Laparoscopic Sleeve Gastrectomy with Rossetti fundoplication. Long-term (5 years) follow-up

Gastroesophageal reflux disease symptoms after sleeve gastrectomy with anterior hemifundoplication: a pilot study

BACKGROUND

Gastroesophageal reflux disease (GORD) is a significant problem after laparoscopic sleeve gastrectomy (SG). This study aimed to assess the long-term effect of SG with an anterior fundoplication on GORD symptoms.

METHODS

A single-centre cohort study of all patients who underwent SG with anterior hemifundoplication (SGAF), with a 2:1 SG only comparison group. GORD symptoms were assessed using a structured symptom questionnaire.

RESULTS

SGAF was performed in 36 patients between 2010 and 2015; 26 patients were available for follow-up and 17 of these were followed up for more than 6 years. The comparison group included 53 consecutive contactable patients who underwent SG without fundoplication during the same period. The two patient groups were similar with regard to pre-operative factors, weight loss, and weight regain. After 6 years, 12 (71%) of SGAF patients reported no GORD symptoms compared to 9 (17%) of SG patients. GORD symptoms were no worse in 21 (81%) following SGAF, whereas GORD symptoms worsened (worse or new symptoms) in 22 (58.5%) of patients after SG. PPI use was similar in both groups. Eight of 26 (31%) SGAF patients had some degree of fundoplication dilatation and underwent conversion to SG or RYGB.

CONCLUSIONS

SGAF provided superior control of symptomatic GORD than SG in this study. Fundoplication dilatation treated by conversion to standard SG was not uncommon and was the reason for suspending this series. Reducing intragastric pressure and reducing fundoplication volume may alleviate this problem, which may also be overestimated in this pilot study.

Nissen sleeve gastrectomy: 5-year follow-up results

BACKGROUND

Nissen sleeve gastrectomy is a new bariatric procedure based on the combination of 2 well-known surgical techniques (vertical sleeve gastrectomy and Nissen fundoplication). It was conceived as a means to prevent the major drawback of the sleeve gastrectomy (SG), the gastroesophageal reflux disease (GERD), while preserving the advantages of SG in terms of weight loss, and remission of obesity-related comorbidities.

OBJECTIVES

The objectives of this study are to present the long-term (5 years) follow-up results on weight loss, evolution of GERD and other comorbidities, and the complication rate of the Nissen sleeve gastrectomy.

SETTING

Montpellier University Hospital, France.

METHODS

This is a prospective analysis of patients who underwent Nissen sleeve gastrectomy as a first-line bariatric procedure between January 2018 and February 2019. A subgroup analysis of patients with no further surgery during follow-up was also performed.

RESULTS

A total of 144 patients underwent Nissen sleeve gastrectomy: After adjusting for exclusion criteria, 133 patients comprised the initial study population, 81.9% of whom had complete follow-up for weight and GERD clinical symptom outcomes at 5 years. The mean total weight loss (TWL%) was 22 (±12.3)% and the mean excess weight loss percentage (EWL%) was 59.4% (±34.2)%. Of the 63 patients with preoperative clinical symptoms of GERD, we observed an 85.5% 5-year clinical remission rate; however, only 25 patients had a gastroscopy at 5 years. The cumulative short- and long-term reoperation rate was 8.1% and the mortality rate was zero.

CONCLUSIONS

The Nissen sleeve gastrectomy achieves a satisfactory long-term TWL% and a significant improvement in comorbidities, particularly regarding the incidence of GERD. The rate of complications requiring surgical reoperation is low.

BariClip: Outcomes and Complications from a Single-Center Experience

BACKGROUND

Laparoscopic BariClip gastroplasty (LBCG) is a new reversible bariatric procedure designed to replicate the restrictive effects of laparoscopic sleeve gastrectomy (LSG) by placing a clip vertically on the stomach. This technique achieves gastric lumen restriction without the need for resection, ensuring organ preservation and reversibility. However, concerns have arisen regarding potential complications such as gastroesophageal reflux disease (GERD), slippage, or erosion of the stomach. The aim of the study is to evaluate the outcomes and complications of LBCG.

METHODS

This is a monocentric retrospective study. We analyzed 149 patients who underwent LBCG procedure between July 2021 and November 2023. A minimum follow-up period of 6 months was observed for all patients, recording clinically relevant GERD through GERD-Q score questionnaires. Weight loss was monitored through body mass index (BMI) and % total weight loss (%TWL), registered during follow-up visits.

RESULTS

Overall, 149 patients were eligible for this study. Overall complication rate was 8% (12/149). The average BMI went from 40 ± 4.37 kg/m2 to 28 ± 4.29 kg/m2 (p < 0.05) in 6 months, while the mean %TWL was 22.6% after at least 6 months of follow-up. Clinically relevant GERD went from 18.1% (27/149) to 10.7% (16/149), p = 0.1262. As expected, also the PPI usage was not altered significantly (17.8% vs 16.4%), p = 0.8714.

CONCLUSIONS

LBCG remains an experimental procedure that must be approached with caution. Nonetheless, the potential of LBCG to reproduce the effects of LSG while reducing GERD makes it a promising new reversible option for the treatment of morbid obesity.

Laparoscopic Toupet-Sleeve gastrectomy in morbid obese patients with preoperative gastro-esophageal reflux: a 4-year follow-up cohort study

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.

Physiological Archetypes of de novo Gastroesophageal Reflux Disease After Laparoscopic Sleeve Gastrectomy

Laparoscopic Sleeve Gastrectomy (LSG) is the most common bariatric surgery in the world. While clinically effective, recent studies have shown increasingly higher rates of gastroesophageal reflux disease (GERD) and esophageal motility disorders. We reviewed all the literature and unraveled the underlying mechanism of post-LSG GERD. Finally, we propose a new classification to help us understand the disease and guide work-up, treatment, and future refinements in the surgical technique.

Effectiveness of sleeve gastrectomy plus fundoplication versus sleeve gastrectomy alone for treatment of patients with severe obesity: a systematic review and meta-analysis

BACKGROUND

Laparoscopic sleeve gastrectomy (SG) is a widely performed bariatric surgery, but it is associated with an increased risk of gastroesophageal reflux (GERD) in the long term. The addition of fundoplication to laparoscopic SG may improve lower oesophageal sphincter function and reduce postoperative GERD.

OBJECTIVES

This systematic review and meta-analysis aims to compare the efficacy and safety of SG plus fundoplication (SG + F) versus SG alone for the treatment of patients with severe obesity (≥35 kg/m2).

SETTING

Meta-analysis.

METHODS

Three electronic databases were searched from inception until January 2023. Studies were included if they compared outcomes of SG + F versus SG in patients with severe obesity (≥35 kg/m2). The primary outcome was remission of GERD postoperatively. Secondary outcomes were the percentage of excess weight loss, percentage of total weight loss, postoperative complication rate, operative time, and length of stay.

RESULTS

A total of 5 studies with 539 subjects (212 SG + F and 327 SG alone) were included. The mean preoperative body mass index was 42.6 kg/m2. SG + F achieved higher remission of GERD compared with laparoscopic SG (odds ratio [OR] = 13.13; 95% CI, 3.54-48.73; I2 = 0%). However, the percentage of total weight loss was lower in the SG + F group (mean difference [MD] = -2.75, 95% CI, -4.28 to -1.23; I2 = 0%), whereas there was no difference in the percentage of excess weight loss (MD = -0.64; 95% CI, -20.62-19.34; I2 = 83%). There were higher postoperative complications in SG + F (OR = 2.56; 95% CI, 1.12-5.87; I2 = 0%) as well. There was no difference in operative time or length of stay between the 2 groups.

CONCLUSION

SG + F achieved better GERD remission but is associated with lesser weight loss and increased postoperative complications compared with SG alone. Further studies are required to ascertain the overall clinical benefit of SG + F for patients with severe obesity.

Incidence of Post-operative Gastro-esophageal Reflux Disorder in Patients Undergoing Laparoscopic Sleeve Gastrectomy: A Systematic Review and Meta-analysis

Gastroesophageal reflux disease (GERD) is a common concern following laparoscopic sleeve gastrectomy (LSG). This paper aimed to assess the incidence of reflux disease following these bariatric procedures. A literature search was conducted to identify observational studies and clinical trials reporting patients developed GERD disease after LSG. Twenty-two studies included in the analysis, involve 20,495 participants, indicated that the estimated proportion of patients who developed post-surgery GERD was 0.35 (95% CI 0.30-0.41). Subgroup analysis revealed a proportion of 0.33 (95% CI 0.27-0.38) in observational studies and 0.58 (95% CI 0.39-0.75) in clinical trials. High heterogeneity was noted across studies (I2 = 98%). Sensitivity analyses and publication bias assessments were performed to enhance the robustness of the results. Our findings highlight a moderate to high risk of developing GERD following LSG surgery.

Updates in Bariatric Surgery

Bariatric surgery is currently the most effective long-term treatment for morbid obesity as well as type-2 diabetes mellitus. The field of metabolic and bariatric surgery has seen tremendous growth over the past decade with dramatically reduced risks. This article aims to provide an update on bariatric surgery, highlighting the latest outcomes, improvements, and challenges in the field. Recently, the American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) released a major update to the indications for bariatric surgery at BMI ≥35 kg/m2 regardless of co-morbidities and 30-34.9 kg/m2 with obesity-related comorbidities. Sleeve gastrectomy has emerged as the most popular bariatric procedure in the last 10 years with its remarkable efficacy and safety profile. The implementation of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) and Enhanced Recovery After Surgery (ERAS) protocols have significantly improved the quality of care for all bariatric patients. The recent introduction and FDA approval of Glucagon-Like Peptide-1 (GLP-1) agonists for chronic obesity has garnered significant media coverage and popularity, but no guidelines exist regarding its use in relation to bariatric surgery. This update underscores the need for tailored approaches, ongoing research, and the integration of evidence-based medicine and innovations to enhance patient care.

Laparoscopic sleeve gastrectomy combined with Toupet fundoplication (T-sleeve): A short report of a Japanese obesity patient with gastroesophageal reflux disease

Laparoscopic sleeve gastrectomy (LSG) is the most frequently performed procedure in bariatric-metabolic surgery (BMS) worldwide, accounting for approximately 90% of BMS procedures in Japan. While numerous studies have reported on the safety and efficacy of LSG, gastroesophageal reflux disease (GERD) remains a major postoperative complication. Although Roux-en-Y gastric bypass (RYGB) is preferred for severe obesity with GERD, it is less suitable for Japanese patients who have a higher risk of gastric cancer due to the remnant stomach which is difficult to observe with esophago-gastro-duodenoscopy. To address de novo and exacerbation GERD after LSG, we conducted LSG with Toupet fundoplication (T-sleeve) for Japanese patients with severe obesity. In our first T-sleeve case, the patient demonstrated sufficient weight loss and improved GERD following surgery. Hence, we suggest that T-sleeve is a feasible option for Japanese patients with obesity and concurrent GERD.

Current Management and Treatment Paradigms of Gastroesophageal Reflux Disease following Sleeve Gastrectomy

Obesity is associated with serious comorbidities and economic implications. Bariatric surgery, most commonly Roux-en-Y gastric bypass and sleeve gastrectomy, are effective options for weight loss and the improvement of obesity-related comorbidities. With the growing obesity epidemic, there has been a concomitant rise in bariatric surgeries, particularly in sleeve gastrectomy, which has been the most widely performed bariatric surgery since 2013. Gastroesophageal reflux disease (GERD) is highly prevalent in obese individuals, can significantly impact quality of life and may lead to serious complications. Obesity and GERD both improve with weight loss. However, as the incidence of sleeve gastrectomy rises, recent data have revealed a risk of exacerbation of pre-existing GERD or the development of de novo GERD following sleeve gastrectomy. We performed a detailed review of GERD post-sleeve gastrectomy, including its overall incidence, pathophysiology and current treatment paradigms.

Gastroesophageal Reflux Disease and Weight Loss After Fundoplication Sleeve Gastrectomy: a Systematic Review and Meta-analysis

INTRODUCTION

Fundoplication sleeve gastrectomy (FSG) is a novel bariatric procedure that combines anti-reflux fundoplication with sleeve gastrectomy (SG) to simultaneously address gastroesophageal reflux disease (GERD) and obesity. We performed a systematic review and meta-analysis to quantify the prevalence of postoperative GERD and amount of weight loss after FSG.

METHODS

We searched PubMed, Embase, and Web of Science Core Collection in May 2023 for full-text reports of case series, registries, cohort studies, and randomized clinical trials that reported postoperative GERD and percent excess weight loss (%EWL) after FSG for patients with preoperative GERD and obesity, excluding reports including patients with previous history of bariatric procedures. We used random effects models to estimate postoperative GERD prevalence and %EWL. Risk of bias and evidence quality were assessed with the ROBINS-I and GRADE frameworks (PROSPERO CRD42023420067).

RESULTS

Of the 935 records initially identified, 13 studies from 8 countries met our inclusion criteria. The prevalence of postoperative GERD pooled from 418 patients was 4.8% (95% CI: 2.8 to 8.4%). Pooled %EWL, available for 225 patients from 7 studies, was 67.8% (95% CI: 55.2 to 80.5). The overall quality of evidence was low, largely due to observational study design, lack of blinded outcome assessment, and evidence of publication bias.

CONCLUSION

Fundoplication sleeve gastrectomy is an emerging surgical approach for patients with obesity and GERD with promising initial outcomes. Additional studies of efficacy and safety are needed to compare FSG and its technical variations with other weight loss procedures.

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

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

Role of Preoperative High-Resolution Manometry in the Identification of Patients at High Risk of Postoperative GERD Symptoms 1 Year After Sleeve Gastrectomy

PURPOSE

Sleeve gastrectomy (SG) has become the most common bariatric procedure, but it is often characterized by the onset of postoperative gastroesophageal reflux disease (GERD). High-resolution manometry (HRM) is a useful tool to detect risk factors for GERD. The aim of this study was to evaluate preoperative manometric parameters as possible predictors of postoperative GERD.

MATERIALS AND METHODS

This was a monocentric retrospective study. We analyzed 164 patients, with preoperative esophagitis/GERD symptoms who underwent preoperative HRM and were submitted to SG (July 2020-February 2022).

RESULTS

Postoperative GERD was observed in 60 patients (36.6%): 41 of them (68%) already had preoperative GERD symptoms, whereas the remaining 19 patients (32%) developed postoperative symptoms. Female patients developed postoperative GERD in a significantly higher fraction of cases as compared to male patients (82% versus 18%; p < 0.001). DCI (distal contractile integral) was identified as the only HRM parameter correlating with the presence of GERD. Patients with DCI ≤ 1623 mmHg*cm*s developed postoperative GERD in 46% of cases (n = 43/94), as compared to 24% of cases (n = 17/70) among patients with DCI > 1623 mmHg*cm*s (p = 0.005). At multivariable analysis, female sex (OR 3.402, p = 0.002), preoperative GERD symptoms (OR 2.489, p = 0.013), and DCI ≤ 1623 mmHg*s*cm (OR 0.335, p = 0.003) were identified as independent determinants of postoperative GERD.

CONCLUSION

All the patients with preoperative risk factors for reflux, such as GERD symptoms or esophagitis on EGDS (esophagogastroduodenoscopy), should be considered for an HRM. Moreover, when a DCI ≤ 1623 mmHg*s*cm is found, a bariatric procedure different from SG might be considered.

Gastroesophageal Reflux Disease in Obesity: Bariatric Surgery as Both the Cause and the Cure in the Morbidly Obese Population

Gastrointestinal reflux disease (GERD) is a chronic, highly prevalent condition in the United States. GERD can significantly impact quality of life and lead to complications including aspiration pneumonia, esophageal stricture, Barrett's esophagus (BE) and esophageal cancer. Obesity is a risk factor for GERD, which often improves with weight loss and bariatric surgery. Though the incidence of bariatric surgery, in particular, minimally invasive sleeve gastrectomy, has risen in recent years, emerging data has revealed that the severity or new onset of GERD may follow bariatric surgery. We performed a literature review to provide a detailed analysis of GERD with an emphasis on bariatric surgery as both the cure and the cause for GERD in the morbidly obese population. We also describe the pathophysiological mechanisms, management approach and treatment strategies of GERD following bariatric surgery.

Obesity, sleeve gastrectomy and gastro-esophageal reflux disease

Sleeve gastrectomy (SG) is the most frequently performed operation for morbid obesity in the world. In spite of its demonstrated efficacy, the Achilles' Heel of this procedure seems to be either pre-existing or de novo gastro-esophageal reflux disease (GERD) with its potential complications such as peptic esophagitis, Barrett's esophagus and, in the long-term, esophageal adenocarcinoma. According to factual literature, it appears clear that Roux-en-Y gastric bypass is the preferred choice in case of pre-existing GERD or hiatal hernia discovered during preoperative workup for bariatric surgery. Nonetheless, certain authors propose performance of SG with an associated antireflux procedure such as Nissen fundoplication. Strict endoscopic surveillance is recommended after bariatric surgery. Revisional surgery (conversion of SG into Roux-en-Y gastric bypass (RYGB)) is the treatment of choice for patients who develop GERD after SG when conservative treatment (modified lifestyle and proton pump inhibitors) has failed. Lastly, with regard to the risk of esophageal adenocarcinoma after SG, large scale studies with adequate follow-up are necessary to come to factual conclusions. In all cases, the management of this conundrum remains a major technical challenge that has to be taken in consideration in future years, especially because of the current expansion of bariatric surgery.