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N-SLEEVE GASTRECTOMY: AN OPTION FOR OBESITY AND GERD

ABSTRACT

Background:

Obesity represents a growing threat to population health all over the world. Laparoscopic sleeve gastrectomy induces alteration of the esophagogastric angle due to surgery itself, hypotony of the lower esophageal sphincter after division of muscular sling fibers, decrease of the gastric volume and, consequently, increase of intragastric pressure; that’s why some patients have reflux after sleeve.

Aim:

To describe a technique and preliminary results of sleeve gastrectomy with a Nissen fundoplication, in order to decrease reflux after sleeve.

Method:

In the current article we describe the technique step by step mostly focused on the creation of the wrap and it care.

Results:

This procedure was applied in a case of 45 BMI female of 53 years old, with GERD. An endoscopy was done demonstrating a hiatal hernia, and five benign polyps. A Nissen sleeve was performed due to its GERD, hiatal hernia and multiple polyps on the stomach. She tolerated well the procedure and was discharged home uneventfully 48 h after.

Conclusion:

N-sleeve is a feasible and safe alternative in obese patients with reflux and hiatal hernia when Roux-en-Y gastric bypass it is not indicated.

HEADINGS:
Sleeve gastrectomy; GERD; Obesity; Bariatric surgery

RESUMO

Racional:

A obesidade representa ameaça crescente à saúde da população em todo o mundo. A gastrectomia por laparoscopia induz alteração do ângulo esofagogástrico devido à própria técnica, hipotonia do esfíncter esofágico inferior após secção de fibras musculares da junção, diminuição do volume gástrico e, consequentemente, aumento da pressão intragástrica; é por isso que alguns pacientes têm refluxo após a gastrectomia vertical.

Objetivo:

Descrever uma técnica e resultados preliminares da gastrectomia vertical com fundoplicatura a Nissen, a fim de diminuir o refluxo após ela.

Método:

No artigo atual, descrevemos a técnica passo a passo, principalmente focada na criação da válvula e seu cuidado.

Resultados:

Este procedimento foi aplicado em um caso de mulher com IMC 45 de 53 anos com DRGE. Foi realizada endoscopia demonstrando hérnia hiatal e cinco pólipos benignos. A gastrectomia vertical com Nissen foi realizada devido à DRGE, à hérnia hiatal e aos múltiplos pólipos no estômago. Ela tolerou bem o procedimento e recebeu alta sem intercorrências 48 h depois.

Conclusão:

A N-gastrectomia vertical (N-sleeve) é alternativa viável e segura em pacientes obesos com refluxo e hérnia hiatal quando não é indicado o desvio gástrico em Y-de-Roux.

DESCRITORES:
Gastrectomia vertical; Doença do refluxo gastroesofágico; Cirurgia bariátrica

INTRODUCTION

Obesity represents a growing threat to population health all over the world. According to data from the National Health and Nutrition Examination Survey, in 2015/2016, the prevalence of obesity was 39.8% in adults and 18.5% in youth in United States11 Angrisani L, Santonicola A, Iovino P, Vitiello A, Higa K, Himpens J, Buchwald H, Scopinaro N. IFSO Worldwide Survey 2016: Primary, Endoluminal, and Revisional Procedures. Obes Surg. 2018 Dec;28(12):3783-3794,22 Braghetto I, Lanzarini E, Korn O, Valladares H, Molina JC, Henriquez A. Manometricchanges of the lower esophageal sphincter after sleeve gastrectomy in obese patients.Obes Surg. mars 2010;20(3):357-62.. Obesity, one of the main factors, is reported to increase the intra-gastric pressure with impaired gastric emptying, the frequency of transient lower esophageal sphincter (LES) relaxation episode and the gastroesophageal pressure gradient, potentially leading to GERD33 Brown CS, Lapin B, Goldstein JL, Linn JG, Talamonti MS, Carbray J, et al. Predicting Progression in Barrett's Esophagus: Development and Validation of the Barrett's Esophagus Assessment of Risk Score (BEAR Score). Ann Surg. 22 févr 2017,44 Brown CS, Lapin B, Wang C, Goldstein JL, Linn JG, Denham W, et al. Reflux control is important in the management of Barrett's Esophagus: results from a retrospective 1,830 patient cohort. SurgEndosc. déc 2015;29(12):3528-34.,55 Chiu S, Birch DW, Shi X, et al. Effect of sleeve gastrectomy on gastroesophageal reflux disease: a systematic review. SurgObesRelat Dis. 20117:510-15.,1717 Kirkil C, Aygen E, Korkmaz MF, Bozan MB. Quality of life after laparoscopic sleeve gastrectomy usi?ng baros system. Arq Bras Cir Dig. 2018 Aug 16;31(3):e1385. doi: 10.1590/0102-672020180001e1385
https://doi.org/10.1590/0102-67202018000...
,1818 Lasnibat JP, Braghetto I, Gutierrez L, Sanchez F. Sleeve gastrectomy and fundoplication as a single procedure in patients with obesity and gastroesophageal reflux. Arq Bras Cir Dig. 2017 Jul-Sep;30(3):216-221. doi: 10.1590/0102-6720201700030012.
https://doi.org/10.1590/0102-67202017000...
,1919 Lazzati A, Guy-Lachuer R, Delaunay V, Szwarcensztein K, Azoulay D Bariatric surgery trends in France: 2005-2011.Surg ObesRelat Dis. 2014 Mar-Apr;10(2):328-34. Laparoscopic sleeve gastrectomy induces alteration of the esophagogastric angle due to surgery itself, hypotony of the LES after division of muscular sling fibers, decrease of the gastric volume and, consequently, increase of intragastric pressure, that’s why some patients have reflux after sleeve.

The objective of this paper was to describe a technique of sleeve gastrectomy with a Nissen fundoplication (described by Prof. Nocca), in order to decrease reflux after sleeve11 Angrisani L, Santonicola A, Iovino P, Vitiello A, Higa K, Himpens J, Buchwald H, Scopinaro N. IFSO Worldwide Survey 2016: Primary, Endoluminal, and Revisional Procedures. Obes Surg. 2018 Dec;28(12):3783-3794,22 Braghetto I, Lanzarini E, Korn O, Valladares H, Molina JC, Henriquez A. Manometricchanges of the lower esophageal sphincter after sleeve gastrectomy in obese patients.Obes Surg. mars 2010;20(3):357-62.,66 Craig M. Hales, Margaret D. Carroll, Cheryl D. Fryar, Cynthia L. Ogden, Prevalence of Obesity Among Adults and Youth: United States, 2015-2016. NCHS Data Brief. 2017 Oct;(288):1-8.),77 David MB, Abu-Gazala S, Sadot E, Wasserberg N, Kashtan H, Keidar A. Laparoscopic conversion of failed vertical banded gastroplasty to Roux-en-Y gastric bypass or biliopancreatic diversion. SurgObesRelat Dis. 2015 Sep-Oct;11(5):1085-91.,88 Disse E, A. Pasquer, P. Espalieu, G. Poncet, C. Gouillat, M. Robert. Greater weight loss with the omega loop bypass compared to the Roux-en-Y gastric bypass: a comparative study ObesSurg, 2014 Jun;24(6):841-6,1010 Fezzi M, Kolotkin RL, Nedelcu M et al. Improvement in quality of life after laparoscopic sleeve gastrectomy. Obes Surg. 2011 Aug;21(8):1161-7.,2323 Nocca D, Skalli EM, Boulay E, Nedelcu M, Michel Fabre J, Loureiro M. Nissen Sleeve (N-Sleeve) operation: preliminary results of a pilot study. Surg Obes Relat Dis. 2016 Dec;12(10):1832-1837. doi: 10.1016/j.soard.2016.02.010. Epub 2016 Feb 22.
https://doi.org/10.1016/j.soard.2016.02....
,2424 Oh DS, Demeester SR. Pathophysiology and treatment of Barrett's esophagus. World J Gastroenterol. 14 août 2010;16(30):3762-72..

METHOD

Surgical technique

By laparoscopic approach with the surgeon standing between the patient’s legs, five trocars are placed (Figure 1). Pneumoperitoneum is insuflated up to to 15 mmHg. The trocar placement is the same as in standard laparoscopic sleeve gastrectomy (LSG) or Roux-en-Y gastric bypass (RYGBP).

FIGURE 1
Placement of the trocars

The first step of the N-sleeve is the dissection and reduction of a hiatal hernia. An extension of at least 5 to 6 cm of abdominal esophagus is mobilized and all the anterior and posterior esophageal hiatal space is dissected (Figure 2A). The greater curvature of the stomach is then dissected from the short gastric vessels and gastrocolic ligament, starting 5 cm from the pylorus. Two non-absorbable sutures are used to close the hiatal hernia and a 36 Fr calibration boggie is inserted as a regular LSG (Figures 2B and C). After that step a short 360º valve of 3 cm is created using silk. The wrap valve is fixed to the anterior part of the esophagus (Figure 3A and B). Then the rest of the greater curvature is dissected. A laparoscopic 60 mm linear stapler is used to perform the first division of the antrum. Then the rest of the sleeve gastrectomy is performed as usual with special care in the last fire in order not to cut the “4” layers (Figures 4A and B). All the staple lines are reinforced as we do in the regular LSG (Figure 5). Blue test is performed. We routinely place a JP drain. The postoperative care is the same than the regular LSG.

FIGURE 2
A) Hiatal hernia; B) closure of the hiatal hernia with silk; C) final aspect of the hernia closure calibrating it with a 36 Fr tube

FIGURE 3
A and B) The wrap is being performed

FIGURE 4
A and B) The last stapling and the final aspect of the N-sleeve

FIGURE 5
Staple line reinforcement with absorbable sutures

Contrary to standard LSG, for the N-sleeve some technical details are very important: 1) avoid ischemia of the gastric wall during short gastric vessels dissection; 2) delicate handling of the gastric fundus during fundoplication; 3) avoid double stapling of the gastric fundus1010 Fezzi M, Kolotkin RL, Nedelcu M et al. Improvement in quality of life after laparoscopic sleeve gastrectomy. Obes Surg. 2011 Aug;21(8):1161-7.,3232 Sohn S, Fischer J, Booth M.Adenocarcinoma of the gastro-oesophageal junction aftersleeve gastrectomy: a case report.ANZ J Surg. 2017 Oct;87(10):E163-E164.,3636 Weiss AC, Parina R, Horgan S, Talamini M, Chang DC, Sandler B. Quality and safety in obesity surgery-15 years of Roux-en-Y gastric bypass outcomes from a longitudinal database. SurgObesRelat Dis. 2016 Jan;12(1):33-40,3737 Woodman G, Cywes R, Billy H, Montgomery K, Cornell C, Okerson T; Effect of adjustable gastric banding on changes in gastroesophageal reflux disease (GERD) and quality of life. APEX Study Group. Curr Med Res Opin. 2012 Apr;28(4):581-9..

RESULTS

This procedure was applied in a female of 53 years; she was admitted to our multidisciplinary group for obesity treatment. She had a BMI of 45. All the preoperative exams were done (laboratory, endoscopy, gastrointestinal series, functional lung test, HPB ultrasound). In the endoscopy a hiatal hernia was demonstrated, and five benign polyps were resected by endoscopy. The patient had GERD. We performed a N-sleeve due to its GERD, hiatal hernia and multiple polyps on the stomach. She tolerated well the procedure, was discharged home uneventfully 48 h after the procedure and in the medium term follow up she did well, with adequate weight loss and non recurrence of her GERD symptoms. We will still follow up her in order to have more long-term data.

A CT scan was performed for another reason not related with the surgery and we could see the wrap with no complications and an adequate sleeve (Figure 6).

FIGURE 6
CT demonstrating and adequate Nissen wrap with no complications and a normal sleeve size.

DISCUSSION

Nocca et al.2323 Nocca D, Skalli EM, Boulay E, Nedelcu M, Michel Fabre J, Loureiro M. Nissen Sleeve (N-Sleeve) operation: preliminary results of a pilot study. Surg Obes Relat Dis. 2016 Dec;12(10):1832-1837. doi: 10.1016/j.soard.2016.02.010. Epub 2016 Feb 22.
https://doi.org/10.1016/j.soard.2016.02....
by 2016 published the first 25 patients all with esophageal syndromes. Ninety-two had typical symptoms of GERD and two asymptomatic but with esophageal injury. Three months after N-sleeve, 76% of the patients remained asymptomatic without proton pump inhibitor use. At six months and one year, three (12%) patients were still experiencing reflux. Excess weight loss at one year was 58±23%, total weight loss was 27±10%, and body mass index change was -11±4 kg/m². They concluded that N-sleeve seems to be a safe procedure that provides an adequate reflux control with no clear interference on the expected bariatric results of a standard LSG1010 Fezzi M, Kolotkin RL, Nedelcu M et al. Improvement in quality of life after laparoscopic sleeve gastrectomy. Obes Surg. 2011 Aug;21(8):1161-7.,1212 Gagner M, Ramos A, Palermo M, Noel P, Nocca D. The perfect Sleeve gastrectomy. SPRINGER. In Press.,2424 Oh DS, Demeester SR. Pathophysiology and treatment of Barrett's esophagus. World J Gastroenterol. 14 août 2010;16(30):3762-72..

Regarding GERD, the Montreal conference defines it as a disorder related to reflux of stomach contents leading to discomfort or complications affecting the patient´s quality of life. Typical symptoms are: heartburn (upstream esophageal burning) and regurgitation, and atypical are: epigastric burns, chest pain, respiratory symptoms (chronic cough and asthma), dental erosions22 Braghetto I, Lanzarini E, Korn O, Valladares H, Molina JC, Henriquez A. Manometricchanges of the lower esophageal sphincter after sleeve gastrectomy in obese patients.Obes Surg. mars 2010;20(3):357-62.,44 Brown CS, Lapin B, Wang C, Goldstein JL, Linn JG, Denham W, et al. Reflux control is important in the management of Barrett's Esophagus: results from a retrospective 1,830 patient cohort. SurgEndosc. déc 2015;29(12):3528-34.,2020 Lundell L, Dent J, Bennett J, Blum A, Armstrong D, Galmiche J, et al. Endoscopic assessment of oesophagitis: clinical and functional correlates and further validation of the Los Angeles classification. Gut. août 1999;45(2):172-80.,2222 Mognol P, Chosidow D, Marmuse JP Roux-en-Y gastric bypass after failed vertical banded gastroplasty. Obes Surg. 2007 Nov;17(11):1431-4.,2323 Nocca D, Skalli EM, Boulay E, Nedelcu M, Michel Fabre J, Loureiro M. Nissen Sleeve (N-Sleeve) operation: preliminary results of a pilot study. Surg Obes Relat Dis. 2016 Dec;12(10):1832-1837. doi: 10.1016/j.soard.2016.02.010. Epub 2016 Feb 22.
https://doi.org/10.1016/j.soard.2016.02....
,2626 Porcelli ICS, Corsi NM, Fracasso MLC, Pascotto RC, Cardelli AAM, Poli-Frederico RC, Nasser D, Maciel SM. Oral health promotion in patients with morbid obesity after gastroplasty: a randomized clinical trial. Arq Bras Cir Dig. 2019 Aug 26;32(2):e1437. doi: 10.1590/0102-672020190001e1437.
https://doi.org/10.1590/0102-67202019000...
.

GERD is complex, especially in the era of bariatric surgery3535 Wada AM, Hashiba K, Otoch JP, Brasil H, Marson FP, Cassab J, Abdalla R, Artifon ELA. Full-thickness endoscopic gastric resection using a stapler and gastrostomy: a feasibility study. Arq Bras Cir Dig. 2018 Aug 16;31(3):e1386. doi: 10.1590/0102-672020180001e1386
https://doi.org/10.1590/0102-67202018000...
. A chronic inflammation can induce more serious lesions, since up to 10-15% of patients develop dysplasia, as Barrett’s esophagus, that can lead to esophageal cancer99 El-Serag HB, Sweet S, Winchester CC, Dent J. Update on the epidemiology of gastro-oesophageal reflux disease: a systematic review. Gut. jun 2014;63(6):871-80.,1010 Fezzi M, Kolotkin RL, Nedelcu M et al. Improvement in quality of life after laparoscopic sleeve gastrectomy. Obes Surg. 2011 Aug;21(8):1161-7.,1111 Gagner M, Hutchinson C, Rosenthal R. Fifth International Consensus Conference: current status of sleeve gastrectomy. SurgObesRelat Dis Off J Am SocBariatr Surg. mai 2016;12(4):750-6.,1313 Genco A, Soricelli E, Casella G, Maselli R, Castagneto-Gissey L, Di Lorenzo N, Basso N. Gastroesophageal reflux disease and Barrett's esophagus after laparoscopic sleeve gastrectomy: a possible, underestimated long-term complication. SurgObesRelat Dis. 2017 Apr;13(4):568-574..

Variables associated with an increased risk of progression of Barrett’s esophagus in dysplasia or adenocarcinoma are: age >70 years, male, absence of treatment with proton pump inhibitor, Barrett’s esophagus longer than 3 cm and esophageal candidiasis1414 Hales CM, Fryar CD, Carroll MD, Freedman DS, Ogden CL. Trends in Obesity and Severe Obesity Prevalence in US Youth and Adults by Sex and Age, 2007-2008 to 2015-2016. JAMA. 2018 Apr 24;319(16):1723-1725.,1515 Higa K, Ho T, Tercero F, Yunus T, Boone KB. Laparoscopic Roux-en-Y gastricbypass: 10-year follow-up. SurgObesRelat Dis. 2011 Jul-Aug;7(4):516-25.,1616 Himpens J, Dapri G, Cadière GB. A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: results after 1 and 3 years. Obes Surg. nov 2006;16(11):1450-6.,1717 Kirkil C, Aygen E, Korkmaz MF, Bozan MB. Quality of life after laparoscopic sleeve gastrectomy usi?ng baros system. Arq Bras Cir Dig. 2018 Aug 16;31(3):e1385. doi: 10.1590/0102-672020180001e1385
https://doi.org/10.1590/0102-67202018000...
.

However, reflux control (by medical treatment or anti-reflux surgery) is associated with regression of Barrett’s mucosa1010 Fezzi M, Kolotkin RL, Nedelcu M et al. Improvement in quality of life after laparoscopic sleeve gastrectomy. Obes Surg. 2011 Aug;21(8):1161-7.,1212 Gagner M, Ramos A, Palermo M, Noel P, Nocca D. The perfect Sleeve gastrectomy. SPRINGER. In Press.,2525 Ponce J, DeMaria EJ, Nguyen NT, Hutter M, Sudan R, Morton JM. American Society for Metabolic and Bariatric Surgery estimation of bariatric surgery procedures in 2015 and surgeon workforce in the United States. SurgObesRelat Dis. 2016 Aug. 26,2727 Rosenthal RJ, International Sleeve Gastrectomy Expert Panel, Diaz AA, Arvidsson D, Baker RS, Basso N, et al. International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of >12,000 cases. SurgObesRelat Dis Off J Am SocBariatr Surg. févr 2012;8(1):819.,2828 Saarinen T, Räsänen J, Salo J, Loimaala A, Pitkonen M, Leivonen M, Juuti A. Bile Reflux Scintigraphy After Mini-Gastric Bypass. ObesSurg. 2017 Aug;27(8):2083-2089, an important reason to combine an anti-reflux mechanism to a bariatric procedure.

LSG has evolved into a primary surgical procedure for morbid obesity. It has gained popularity worldwide as a primary bariatric procedure, now established as the most frequent bariatric procedure worldwide1212 Gagner M, Ramos A, Palermo M, Noel P, Nocca D. The perfect Sleeve gastrectomy. SPRINGER. In Press.,2323 Nocca D, Skalli EM, Boulay E, Nedelcu M, Michel Fabre J, Loureiro M. Nissen Sleeve (N-Sleeve) operation: preliminary results of a pilot study. Surg Obes Relat Dis. 2016 Dec;12(10):1832-1837. doi: 10.1016/j.soard.2016.02.010. Epub 2016 Feb 22.
https://doi.org/10.1016/j.soard.2016.02....
,3434 Tolonen P, Victorzon M, Niemi R, Mäkelä J. Does gastric banding for morbid obesity reduce or increase gastroesophageal reflux? Obes Surg. 2006 Nov;16(11):1469-74.,3737 Woodman G, Cywes R, Billy H, Montgomery K, Cornell C, Okerson T; Effect of adjustable gastric banding on changes in gastroesophageal reflux disease (GERD) and quality of life. APEX Study Group. Curr Med Res Opin. 2012 Apr;28(4):581-9.. This growth can be explained by several advantages that LSG carries over more complex bariatric procedures, such as RYGBP or duodenal switch, including the absence of most side effects of bypass procedures like dumping syndrome, marginal ulcers, malabsorption, small bowel obstruction and internal hernia, and a better quality of life over gastric banding1717 Kirkil C, Aygen E, Korkmaz MF, Bozan MB. Quality of life after laparoscopic sleeve gastrectomy usi?ng baros system. Arq Bras Cir Dig. 2018 Aug 16;31(3):e1385. doi: 10.1590/0102-672020180001e1385
https://doi.org/10.1590/0102-67202018000...
,2323 Nocca D, Skalli EM, Boulay E, Nedelcu M, Michel Fabre J, Loureiro M. Nissen Sleeve (N-Sleeve) operation: preliminary results of a pilot study. Surg Obes Relat Dis. 2016 Dec;12(10):1832-1837. doi: 10.1016/j.soard.2016.02.010. Epub 2016 Feb 22.
https://doi.org/10.1016/j.soard.2016.02....
,2424 Oh DS, Demeester SR. Pathophysiology and treatment of Barrett's esophagus. World J Gastroenterol. 14 août 2010;16(30):3762-72.,3232 Sohn S, Fischer J, Booth M.Adenocarcinoma of the gastro-oesophageal junction aftersleeve gastrectomy: a case report.ANZ J Surg. 2017 Oct;87(10):E163-E164..

Besides prior described alterations, LSG decreases ghrelin, hence dismotility1010 Fezzi M, Kolotkin RL, Nedelcu M et al. Improvement in quality of life after laparoscopic sleeve gastrectomy. Obes Surg. 2011 Aug;21(8):1161-7.,2424 Oh DS, Demeester SR. Pathophysiology and treatment of Barrett's esophagus. World J Gastroenterol. 14 août 2010;16(30):3762-72.,2525 Ponce J, DeMaria EJ, Nguyen NT, Hutter M, Sudan R, Morton JM. American Society for Metabolic and Bariatric Surgery estimation of bariatric surgery procedures in 2015 and surgeon workforce in the United States. SurgObesRelat Dis. 2016 Aug. 26,2727 Rosenthal RJ, International Sleeve Gastrectomy Expert Panel, Diaz AA, Arvidsson D, Baker RS, Basso N, et al. International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of >12,000 cases. SurgObesRelat Dis Off J Am SocBariatr Surg. févr 2012;8(1):819.. All these factors contribute to expose the patient to the risk of increasing GERD and proton pump inhibitors dependency or developing new GERD onset. On the other hand, weight loss after surgery together with accelerated gastric emptying, decreases acid production and restores esophagogastric angle over time supposing to improve reflux symptoms. However, the presence of preoperative GERD should be considered a relative contraindication to LSG1212 Gagner M, Ramos A, Palermo M, Noel P, Nocca D. The perfect Sleeve gastrectomy. SPRINGER. In Press.,2424 Oh DS, Demeester SR. Pathophysiology and treatment of Barrett's esophagus. World J Gastroenterol. 14 août 2010;16(30):3762-72.,3131 Sebastianelli L, Benois M, Vanbiervliet G, Bailly L, Robert M, Turrin N, Gizard E, Foletto M, Bisello M, Albanese A, Santonicola A, Iovino P, Piche T, Angrisani L, Turchi L, Schiavo L, Iannelli A. Systematic Endoscopy 5 Years After Sleeve Gastrectomy Results in a High Rate of Barrett's Esophagus: Results of a Multicenter Study. Obes Surg. 2019 Jan 21. doi: 10.1007/s11695-019-03704.
https://doi.org/10.1007/s11695-019-03704...
.

Here we introduced the concept of N-sleeve as an option to prevent GERD. Although the laparoscopic RYGB was considered the gold standard procedure for obese patients with reflux disease, more than one third of patients who underwent this operation had at least one complication within the 10-year follow-up period3333 Soricelli E, Iossa A, Casella G, Abbatini F, Calì B, Basso N. Sleeve gastrectomy and crural repair in obese patients with gastroesophageal reflux disease and/or hiatal hernia. SurgObesRelat Dis Off J Am SocBariatr Surg. juin 2013;9(3):356-61.. Himpens et al. reported new gastro-esophageal reflux complaints in 21% of patients. Considering all these findings and encouraged by the good results of LSG and concomitant hiatal hernia repair1010 Fezzi M, Kolotkin RL, Nedelcu M et al. Improvement in quality of life after laparoscopic sleeve gastrectomy. Obes Surg. 2011 Aug;21(8):1161-7.,1212 Gagner M, Ramos A, Palermo M, Noel P, Nocca D. The perfect Sleeve gastrectomy. SPRINGER. In Press.,2121 Melissas J, Daskalakis M, Koukouraki S, Askoxylakis I, Metaxari M, Dimitriadis E, et al. Sleeve gastrectomy-a " food limiting " operation. Obes Surg. oct 2008;18(10):1251-6.,3434 Tolonen P, Victorzon M, Niemi R, Mäkelä J. Does gastric banding for morbid obesity reduce or increase gastroesophageal reflux? Obes Surg. 2006 Nov;16(11):1469-74., David Nocca and his team have developed a modification to the usual surgical technique by adding a Nissen fundoplication in order to minimize both leaks and GERD3232 Sohn S, Fischer J, Booth M.Adenocarcinoma of the gastro-oesophageal junction aftersleeve gastrectomy: a case report.ANZ J Surg. 2017 Oct;87(10):E163-E164.,3737 Woodman G, Cywes R, Billy H, Montgomery K, Cornell C, Okerson T; Effect of adjustable gastric banding on changes in gastroesophageal reflux disease (GERD) and quality of life. APEX Study Group. Curr Med Res Opin. 2012 Apr;28(4):581-9..

The aim of this article was to describe our N-sleeve technique performed in Buenos Aires as an option for patients who have hiatal hernia with reflux and are not candidates to perform a RYGBP.

CONCLUSION

N-sleeve is a feasible and safe alternative in obese patients with reflux and hiatal hernia when RYGBP it is not indicated.

REFERENCES

  • 1
    Angrisani L, Santonicola A, Iovino P, Vitiello A, Higa K, Himpens J, Buchwald H, Scopinaro N. IFSO Worldwide Survey 2016: Primary, Endoluminal, and Revisional Procedures. Obes Surg. 2018 Dec;28(12):3783-3794
  • 2
    Braghetto I, Lanzarini E, Korn O, Valladares H, Molina JC, Henriquez A. Manometricchanges of the lower esophageal sphincter after sleeve gastrectomy in obese patients.Obes Surg. mars 2010;20(3):357-62.
  • 3
    Brown CS, Lapin B, Goldstein JL, Linn JG, Talamonti MS, Carbray J, et al. Predicting Progression in Barrett's Esophagus: Development and Validation of the Barrett's Esophagus Assessment of Risk Score (BEAR Score). Ann Surg. 22 févr 2017
  • 4
    Brown CS, Lapin B, Wang C, Goldstein JL, Linn JG, Denham W, et al. Reflux control is important in the management of Barrett's Esophagus: results from a retrospective 1,830 patient cohort. SurgEndosc. déc 2015;29(12):3528-34.
  • 5
    Chiu S, Birch DW, Shi X, et al. Effect of sleeve gastrectomy on gastroesophageal reflux disease: a systematic review. SurgObesRelat Dis. 20117:510-15.
  • 6
    Craig M. Hales, Margaret D. Carroll, Cheryl D. Fryar, Cynthia L. Ogden, Prevalence of Obesity Among Adults and Youth: United States, 2015-2016. NCHS Data Brief. 2017 Oct;(288):1-8.)
  • 7
    David MB, Abu-Gazala S, Sadot E, Wasserberg N, Kashtan H, Keidar A. Laparoscopic conversion of failed vertical banded gastroplasty to Roux-en-Y gastric bypass or biliopancreatic diversion. SurgObesRelat Dis. 2015 Sep-Oct;11(5):1085-91.
  • 8
    Disse E, A. Pasquer, P. Espalieu, G. Poncet, C. Gouillat, M. Robert. Greater weight loss with the omega loop bypass compared to the Roux-en-Y gastric bypass: a comparative study ObesSurg, 2014 Jun;24(6):841-6
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    El-Serag HB, Sweet S, Winchester CC, Dent J. Update on the epidemiology of gastro-oesophageal reflux disease: a systematic review. Gut. jun 2014;63(6):871-80.
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    Fezzi M, Kolotkin RL, Nedelcu M et al. Improvement in quality of life after laparoscopic sleeve gastrectomy. Obes Surg. 2011 Aug;21(8):1161-7.
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    Gagner M, Hutchinson C, Rosenthal R. Fifth International Consensus Conference: current status of sleeve gastrectomy. SurgObesRelat Dis Off J Am SocBariatr Surg. mai 2016;12(4):750-6.
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    Gagner M, Ramos A, Palermo M, Noel P, Nocca D. The perfect Sleeve gastrectomy. SPRINGER. In Press.
  • 13
    Genco A, Soricelli E, Casella G, Maselli R, Castagneto-Gissey L, Di Lorenzo N, Basso N. Gastroesophageal reflux disease and Barrett's esophagus after laparoscopic sleeve gastrectomy: a possible, underestimated long-term complication. SurgObesRelat Dis. 2017 Apr;13(4):568-574.
  • 14
    Hales CM, Fryar CD, Carroll MD, Freedman DS, Ogden CL. Trends in Obesity and Severe Obesity Prevalence in US Youth and Adults by Sex and Age, 2007-2008 to 2015-2016. JAMA. 2018 Apr 24;319(16):1723-1725.
  • 15
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  • Financial source:

    none

Publication Dates

  • Publication in this collection
    20 Dec 2019
  • Date of issue
    2019

History

  • Received
    12 Aug 2019
  • Accepted
    01 Oct 2019
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