Laparoscopic Management of Severe Reflux After Sleeve Gastrectomy,in Selected Patients,Without Conversion to Roux-en-Y Gastric Bypass

Abstract

Background:

Treatment of severe reflux after laparoscopic sleeve gastrectomy (LSG) may require conversion to Roux-en-Y gastric bypass (RYGB). We conducted a pilot study to evaluate the feasibility and effectiveness of performing laparoscopic anterior fundoplication with posterior crura approximation (LAF/pCA), in selected patients, to correct the reflux without conversion to RYGB.

Patients and Methods:

From October 2012 to April 2013, 6 patients with confirmed severe de novo reflux after LSG were treated with LAF/pCA.

Results:

All patients were females with a mean age of 41.5±14.2 years. All patients had lost weight after initial LSG. The percentage excess body mass index (BMI) loss (%EBL) was 61.2±33.2%. The mean time from the initial LSG to LAF/pCA was 33.2±12.5 months. Four patients had reduction of gastric fundus size. One patient required resleeving. Reflux resolved immediately in all patients with a follow-up of 18.5±2.7 months. All patients continued to lose weight, with %EBL reaching 75.5±22.9% and a mean BMI of 32±7.3 kg/m².

Conclusions:

LAF/pCA with reduction of gastric fundus size, when needed, may be considered an alternative option to correct severe reflux after LSG in selected patients.

Introduction

Laparoscopic sleeve gastrectomy (LSG) has become increasingly popular as a stand-alone bariatric procedure.^1,2 Further experience with this surgery has established its efficacy and high safety profile regarding weight loss and remission of associated comorbidities, while maintaining a low complication rate.^3–6 Additionally, it has demonstrated lower perioperative morbidity and mortality while being technically easier to perform than Roux-en-Y gastric bypass (RYGB).¹ With this gain in popularity, however, there has been an increase in concerns regarding the development of postoperative de novo gastroesophageal reflux disease (GERD).^4,6,7

RYGB has been considered the ideal procedure for obese patients with GERD and has been recommended as a conversion procedure for patients suffering from GERD after LSG.^1,7 Some patients who develop reflux after LSG, however, may not want to convert to RYGB. For this reason, we conducted a chart review to evaluate the safety and effectiveness of performing laparoscopic anterior fundoplication with posterior crura approximation (LAF/pCA) on patients who developed severe reflux, not controlled medically, after LSG. The procedure was done on selected patients as an alternative to conversion to RYGB, allowing maintenance of the physiologic benefits of LSG. We reviewed the charts of these patients to determine the safety and effectiveness of the procedure.

Patients and Methods

We evaluated patients who presented with severe reflux after LSG between October 2012 and April 2013. Patients with severe de novo reflux who failed a prolonged period of medical management with proton pump inhibitors (PPIs) were considered. Presurgical characteristics were recorded, and the patients were followed up prospectively via medical record review. The study was approved by the Institutional Review Board.

All patients had radiographic confirmation of reflux via upper gastrointestinal (UGI) contrast studies (Fig. 1). Prior to the procedure, all films were evaluated for gastric dilatation and feasibility of performing fundoplication based on the volume of tissue in the proximal gastric pouch. Absolute confirmation of GERD was accomplished with esophagogastroduodenoscopy and a Bravo capsule (Given^® Imaging, Duluth, GA) 48-hour pH monitoring; a DeMeester reflux score of >14.7 was confirmatory of reflux as per the manufacturer's determination. Patients with evidence of esophagitis were biopsied at the time of esophagogastroduodenoscopy to role out Barrett's esophagus.

FIG. 1.

Preoperative upper gastrointestinal contrast study.

LAF/pCA was performed on all patients. A postoperative UGI swallow study was performed to document the resolution of the reflux (Fig. 2). Intraoperative and postoperative complications were recorded. Hospital length of stay, 30-day morbidity, and mortality were recorded as well. Patients' weights were recorded at different intervals. Resolution of GERD after surgical intervention was determined by clinical resolution of symptoms, the cessation of the use of PPIs, and using the quality of life (QOL) scores.

FIG. 2.

Postoperative upper gastrointestinal contrast study.

Data were analyzed using a paired t test. Differences in QOL scores were assessed using the Wilcoxon signed ranks test. All data were analyzed using SPSS version 22.0 software (SPSS, Inc., Chicago, IL), and a P value of ≤.05 was considered to indicate statistical significance.

Surgical technique

The positions of the trocars were similar to the initial trocar positioning for the LSG (five incisions with four trocars) (Fig. 3). The omentum was separated from the body and fundus of the stomach using the SonoSurg^® ultrasonic device (Olympus, Tokyo, Japan). The peritoneum around the esophagus was opened. The crura of the diaphragm were cleared to expose the hiatus. An esophageal retractor was used through the supraumbilical trocar site to expose the posterior crus. The crura of the diaphragm were approximated posteriorly using poly(ethylene terephthalate) (0-Ethebond; Ethicon, Somerville, NJ) 2-0 sutures introduced through the left upper quadrant (11-mm) trocar site (Fig. 4). A 40 French blunt-tip bougie was placed, while the patient was under anesthesia, to prevent a tight closure of the crus and used also to prevent a tight lumen if the partial gastrectomy or gastric fundus imbrication was needed to reduce its size. The freed proximal pouch (Fig. 5) was then sutured over the esophagus at the 11 o'clock position using 2-0 Ethibond sutures in three sites. Another suture was placed between the wrapped portion and the right crus to prevent unwrapping of the fundus. If the fundus was dilated, it was imbricated using 2-0 silk sutures. If the fundus and body were dilated, a resleeving was done (Fig. 6) (the video link for this procedure is https://docs.google.com/file/d/0BxHiC8_HwU0GUndPaDk4Mjl1STQ/edit?usp=drive_web).

FIG. 3.

Positions of trocars.

FIG. 4.

Closed hiatus.

FIG. 5.

The dilated fundus.

FIG. 6.

Dilated fundus sutured over the esophagus (anterior fundoplication).

Results

We reviewed the charts of 6 patients who qualified for this study. These patients presented with severe de novo reflux uncontrolled with intense medical treatment with PPIs and underwent LAF/pCA to correct their reflux symptoms. Data included presurgical information as well as follow-up information after the procedure. All patients were females; the mean age was 41.5±14.2 years. Five of these patients had their initial LSG done by our team. Their operation was performed according to standard technique using a 36 French bougie. None of these patients had any history of reflux or hiatal hernia based on their initial pre-LSG upper endoscopy. Their UGI studies before the LAF/pCA showed no hiatal hernia in 3 patients and a small hiatal hernia in 2 patients. Reflux was present in all patients. Three patients had some degree of gastric fundus dilation. The sixth patient had her LSG done at an outside institution. Her UGI studies showed no hiatal hernia, but there was dilation of both the body and fundus of the stomach along with the reflux. All patients refused to have RYGB as the treatment of choice to correct their condition. Preoperative endoscopy with a Bravo capsule showed esophagitis in 3 patients. The average pH DeMeester score was 38.2±27.6 (normal, 14.7).

All patients had lost weight from a mean preoperative weight before the initial LSG of 333.5±104.6 pounds to a mean of 216.3±66.7 pounds (P=.043) before the LAF/pCA. Their mean body mass index (BMI) initially was 56.2±15.1 kg/m² and dropped to 36.7±10.1 kg/m² (P=.042). The percentage excess BMI loss (%EBL) was 61.2±33.2%. The mean time from patients' initial LSG to the LAF/pCA was 33.2±12.5 months. The success of the LSG in weight loss was evident in these patients achieving their lowest weight of 193.0±46.2 pounds and BMI of 32.7±6.7 kg/m² after a mean of 18.3±7.1 months from the initial LSG with a mean %EBL of 73.4±20.7%. However, 5 (83.3%) patients regained some weight before the LAF/pCA. Three (50%) patients had regained ≥3 BMI units at time of surgery for their reflux (Fig. 7).

FIG. 7.

Body mass index (BMI) chart. LAF, laparoscopic anterior fundoplication; LSG, laparoscopic sleeve gastrectomy.

In addition to LAF/pCA, 1 patient, who had dilation of the fundus and body of the stomach, required partial gastrectomy as a resleeve. Three of the other 5 patients had gastric imbrication to reduce the size of the gastric pouch dilatation. All patients had enough gastric fundus tissue to perform the anterior fundoplication. All patients had approximation of the crus along with the 2 patients with the small hiatal hernia. There were no intraoperative or postoperative complications. Additionally, there was no mortality associated with LAF/pCA. The average operative time was 77.2±19.3 minutes. The average hospital length of stay after the procedure was 1.3±0.5 days. Patients were followed up for an average of 18.5±2.7 months (range, 15–22 months). In this short period of follow-up their weight loss continued such that the mean %EBL reached 75.4±22.9%. Mean weight was 192.8±52.5 pounds, and mean BMI was 32.7±7.3 kg/m². These values were similar to their nadir values achieved after their initial LSG (Table 1).

Table 1.

Patients' Weight Progression over Time

	Initial (pre-SG)	Lowest (post-LSG)	Before LAF/pCA	After LAF/pHHR
Mean weight (pounds)	333.5±104.6	193.0±46.2	216.3±66.7	192.8±52.5
BMI (kg/m²)	56.2±15.1	32.7±6.7	36.7±10.1	32.7±7.3
Mean %EBL		75.6±23.0	61.2±33.2	75.4±22.9
Time (months)		18.3±7.1	33.2±12.5	18.5±2.7
Weight gain (≥3 BMI units)			3 (50%)	0

%EBL, percentage excess body mass index (BMI) loss; LAF/pCA, laparoscopic anterior fundoplication with posterior crura approximation; LAF/pHHR, laparoscopic anterior fundoplication with posterior hiatal hernia repair; LSG, laparoscopic sleeve gastrectomy; SG, sleeve gastrectomy.

Reflux resolved in all patients immediately postoperatively. One patient had recurrence of her symptoms, for a 83.3% success rate. All patients completed the postoperative QOL survey. The median score went down from 44/75 (range, 15–75) preoperatively to a median of 13/ 75 (range, 0–26) postoperatively (P=.05). The 1 patient who had recurrent reflux had a QOL score going up from 24/75 to 26/75.

Discussion

LSG has attained a recent increase in popularity.^1,2 This status among patients is largely attributable to its proven efficacy and exceptional safety profile. Surgeons have embraced LSG for its technical ease and limited metabolic side effects.^3–5 There is, however, a growing concern about an association between LSG and GERD, with some studies citing 18%–35% of patients developing de novo reflux after sleeve gastrectomy.^4,6,8–10 Investigators have identified weakening of the contraction amplitude of the lower esophageal sphincter after LSG as a possible cause.^11,12 This phenomenon is attributed to the possibility of altering the sling fibers.¹¹ As well, the presence of a hiatal hernia, dilation of the fundus, and relative narrowing of the distal sleeve have been implicated.^13–15

Traditionally, patients who developed severe reflux after sleeve gastrectomy have been converted to RYBG for symptom control.¹ This may not be an attractive option for some patients who do not wish to undergo a malabsorptive procedure to ameliorate their reflux.

Our study was designed to evaluate the effect of LAF/pCA on the course of reflux in a selected group of patients whose symptoms were not controlled medically after LSG. These patients were willing to undergo this procedure because of their frustration with their symptoms, yet they did not want to have a conversion to RYGB. Our intentions were to evaluate the technical feasibility of performing an anterior fundoplication, in selected patients, to control the reflux symptoms in place of the RYGB after LSG.

Developing reflux after LSG takes time, as it is a long-term complication. In our study we found that the mean time before patients developed their severe symptoms of reflux leading to the corrective surgical procedure was 33.2±12.5 months. During this period, some patients developed weight regain, which could have been the consequence of the dilation of the proximal gastric pouch. This in turn could have been a factor in developing the reflux as well. This relationship between the weight regain and the development of the reflux was present in 5 (83.3%) of our patients: some degree of dilation in the gastric pouch was present in 4 patients, and 1 patient had dilation of both the body and fundus of the stomach. A small hiatal hernia was found in 2 patients only. The question that can be raised is whether managing the weight regain alone would have resolved the reflux without resorting to the surgical intervention. This may be a valid point in patients who did not develop dilation in the gastric pouch along with the weight regain. Unfortunately, our attempts at weight reduction with the dilated gastric pouch were difficult. We thought, however, that correcting the gastric pouch dilation was an important factor in resolving the reflux and giving these patients another chance at continuing weight loss, which what was proven to be the case as shown in Table 1.

Another question that could be raised also about the reasons behind the development of this reflux in our patients is whether the initial LSG technique was a factor in the development of this complication, or if missing a hiatal hernia could have been a contributing factor as well. All of our patients had preoperative endoscopy before their LSG, and none of them had hiatal hernia. Even the patient who had the LSG surgery at an outside institution did not show a hiatal hernia in her UGI studies and preoperative endoscopy before the LAF/pCA. So this argument could not be used as for the reason why these patients developed reflux. In addition, if our initial LSG technique was a factor, then the number of our patients who should have developed this type of complication would have been much higher than the 5 patients who were studied. Other authors have reported the development of this complication in their patients as well, so it is unlikely that all these authors have done the wrong operation on their patients or they missed the presence of an initial hiatal hernia.^{4,6,8–10,13–15} The same argument would be for the use of a 36 French bougie at the initial LSG, where the body of the stomach would increase the pressure because of a small-size bougie.

Anterior fundoplication is a known procedure originally described by Dor in 1962 as part of Heller's myotomy for the treatment of achalasia. In the 1970s, Watson performed a similar operation but for the management of GERD. Watson et al.¹⁶ reported their results in 1991 as an alternative, more physiologic method to control reflux in place of the most commonly done Nissen fundoplication. Since then several other reports, open and laparoscopic, have shown the efficacy and long-term results of this approach in controlling reflux.^17–19 We thought of adapting this technique because our patients did not have enough dilated fundus after LSG to perform a complete 360° wrap. The anterior fundoplication seemed to be the most logical technique in order to achieve our goal in controlling the reflux symptoms while maintaining the benefits of the LSG.

To our knowledge so far there are no data on the value of using fundoplication to treat severe reflux after LSG. In this small study we were able to demonstrate that this technique can be offered as an alternative option to correct the severe uncontrolled reflux after LSG in selected patients who had some degree of gastric fundus dilatation with or without a hiatal hernia.

Our investigation is one of the first of its kind in the literature to assess the outcomes of LAF/pCA in patients with severe de novo reflux following LSG. Although limited by the small number of patients and relatively short follow-up period, the results of our study are encouraging. We hope to open the door to further similar studies to ensure that these results are reproducible. Additionally, through longer follow-up we can truly see the efficacy of LAF/pCA in controlling reflux and the effect on LSG in long-term weight loss with remission of other obesity-associated comorbidities. The repeat of Bravo pH studies after 2–3 years would be an objective way, in addition to repeating the QOL survey, in assessing the effectiveness of this technique in controlling the reflux for the long term.

Conclusions

As LSG becomes more popular in the management of morbid obesity, more patients are going to develop weight regain and severe reflux as a late complication. These patients should not be deprived of the value of their initial choice of the LSG in their quest for weight loss. An option of performing an anterior fundoplication to LSG, in selected patients, should be offered as an alternative to converting to a malabsorptive procedure in order to correct these complications. More studies and a longer follow-up, as well as repeating the pH studies and QOL survey, are needed to evaluate the long-term effectiveness of this procedure in controlling severe reflux after LSG.

Footnotes

Disclosure Statement

No competing financial interests exist.

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