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

Is It Safe to Combine a Fundoplication to Sleeve Gastrectomy? Review of Literature

Background and Objectives: The rising numbers of laparoscopic sleeve gastrectomy (LSG) procedures now being performed worldwide will likely be followed by an increasing number of patients experiencing gastro-esophageal reflux disease (GERD). The purpose of the current review was to analyze in terms of safety different techniques of fundoplication used to treat GERD associated with LSG. Methods: An online search was performed in PubMed/MEDLINE in December 2020 to identify articles reporting LSG and fundoplication. The following term combination was used: (sleeve, fundoplication), (sleeve, Nissen), (sleeve, Rossetti), (sleeve, Toupet) and (sleeve, Dor). The extracted information included details of the methods (e.g., retrospective case series), demographic characteristics (e.g., age, gender), clinical characteristics, number of patients, rate of conversion, and postoperative outcomes. Results: A total of 154 studies were identified and after an assessment of title according to our exclusion criteria, 116 articles were removed. Of the 38 studies analyzed for full content review, a total of seven primary studies (487 patients) were identified with all inclusion criteria. Analyzing the different types of fundoplication used, we have identified: 236 cases of Nissen-Sleeve, 220 cases with modified Rossetti fundoplication, 31 cases of Dor fundoplication, and no case of Toupet fundoplication. The overall postoperative complication rate was 9.4%, with the most common reported complication being gastric perforation, 15 cases-3.1%. The second most common complication was bleeding identified in nine cases (1.8%) followed by gastric stenosis in six cases (1.2%). The mortality was nil. Conclusions: Different types of fundoplication associated with LSG appear to be a safe surgical technique with an acceptable early postoperative complication rate. Any type of fundoplication associated with LSG to decrease GERD should be evaluated cautiously while prospective clinical randomized trials are needed.

The Nissen-Sleeve: Early Postoperative Complications

Introduction: Nissen Sleeve (NS) was introduced in the bariatric armamentarium with the purpose to decrease the risk of reflux symptoms following sleeve gastrectomy. The aim of this study was to evaluate our personal experience with this new technique, in particular concerning early postoperative complications (<30 days). Methods: We retrospectively reviewed our prospectively collected data on consecutive morbid patients with obesity receiving NS from December 2019 to August 2020. All data pertaining to each patient, including demographic data and preoperative and postoperative clinical data, were collected. Results: A total of 28 N-sleeve procedures were performed in the considered period. All the patients had a hiatal hernia that was evaluated between 2 and 6 cm of extent in the preoperative work. Esophagitis of stage A, according to the Los Angeles classification, was detected in 71% of the patients, while 8 out of 28 patients presented a stage B esophagitis. One of the patients had a preoperative diagnosis of Barrett esophagus. A complete disappearance of gastroesophageal reflux disease (GERD) symptoms was achieved in 25 patients out of 28, while the remaining patients reported an improvement in symptoms and continued to be treated with low doses of proton pomp inhibitors. Two reinterventions (7.1%) were performed (Clavien-Dindo IIIb). Three other patients (10.7%) experienced a transient postoperative dysphagia that in one case persisted for 4 months (Clavien-Dindo II). All the patients were managed with conservative treatment, and in each case an endoscopic dilatation was necessary. Conclusions: NS appears to be a safe surgical technique with an acceptable early postoperative complication rate. NS appears to be effective in treating patients suffering from obesity and preoperative reflux, but the data are insufficient to establish whether it can reduce the long-term risk of de novo GERD in laparoscopic sleeve gastrectomy patients.