Sydney New South Wales Australia
| | - Simon K-H Wong
- Division of Upper Gastrointestinal and Metabolic Surgery, Department of Surgery, Faculty of Medicine The Chinese University of Hong Kong Hong Kong SAR China
| | - Hon Ting Lok
- Division of Upper Gastrointestinal and Metabolic Surgery, Department of Surgery, Faculty of Medicine The Chinese University of Hong Kong Hong Kong SAR China
| | - Jim Iliopoulos
- School of Medicine Western Sydney University Sydney New South Wales Australia
| | - Michael L Talbot
- School of Medicine Western Sydney University Sydney New South Wales Australia.,Faculty of Medicine The University of New South Wales Sydney New South Wales Australia
| | - Annemarie Hennessy
- School of Medicine Western Sydney University Sydney New South Wales Australia
| | - Enders K-W Ng
- Division of Upper Gastrointestinal and Metabolic Surgery, Department of Surgery, Faculty of Medicine The Chinese University of Hong Kong Hong Kong SAR China
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Dimbezel V, Nedelcu A, Danan M, Carandina S, Collet D, Gronnier C, Nedelcu M. Endoscopic Findings 5 Years Following Sleeve Gastrectomy. Obes Surg 2020; 30:3847-3851. [PMID: 32524524 DOI: 10.1007/s11695-020-04757-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 05/30/2020] [Accepted: 05/31/2020] [Indexed: 01/23/2023]
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Letter in Reply: Long-term Results After Laparoscopic Sleeve Gastrectomy with Concomitant Posterior Cruroplasty: Five-Year Follow-up. J Gastrointest Surg 2020; 24:1455-1457. [PMID: 32232644 DOI: 10.1007/s11605-020-04573-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 03/16/2020] [Indexed: 01/31/2023]
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43
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Janik MR, Ibikunle C, Aryaie AH. Safety of concurrent sleeve gastrectomy and hiatal hernia repair: a propensity score-matched analysis of the MBSAQIP registry. Surg Obes Relat Dis 2019; 16:365-371. [PMID: 32001206 DOI: 10.1016/j.soard.2019.12.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 12/07/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hiatal hernia repair is an essential step to reduce the incidence of gastroesophageal acid reflux disease in patients undergoing sleeve gastrectomy. The safety of addition, a hiatal hernia repair to sleeve gastrectomy, is a critical question. OBJECTIVES Our study aimed to assess the safety of concurrent hiatal hernia repair and sleeve gastrectomy based on Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data. SETTING University health network, United States. METHODS This study was a registry-based analysis. Preoperative characteristics and 30-day outcomes from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Participant Use Files 2015 to 2017 were selected for all patients who underwent sleeve gastrectomy with hiatal hernia repair. Propensity score matching (1:1) was used to control for potential confounding. RESULTS A total of 101,902 patients (50,951 patients matched pairs) were included in the study. The groups were closely matched as intended. Sleeve gastrectomy with hiatal hernia repair, compared with sleeve gastrectomy alone, was associated with similar risks of death (.02% versus .02%; relative risk [RR], 1.50; 95% confidence interval [CI], .61-3.67, P = .503), and higher risk of 30-day readmission (4.01% versus 2.96%; RR, 1.35; 95%CI, 1.27-1.45, P < .001), 30-day reoperation (1.10% versus .77%; RR, 1.42; 95% CI, 1.25-1.61, P < .001), 30-day intervention (1.24% versus .95%; RR, 1.31; 95%CI, 1.16-1.47, P < .001), and 30-day morbidity (1.85% versus 1.47%; RR, 1.25; 95%CI, 1.14-1.38, P < .001). CONCLUSIONS Sleeve gastrectomy with hiatal hernia repair is relatively safe in the short term with no increase in the risk of mortality. However, this additional procedure slightly increases the risk of readmission, reoperation, and postoperative intervention, as well as morbidity.
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Affiliation(s)
- Michał R Janik
- Bariatric Center of Excellence, Department of Surgery, Texas Tech University Health Science Center, Lubbock, Texas; Department of General, Oncologic, Metabolic and Thoracic Surgery, Military Institute of Medicine, Warsaw, Poland.
| | - Christopher Ibikunle
- Bariatric and Reflux Center, Georgia SurgiCare, Atlanta, Georgia; Medical College of Georgia, Augusta, Georgia
| | - Amir H Aryaie
- Bariatric Center of Excellence, Department of Surgery, Texas Tech University Health Science Center, Lubbock, Texas; Bariatric and Reflux Center, Georgia SurgiCare, Atlanta, Georgia; Medical College of Georgia, Augusta, Georgia
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Mahawar KK, Parmar C, Graham Y. Procedure and patient selection in bariatric and metabolic surgery. MINERVA CHIR 2019; 74:407-413. [DOI: 10.23736/s0026-4733.19.08121-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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45
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Nau P, Jackson HT, Aryaie A, Ibele A, Shouhed D, Lo Menzo E, Kurian M, Khaitan L. Surgical management of gastroesophageal reflux disease in the obese patient. Surg Endosc 2019; 34:450-457. [PMID: 31720811 DOI: 10.1007/s00464-019-07231-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 10/28/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) affects two thirds of the American population. Obesity is also a disease that affects two thirds of the population. The pathophysiology of reflux disease is reasonably understood, however, the degree to which obesity affects this disease remains poorly defined. Therefore the approach to GERD in the obese patient requires special attention and its own algorithm. METHODS A literature search was conducted to consolidate the current available literature on GERD and its management in the obese. In addition, the authors reviewed the literature and present expert opinion on controversial topics. RESULTS It is well established that GERD is increased in obesity and the pathophysiology is reviewed. Management options for GERD are discussed, with a focus on the obese population. Management strategies including fundoplication and gastric bypass are discussed. In addition, bariatric surgery in the setting of GERD is also reviewed. CONCLUSIONS Currently this is an extremely controversial topic and this white paper presents a strong review of the literature to help guide the management of this challenging disease in this population. Expert recommendations are given throughout the paper based upon the current available data.
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Affiliation(s)
- P Nau
- Department of Surgery, Carver College of Medicine, Iowa City, IA, USA
| | - H T Jackson
- George Washington School of Medicine and Life Sciences, Washington, DC, USA
| | - A Aryaie
- Department of Surgery, Texas Tech, Lubbock, TX, USA
| | - A Ibele
- University of Utah College of Medicine, Salt Lake City, UT, USA
| | - D Shouhed
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - E Lo Menzo
- Department of Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - M Kurian
- New York University School of Medicine, New York, NY, USA
| | - L Khaitan
- Cleveland Medical Center, University Hospitals of Cleveland, 11100 Euclid Avenue, Cleveland, OH, 44106, USA.
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Bakhos CT, Patel SP, Petrov RV, Abbas AES. Management of Paraesophageal Hernia in the Morbidly Obese Patient. Thorac Surg Clin 2019; 29:379-386. [DOI: 10.1016/j.thorsurg.2019.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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47
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Boru CE, Rengo M, Iossa A, De Angelis F, Massaro M, Spagnoli A, Guida A, Laghi A, Silecchia G. Hiatal Surface Area's CT scan measurement is useful in hiatal hernia's treatment of bariatric patients. MINIM INVASIV THER 2019; 30:86-93. [PMID: 31671007 DOI: 10.1080/13645706.2019.1683033] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Hiatal surface area (HSA) measurement has been recently proposed as useful tool for tailored treatment of hiatal defects. Multidetector CT scan (MDCT) of the hiatal area was shown to be useful in hiatal hernia (HH) management. PURPOSE MDCT preoperative HSA measurements validation as a useful method in the surgical repair decision making process of hiatal defects in candidates to antireflux ± bariatric surgery. MATERIAL AND METHODS Twenty-five obese patients (group A), candidates to laparoscopic cruroplasty ± bariatric surgery, were prospectively evaluated preoperatively and after one year, using an original MDCT algorithm, compared with intraoperative HSA measurement. Twelve non-obese (group B) and 12 obese patients (group C), without GERD or HH, were used as control groups. RESULTS Median preoperative HSA was 7.9 cm2, (interquartile IQR 5.97-9.80) while intraoperative median HSA was 6 cm2 (6-9.5), p = .84. Postoperative median HSA was 3.8 cm2 (3.21-4.8), showing the efficacy of cruroplasty, comparable with HSA calculated in the control groups (3.98 for B and 3.69 cm2 for C, p = .8547). No statistically significant difference between MDCT preoperative measurement and intraoperative findings was observed. CONCLUSIONS Preliminary results demonstrate MDCT scan HSA measurements as a valid, non-invasive method to predict intraoperative findings. It allows the HSA monitoring in order to correlate the symptoms onset and failure of cruroplasty.
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Affiliation(s)
- Cristian E Boru
- Department of General Surgery and Bariatric Center of Excellence IFSO-EC, University La Sapienza of Rome, Latina, Italy
| | - Marco Rengo
- Department of Radiological Sciences, Oncology and Pathology, University La Sapienza of Rome, Latina, Italy
| | - Angelo Iossa
- Department of General Surgery and Bariatric Center of Excellence IFSO-EC, University La Sapienza of Rome, Latina, Italy
| | - Francesco De Angelis
- Department of General Surgery and Bariatric Center of Excellence IFSO-EC, University La Sapienza of Rome, Latina, Italy
| | - Matteo Massaro
- Department of General Surgery and Bariatric Center of Excellence IFSO-EC, University La Sapienza of Rome, Latina, Italy
| | - Alessandra Spagnoli
- Department of Public Health and Infectious Diseases, University La Sapienza of Rome, Rome, Italy
| | - Anna Guida
- Department of General Surgery and Bariatric Center of Excellence IFSO-EC, University La Sapienza of Rome, Latina, Italy
| | - Andrea Laghi
- Department of Radiological Sciences, Oncology and Pathology, University La Sapienza of Rome, Latina, Italy
| | - Gianfranco Silecchia
- Department of General Surgery and Bariatric Center of Excellence IFSO-EC, University La Sapienza of Rome, Latina, Italy
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Sfara A, Dumitrascu DL. The management of hiatal hernia: an update on diagnosis and treatment. Med Pharm Rep 2019; 92:321-325. [PMID: 31750430 PMCID: PMC6853045 DOI: 10.15386/mpr-1323] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 06/13/2019] [Indexed: 12/15/2022] Open
Abstract
Background and aim Hiatal hernia (HH) occurs quite frequently in the general population and is characterized by a wide range of non-specific symptoms, most of them related to gastroesophageal reflux disease. Treatment can be challenging at times, depending on the existence of complications. The most recent guideline regarding the management of hiatal hernia was released by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) in the year 2013. This review aims to present the most recent updates on the diagnosis and management of hiatal hernia for clinical practitioners. Methods The PubMed database was screened for publications using the terms: “hiatal hernia”, “paraesophageal hernia”, “management”, “treatment”, “hiatal repair”. A literature review of contemporary and latest studies was completed. The studies that we looked into include prospective, randomized trials, systematic reviews, clinical reviews and original articles. The information was compiled in narrative review format. Results This narrative review presents new data on the diagnosis and management of hiatal hernia. While the diagnostic pathway has remained virtually unchanged, new data have come to light regarding the surgical treatment of hiatal hernia. We present the imaging methods used for its diagnosis, as well as the medical and surgical treatment currently available. Conclusion In the last five years, there has been vast research in the field of hiatal hernia management, especially regarding the surgical treatment. However, unanswered questions still remain and solid updates on the guidelines have yet to be formulated. To address this, more randomized studies need to be done on subsets of patients, stratified by age, gender, symptoms and comorbidities.
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Affiliation(s)
- Alice Sfara
- Gastroenterology Department, "Prof. Dr. Octavian Fodor" Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Dan L Dumitrascu
- 2 Medical Department, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
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Kavanagh R, Smith J, Bashir U, Jones D, Avgenakis E, Nau P. Optimizing bariatric surgery outcomes: a novel preoperative protocol in a bariatric population with gastroesophageal reflux disease. Surg Endosc 2019; 34:1812-1818. [DOI: 10.1007/s00464-019-06934-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 06/12/2019] [Indexed: 12/12/2022]
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50
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Mizrahi I, Abubeih A, Rachmuth J, Plotkin Y, Beglaibter N, Grinbaum R, Greenstein I, Cohain NL. Routine Upper Gastrointestinal Fluoroscopy Before Laparoscopic Sleeve Gastrectomy: Is It Necessary? Obes Surg 2019; 29:1704-1708. [DOI: 10.1007/s11695-019-03777-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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