Laparoscopic Undo of Fundoplication with Roux-en-Y Gastric Bypass in a Morbidly Obese Patient with Prior Nissen's Fundoplication: A Video Report

Gastroesophageal reflux disease complicating laparoscopic sleeve gastrectomy: current knowledge and surgical therapies

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is currently the most commonly performed bariatric procedure worldwide. However, the incidence of gastroesophageal reflux disease (GERD) after LSG is high.

OBJECTIVES

The aim of this systematic review was to identify the optimal surgical strategy for treating GERD after LSG.

SETTING

West China Hospital, Sichuan University, Chengdu, China.

METHODS

A systematic literature search was performed to identify studies on surgical treatments for GERD after LSG. The effectiveness and safety profile of surgical management on GERD after LSG were analyzed.

RESULTS

A total of 40 articles enrolling 2049 patients were included in this review. Surgical strategies to prevent GERD after LSG were mainly of 2 types: concomitant LSG + antireflux procedures (hiatal hernia repair or fundoplication) and secondary procedures (conversion to Roux-en-Y gastric bypass [RYGB] or repeat sleeve gastrectomy). The short-term remission or improvement rate of GERD was 34.6%-100% after concomitant LSG + antireflux procedures. The postoperative complication rate was the same (3.0%) for both LSG + antireflux procedures and LSG alone. The remission or improvement rate of GERD was 57.1%-100% after conversion to RYGB and 100% after repeat sleeve gastrectomy.

CONCLUSIONS

The effectiveness and safety profile of concomitant LSG + antireflux procedures is uncertain. However, secondary operations after LSG, such as conversion to RYGB, appear to provide good results. The data overall are heterogeneous, with imprecise methods of documenting and defining GERD complicating LSG. More cohort studies or RCT studies of high quality with long-term follow-up are needed in the future.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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