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Perez SC, Ericksen F, Richardson N, Thaqi M, Wheeler AA. Propensity score matched analysis of laparoscopic revisional and conversional sleeve gastrectomy with concurrent hiatal hernia repair. Surg Endosc 2024; 38:3866-3874. [PMID: 38831216 DOI: 10.1007/s00464-024-10902-y] [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: 01/07/2024] [Accepted: 05/02/2024] [Indexed: 06/05/2024]
Abstract
INTRODUCTION The primary aim of this study was to evaluate outcomes associated with concurrent hiatal hernia repair (CHHR) when performing a conversional or revisional vertical sleeve gastrectomy (VSG). CHHR is often necessary during VSG due to potential gastroesophageal reflux disease (GERD) development or obstructive symptoms. METHODS The Metabolic and Bariatric Surgery Accreditation and Quality Improvement (MBSAQIP) participant use file was assessed for the years 2015-2020 for revisional/conversional VSG procedures. The presence of CHHR was used to create two groups. Propensity score matching (PSM) was performed with E-analysis. RESULTS There were 33,909 patients available, with 5986 undergoing the VSG procedure with CHHR. In the unmatched analysis, there was an increased frequency of patients being female (85.72 vs 83.30%; p < 0.001), having a history of GERD (38.01 vs 31.25%; p < 0.001), and being of older age (49.59 ± 10.97 vs 48.70 ± 10.83; p < 0.001). Patients undergoing VSG with CHHR experienced decreased sleep apnea (25.00 vs 28.84%; p < 0.001) and diabetes (14.27 vs 17.80%; p < 0.001). PSM yielded 5986 patient pairs. Matched patients with CHHR experienced increased operative time (115 min ± 53 vs 103 min ± 51; p < 0.001), increased risk of postoperative pneumonia (0.45 vs 0.15%; p = 0.005) and readmission (4.69 vs 3.58%; p = 0.002) within thirty days. However, patients undergoing CHHR with revisional or conversional VSG did not experience increased risk of death, postoperative bleeding, postoperative leak, or reoperations. CONCLUSION Despite a small association with increased postoperative pneumonia, the rate of complications in patients undergoing laparoscopic revisional/conversional VSG and CHHR are low. CHHR is a safe option when combined with the laparoscopic revisional/conversional VSG procedure in the early postoperative period.
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Affiliation(s)
- Samuel C Perez
- Department of Surgery, University of Missouri School of Medicine, Columbia, MO, USA.
| | - Forrest Ericksen
- Department of Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Norbert Richardson
- Department of Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Milot Thaqi
- Department of Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Andrew A Wheeler
- Department of Surgery, University of Missouri School of Medicine, Columbia, MO, USA
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Clapp B, Cottam S, Salame M, Marr JD, Galvani C, Ponce J, English WJ, Ghanem OM. Comparative analysis of sleeve conversions of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program 2020 Database. Surg Obes Relat Dis 2024; 20:47-52. [PMID: 37666727 DOI: 10.1016/j.soard.2023.07.011] [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: 09/30/2022] [Revised: 07/03/2023] [Accepted: 07/23/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND Although the sleeve gastrectomy (SG) is the dominant bariatric procedure, studies have shown conversion rates of up to 30%. These conversions are generally for weight regain (WR), insufficient weight loss (IWL) or gastroesophageal reflux disease (GERD). Before 2020, details on why conversions were being performed were not collected in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Participant Use Data File (PUF). Now, the indication for sleeve conversion is noted in the PUF, allowing identification and reporting sleeve conversion reasons. OBJECTIVE We aimed to examine the reasons for SG conversions nationwide. SETTING The 2020 MBSAQIP PUF. METHODS The 2020 MBSAQIP PUF was examined to determine the reasons why SG were converted to other operations. The data field of "Revision/Conversion Final Indication" was used along with "Procedure type." Primary bariatric operations were excluded. Descriptive statistics were applied. Different reasons for conversion and operations were compared by preoperative characteristics and operative outcomes. RESULTS There were 103,782 primary SG reported in the 2020 PUF. There were 7181 SG that were converted to other operations. The most common conversion (86.2%) was to Roux-en-Y gastric bypass (RYGB). The main reason for SG conversion was GERD at 48.4%, followed by WR/IWL (41.9%). Biliopancreatic diversion with duodenal switch and single-anastomosis duodenoileal bypass with sleeve patients differed significantly from RYGB patients in specific preoperative characteristics and operative outcomes. CONCLUSION The most common procedure SG is converted to is the RYGB. GERD was the most common reason for SG conversion, followed by WR/IWL.
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Affiliation(s)
- Benjamin Clapp
- Department of Surgery, Texas Tech University Health Sciences Center El Paso, El Paso, Texas
| | | | - Marita Salame
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - John D Marr
- Department of Surgery, Texas Tech University Health Sciences Center El Paso, El Paso, Texas
| | - Carlos Galvani
- Department of Surgery, Tulane University, New Orleans, Louisiana
| | - Jaime Ponce
- Department of Surgery, CHI Memorial Medical Group, Chattanooga, Tennessee
| | - Wayne J English
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Omar M Ghanem
- Department of Surgery, Mayo Clinic, Rochester, Minnesota.
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Mills H, Alhindi Y, Idris I, Al-Khyatt W. Outcomes of Concurrent Hiatus Hernia Repair with Different Bariatric Surgery Procedures: a Systematic Review and Meta-analysis. Obes Surg 2023; 33:3755-3766. [PMID: 37917388 PMCID: PMC10687114 DOI: 10.1007/s11695-023-06914-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 10/13/2023] [Accepted: 10/18/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND Hiatus hernia (HH) is prevalent among patients with obesity. Concurrent repair is often performed during metabolic and bariatric surgery (MBS), but a consensus on the safety and effectiveness of concurrent HH repair (HHR) and MBS remains unclear. We performed a systematic review of the safety and effectiveness of concurrent HHR and MBS through the measurement of multiple postoperative outcomes. METHOD Seventeen studies relating to concurrent MBS and HHR were identified. MBS procedures included laparoscopic sleeve gastrectomy (LSG), Roux-en-Y gastric bypass (LRYGB), and adjustable gastric banding (LAGB). Studies with pre- and postoperative measurements and outcomes were extracted. RESULTS For LSG, 9 of 11 studies concluded concurrent procedures to be safe and effective with no increase in mortality. Reoperation and readmission rates however were increased with HHR, whilst GORD rates were seen to improve, therefore providing a solution to the predominant issue with LSG. For LRYGB, in all 5 studies, concurrent procedures were concluded to be safe and effective, with no increase in mortality, length of stay, readmission and reoperation rates. Higher complication rates were observed compared to LSG with HHR. Among LAGB studies, all 4 studies were concluded to be safe and effective with no adverse outcomes on mortality and length of stay. GORD rates were seen to decrease, and reoperation rates from pouch dilatation and gastric prolapse were observed to significantly decrease. CONCLUSION Concurrent HHR with MBS appears to be safe and effective. Assessment of MBS warrants the consideration of concurrent HHR depending on specific patient case and the surgeon's preference.
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Affiliation(s)
- Henry Mills
- Medical School University of Nottingham, Nottingham, UK
| | - Yousef Alhindi
- Clinical, Metabolic and Molecular Physiology Research Group, MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, University of Nottingham, Royal Derby Hospital Centre, Uttoxeter Road, Derby, DE22 3NE, UK
- National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham, UK
- Division of Applied Medical Sciences, University of Hail, Hail, Saudi Arabia
| | - Iskandar Idris
- Clinical, Metabolic and Molecular Physiology Research Group, MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, University of Nottingham, Royal Derby Hospital Centre, Uttoxeter Road, Derby, DE22 3NE, UK.
- East Midlands Bariatric & Metabolic Institute, Royal Derby Hospital, Derby, DE22 3NE, UK.
| | - Waleed Al-Khyatt
- Medical School University of Nottingham, Nottingham, UK.
- National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham, UK.
- Bariatric & Metabolic Surgery Department of Excellence, Health Point Hospital, A Mubadala Health Partner, Zayed Sports City, United Arab Emirates.
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Fernández-Ananín S, Balagué Ponz C, Sala L, Molera A, Ballester E, Gonzalo B, Pérez N, Targarona EM. Gastroesophageal reflux after sleeve gastrectomy: The dimension of the problem. Cir Esp 2023; 101 Suppl 4:S26-S38. [PMID: 37952718 DOI: 10.1016/j.cireng.2023.05.019] [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: 05/02/2023] [Accepted: 05/28/2023] [Indexed: 11/14/2023]
Abstract
Sleeve gastrectomy is a safe and effective bariatric surgery in terms of weight loss and longterm improvement or resolution of comorbidities. However, its achilles heel is the possible association with the development with the novo and/or worsening of pre-existing gastroesophageal reflux disease. The anatomical and mechanical changes that this technique induces in the esophagogastric junction, support or contradict this hypothesis. Questions such as «what is the natural history of gastroesophageal reflux in the patient undergoing gastric sleeve surgery?», «how many patients after vertical gastrectomy will develop gastroesophageal reflux?» and «how many patients will worsen their previous reflux after this technique?» are intended to be addressed in the present article.
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Affiliation(s)
- Sonia Fernández-Ananín
- Unidad de Cirugía Gastrointestinal y Hematología, Servicio de Cirugía General y del Aparato Digestivo, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain.
| | - Carme Balagué Ponz
- Unidad de Cirugía Esofagogástrica, Bariátrica y Metabólica, Servicio de Cirugía General y Digestiva, Hospital Universitari Mutua de Terrassa, Universitat de Barcelona, Barcelona, Spain
| | - Laia Sala
- Unidad de Cirugía Gastrointestinal y Hematología, Servicio de Cirugía General y del Aparato Digestivo, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Antoni Molera
- Unidad de Cirugía Gastrointestinal y Hematología, Servicio de Cirugía General y del Aparato Digestivo, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Eulalia Ballester
- Unidad de Cirugía Gastrointestinal y Hematología, Servicio de Cirugía General y del Aparato Digestivo, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Berta Gonzalo
- Unidad de Cirugía Gastrointestinal y Hematología, Servicio de Cirugía General y del Aparato Digestivo, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Noelia Pérez
- Unidad de Cirugía Gastrointestinal y Hematología, Servicio de Cirugía General y del Aparato Digestivo, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Eduardo M Targarona
- Unidad de Cirugía Gastrointestinal y Hematología, Servicio de Cirugía General y del Aparato Digestivo, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
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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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Alvarez R, Ward BL, Xiao T, Zadeh J, Sarode A, Khaitan L, Abbas M. Independent association of preoperative Hill grade with gastroesophageal reflux disease 2 years after sleeve gastrectomy. Surg Obes Relat Dis 2022; 19:563-575. [PMID: 36635190 DOI: 10.1016/j.soard.2022.12.013] [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: 09/04/2022] [Revised: 11/01/2022] [Accepted: 12/01/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND The sleeve gastrectomy (SG) is associated with postoperative gastroesophageal reflux disease (GERD). Higher endoscopic Hill grade has been linked to GERD in patients without metabolic surgery. How preoperative Hill grade relates to GERD after SG is unknown. OBJECTIVE To explore the relationship between preoperative Hill grade and GERD outcomes 2 years after SG. SETTING Academic hospital, United States. METHODS All patients (n = 882) undergoing SG performed by 5 surgeons at a single academic institution from January 2015 to December 2019 were included. Complete data sets were available for 360 patients, which were incorporated in analyses. GERD was defined as the presence of a diagnosis in the medical record accompanied by pharmacotherapy. Patients with GERD postoperatively (n = 193) were compared with those without (n = 167). Univariable and multivariable analyses were conducted to explore independent associations between preoperative factors and GERD outcomes. RESULTS The presence of any GERD increased at the postoperative follow-up of 25.2 (3.9) months compared with preoperative values (53.6% versus 41.1%; P = .0001). Secondary GERD outcomes at follow-up included de novo (41.0%), persistent (33.1%), resolved (28.4%), worsened (26.4%), and improved (12.2%) disease. Postoperative endoscopy and reoperation for GERD occurred in 26.4% and 6.7% of the sample. Patients with GERD postoperatively showed higher prevalence of Hill grade III-IV (32.6% versus 19.8%; P = .0062) and any hiatal hernia (HH) (36.3% versus 25.1%; P = .0222) compared with patients without postoperative GERD. Frequencies of gastritis, esophagitis A or B, duodenitis, and peptic ulcer disease were similar between groups. Higher prevalence of preoperative GERD (54.9% versus 25.1%; P < .0001), obstructive sleep apnea (66.8% versus 54.5%; P = .0171), and anxiety (25.4% versus 15.6%; P = .0226) was observed in patients with postoperative GERD compared with those without it. Baseline demographics, weight, other obesity-associated diseases, whether an HH was repaired at index SG, and follow-up length were statistically similar between groups. After adjusting for collinearity, preoperative GERD (odds ratio [OR] = 3.6; 95% confidence interval [CI], 2.2-5.7; P < .0001) and Hill grade III-IV (OR [95% CI]: 1.9 [1.1-3.1]; P = .0174) were independently associated with the presence of any GERD postoperatively. The preoperative presence of an HH >2 cm and whether an HH was repaired at index SG showed no independent association with GERD at follow-up. CONCLUSIONS More than 50% of patients experienced GERD 2 years after SG. Preoperative GERD confers the highest risk for GERD postoperatively. Hill grade III-IV is independently associated with GERD after SG. Whether a hiatal hernia repair was performed did not influence GERD outcomes. Preoperative esophagogastroduodenoscopy should be obtained before SG and Hill grade routinely captured and used to counsel patients about the risk of postoperative GERD after this procedure. Hill grade may help guide the choice of metabolic operation.
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Affiliation(s)
- Rafael Alvarez
- University Hospitals, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio.
| | - Brandon L Ward
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Tianqi Xiao
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jonathan Zadeh
- University Hospitals, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Anuja Sarode
- University Hospitals, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Leena Khaitan
- University Hospitals, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Mujjahid Abbas
- University Hospitals, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
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Clapp B, Kara AM, Nguyen-Lee PJ, Alvarado L, Marr JD, Annabi HM, Davis B, Ghanem OM. Does the use of bioabsorbable mesh for hiatal hernia repair at the time of bariatric surgery reduce recurrence rates? A meta-analysis. Surg Obes Relat Dis 2022; 18:1407-1415. [PMID: 36104252 DOI: 10.1016/j.soard.2022.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 07/15/2022] [Accepted: 08/03/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Anywhere from 16% to 37% of patients undergoing bariatric and metabolic surgery are estimated to have a hiatal hernia. To address the lack of long-term data showing the efficacy of bioabsorbable mesh in reducing the recurrence of hiatal hernia in patients who undergo bariatric surgery, we evaluated the world literature and performed a meta-analysis. OBJECTIVE To evaluate hiatal hernia recurrence rates after placement of bioabsorbable mesh in bariatric patients. SETTING Meta-analysis of world literature. METHODS We performed a literature search using PubMed and MEDLINE with search terms including "hiatal hernia recurrence," "bariatric surgery," "bioabsorbable mesh," "Gore BIO-A," and "trimethylene carbonate." Analysis was conducted to compare surgical time, length of stay, recurrence rate, hernia size, and changes in body mass index before and after surgery between mesh-group (MG) and nonmesh (NM) patients. The meta-analysis was described using standardized mean difference, weighted mean difference, effect size, and 95% confidence interval (CI). An I2 statistic was computed to assess heterogeneity. RESULTS Twelve studies with 1351 patients were included in our meta-analysis. Four studies had both an MG and an NM group. There were 668 patients in the MG and 683 patients in the NM group. Hernia size noted in the NM group (7 cm2) was compared with that in the MG (6.5 cm2) (95% CI: 3.89-9.14; P = .86). The MG had fewer recurrences than the NM group (effect size, 2% versus 14%; 95% CI: -.26 to -.02; P = .027). The average follow-up was 28.8 months for the MG and 32.8 months for the NM group. CONCLUSION Repair with bioabsorbable mesh at the time of the index bariatric surgery is more effective at reducing the recurrence rate of hiatal hernia than suture cruroplasty. Further studies investigating the long-term outcomes of bioabsorbable mesh placed at the time of bariatric surgery are needed.
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Affiliation(s)
- Benjamin Clapp
- Department of Surgery, Texas Tech Health Sciences Center School of Medicine, El Paso Texas.
| | - Ali M Kara
- Department of Surgery, Texas Tech Health Sciences Center School of Medicine, El Paso Texas
| | - Paul J Nguyen-Lee
- Department of Surgery, Texas Tech Health Sciences Center School of Medicine, El Paso Texas
| | - Luis Alvarado
- Department of Surgery, Texas Tech Health Sciences Center School of Medicine, El Paso Texas
| | - John D Marr
- Department of Surgery, Texas Tech Health Sciences Center School of Medicine, El Paso Texas
| | - Hani M Annabi
- Department of Surgery, Texas Tech Health Sciences Center School of Medicine, El Paso Texas
| | - Brian Davis
- Department of Surgery, Texas Tech Health Sciences Center School of Medicine, El Paso Texas
| | - Omar M Ghanem
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
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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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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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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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11
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Guzman-Pruneda FA, Brethauer SA. Gastroesophageal Reflux After Sleeve Gastrectomy. J Gastrointest Surg 2021; 25:542-550. [PMID: 32935271 DOI: 10.1007/s11605-020-04786-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 09/03/2020] [Indexed: 01/31/2023]
Abstract
Sleeve gastrectomy continues to be the most commonly performed bariatric operation worldwide. Development or worsening of pre-existing GERD has been recognized as a significant issue postoperatively. There is a paucity of information concerning the most appropriate preoperative workup and the technical and anatomical factors that may or may not contribute to the occurrence of reflux symptoms. Contemporary data quality is deficient given the predominantly retrospective nature, limited follow-up time, and heterogeneous outcome measures across studies. This has produced mixed results regarding the postoperative incidence and severity of GERD. Ultimately, better-constructed investigations are needed in order to offer evidence-based recommendations that may guide preoperative workup and improved patient selection criteria.
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Affiliation(s)
- Francisco A Guzman-Pruneda
- Department of Surgery, Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Stacy A Brethauer
- Department of Surgery, Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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12
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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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13
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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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14
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Naeem Z, Yang J, Park J, Wang J, Docimo S, Pryor AD, Spaniolas K. A Step in the Right Direction: Trends over Time in Bariatric Procedures for Patients with Gastroesophageal Reflux Disease. Obes Surg 2020; 30:4243-4249. [PMID: 32562133 DOI: 10.1007/s11695-020-04776-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 06/08/2020] [Accepted: 06/09/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION While laparoscopic sleeve gastrectomy (LSG) has recently emerged as the predominant surgery type for the national bariatric cohort, the literature suggests that laparoscopic Roux-en-Y gastric bypass (LRYGB) may be more effective in normalizing gastroesophageal physiology for the subset of patients with GERD. This study explored practice patterns over time for patients with GERD or hiatal hernia, a related comorbidity, undergoing bariatric surgery. METHODS Data for LSG and LRYGB were extracted from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) datasets for 2015-2018. Multivariable logistic regression analyses were performed to determine the effects of pre-existing GERD or concomitant hiatal hernia repair on surgery type. RESULTS A total of 130,772 patients underwent LRYGB (30.5%) or LSG (69.5%) in 2015, which increased year-to-year to 161,275 patients in 2018 (74.61% LSG). A total of 38.4% LRYGB patients had pre-existing GERD vs. 27.55% LSG patients. Patients with pre-existing GERD were increasingly likely to undergo LRYGB vs. those without GERD (OR 1.205 [95% CI 1.17-1.24] in 2015 vs. OR 1.510 [95% CI 1.47-1.55] in 2018, p < 0.0001 across years). Concomitant hiatal hernia repair was less common among LRYGB patients across all years (OR 0.413 [95% CI 0.4-0.43] for 2015; OR 0.381 [95% CI 0.37-0.4] for 2016; OR 0.403 [95% CI 0.39-0.42] for 2017, OR 0.464 [95% CI 0.45-0.48] for 2018, p < 0.0001). DISCUSSION Bariatric patients with pre-existing GERD are increasingly likely to undergo LRYGB, consistent with the literature. LSG is presently more common in the overall cohort and among those undergoing concomitant hiatal hernia repair. Despite the growing recognition of GERD in bariatric patients, a significant discrepancy persists in hiatal hernia management per bariatric procedure type.
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Affiliation(s)
- Zaina Naeem
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Department of Surgery, Renaissance School of Medicine, Health Sciences Center T18-040, Stony Brook University, Stony Brook, NY, 11794-8191, USA
| | - Jie Yang
- Department of Applied Mathematics and Statistics, Stony Brook University, Stony Brook, NY, USA
| | - Jihye Park
- Department of Applied Mathematics and Statistics, Stony Brook University, Stony Brook, NY, USA
| | - Junying Wang
- Department of Applied Mathematics and Statistics, Stony Brook University, Stony Brook, NY, USA
| | - Salvatore Docimo
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Department of Surgery, Renaissance School of Medicine, Health Sciences Center T18-040, Stony Brook University, Stony Brook, NY, 11794-8191, USA
| | - Aurora D Pryor
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Department of Surgery, Renaissance School of Medicine, Health Sciences Center T18-040, Stony Brook University, Stony Brook, NY, 11794-8191, USA
| | - Konstantinos Spaniolas
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Department of Surgery, Renaissance School of Medicine, Health Sciences Center T18-040, Stony Brook University, Stony Brook, NY, 11794-8191, USA.
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15
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Assalia A, Gagner M, Nedelcu M, Ramos AC, Nocca D. Gastroesophageal Reflux and Laparoscopic Sleeve Gastrectomy: Results of the First International Consensus Conference. Obes Surg 2020; 30:3695-3705. [PMID: 32533520 DOI: 10.1007/s11695-020-04749-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/22/2020] [Accepted: 05/28/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) is probably the main drawback of laparoscopic sleeve gastrectomy (LSG). Herein, we critically discuss the issue and report the results of the first international consensus conference held in Montpellier, France, during June 2019. METHODS Fifty international bariatric experts from 25 countries convened for 2 days for interactive discussions, and to formulate the most relevant questions by electronically submitting 55 preliminary questions to panelists. Following the meeting, a final drafted questionnaire comprised of 41 questions was sent to all experts via e-mail. RESULTS Forty-six experts responded (92%). Esophago-gastro-duodenoscopy was considered mandatory before (92%) and after (78%) surgery. No consensus was achieved as to time intervals after surgery and the role of specialized tests for GERD. Higher degrees of erosive esophagitis (94%) and Barrett's esophagus (96%) were viewed as contra-indications for LSG. Roux-en-Y gastric bypass was recommended in postoperative patients with uncontrolled GERD and insufficient (84%) or sufficient (76%) weight loss and Barrett's esophagus (78%). Hiatal hernia (HH) repair was deemed necessary even in asymptomatic patients without GERD (80% for large and 67% for small HH). LSG with fundoplication in patients with GERD was considered by 77.3% of panelists. CONCLUSIONS The importance of pre- and postoperative endoscopy has been emphasized. The role of specialized tests for GERD and the exact surveillance programs need to be further defined. LSG is viewed as contra-indicated in higher degrees of endoscopic and clinical GERD. LSG with anti-reflux fundoplication emerges as a new valid option in patients with GERD.
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Affiliation(s)
- Ahmad Assalia
- Division of Advanced Laparoscopic and Bariatric Surgery, Department of General Surgery, Rambam Health Care Campus and the Technion Faculty of Medicine, 8 Haalia str, 3109601, Haifa, Israel.
| | - Michel Gagner
- Hôpital du Sacre Coeur, Montreal, Canada.,Herbert Wertheim School of Medicine, Miami, FL, USA
| | - Marius Nedelcu
- Centre de Chirurgie de l'Obesite (CCO), Clinique Bouchard, Marseille, France.,Centre de Chirurgie de l'Obesite (CCO), Clinique Saint Michel, Toulon, France
| | - Almino C Ramos
- Gastro-Obeso-Center Institute for Metabolic Optimization, Sao Paulo, Brazil
| | - David Nocca
- Bariatric Unit, CHU Montpellier, Institut de génomique fonctionnelle, CNRS, INSERM, University of Montpellier, Montpellier, France
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