Improvement of Gastroesophageal Reflux Symptoms After Standardized Laparoscopic Sleeve Gastrectomy

Background

Gastroesophageal reflux disease (GERD) is present in half of morbidly obese patients. Published data reporting the results of laparoscopic sleeve gastrectomy (LSG) in patients with GERD are contradictory. We have shown in a previous study that symptoms of GERD can be reduced for up to 12 months after LSG with careful attention to surgical technique. The present study prospectively evaluated the effect of a standardized LSG technique on the incidence of postoperative GERD symptoms in a larger sample, and followed patients for up to 22 months.

Methods

This was a concurrent cohort study. All patients who underwent LSG at our center completed a standard multidisciplinary preoperative evaluation and were followed prospectively.

Results

A total of 382 patients underwent surgery. There were no cases of death or fistula. GERD was diagnosed in 170 patients (44.5 %) preoperatively, and hiatal hernia (HH) was detected in 142 patients (37.2 %) intraoperatively. Between 6 and 22 months postoperatively, 373 patients were completely evaluated. Ten (2.6 %) had GERD symptoms 6–22 months postoperatively, and 94 % of patients with preoperative GERD symptoms were asymptomatic at follow-up 6–22 months after LSG. Only 1 patient (0.5 %) of a subgroup of 174 without HH or esophagitis at preoperative evaluation had GERD at follow-up.

Conclusions

Our results confirm that, contrary to previous reports of LSG in the literature, careful attention to surgical technique can result in significantly reduced GERD symptoms up to 22 months postoperatively suggesting that LSG does not predispose patients to GERD during that period.     

Effect of Sleeve Gastrectomy on Gastroesophageal Reflux

Laparoscopic sleeve gastrectomy (LSG) is effective as a stand-alone bariatric procedure. Despite its positive effect with regard to weight loss and improvement of obesity-related co-morbidities, some patients develop gastroesophageal reflux symptoms postoperatively. The pathogenesis of these symptoms is not completely understood. Hence, this study aimed to assess the effect of sleeve gastrectomy on acid and non-acid gastroesophageal reflux, reflux symptoms and esophageal function. In a prospective study, patients underwent esophageal function tests (high-resolution manometry (HRM) and 24-h pH/impedance metry) before and 3 months after LSG. Preoperative and postoperative symptoms were assessed using the Reflux Disease Questionnaire (RDQ). In total, 20 patients (4 male/16 female, mean age 43?±?12 years, mean weight 137.3?±?25 kg, and mean BMI 47.6?±?6.1 kg/m²) participated in this study. GERD symptoms did not significantly change after sleeve gastrectomy, but other upper gastrointestinal symptoms, particularly belching, epigastric pain and vomiting increased. Esophageal acid exposure significantly increased after sleeve gastrectomy: upright from 5.1?±?4.4 to 12.6?±?9.8 % (p?=?0.003), supine from 1.4?±?2.4 to 11?±?15 % (p?=?0.003) and total acid exposure from 4.1?±?3.5 to 12?±?10.4 % (p?=?0.004). The percentage of normal peristaltic contractions remained unchanged, but the distal contractile integral decreased after LSG from 2,006.0?±?1,806.3 to 1,537.4?±?1,671.8 mmHg?·?cm?·?s (p?=?0.01). The lower esophageal sphincter (LES) pressure decreased from 18.3?±?9.2 to 11.0?±?7.0 mmHg (p?=?0.02). After LSG, patients have significantly higher esophageal acid exposure, which may well be due to a decrease in LES resting pressure following the procedure.     

Role of Preoperative Imaging with Multidetector Computed Tomography in the Management of Patients with Gastroesophageal Reflux Disease Symptoms After Laparoscopic Sleeve Gastrectomy

Background

The aims of the study were to evaluate if multidetector computed tomography (MDCT) can be helpful and useful in the decision-making process in sleeve patients with gastroesophageal reflux disease (GERD) symptoms and to demonstrate the reproducibility and accuracy of the technique.

Methods

Twenty-three patients submitted to laparoscopic sleeve gastrectomy (LSG), complaining upper gastrointestinal (GI) symptoms and/or weight regain and candidated to laparoscopic surgical revision were investigated. All patients underwent upper GI barium study, endoscopy, and MDCT for the identification of esophageal dilatation, neofundus development, thoracic sleeve migration, sleeve dilatation, and/or antrum dilatation. Selected patients underwent laparoscopic sleeve revision, cruroplasty, and/or fundectomy according to MDCT findings. Surgical findings were considered as “gold standard.” Symptom persistence or resolution was investigated after 6 months with a standard clinical questionnaire. A total of 21 patients with sleeve migration or dilatation and neofundus underwent laparoscopic revision.

Results

A strong correlation between MDCT preoperative findings and intraoperative findings was observed. The presence of sleeve migration was significantly underestimated by both conventional radiology and upper GI endoscopy (sensitivity of 57.1 and 50 %, respectively). Symptom remission was observed in 19 out of 21 patients at 6 months. In two cases, surgical revision was not indicated on the basis of MDCT findings.

Conclusions

MDCT is more accurate than the conventional radiology and endoscopy for the detection of morphological alteration causing GERD symptoms after LSG and can be considered a valid noninvasive method to guide surgery and monitoring patients following revision.     

Gastric Leak After Laparoscopic Sleeve Gastrectomy

Sleeve gastrectomy is a recently developed technique for treating morbid obesity. Since it is a simple procedure, the number of surgeons using it has grown in recent years. The patients who present fistulas after surgery often undergo a harrowing postoperative period as well as increased morbidity and mortality. Our aim was to assess the incidence, causes, diagnosis, management, and prevention of leaks after sleeve gastrectomy.     

Pathophysiological Measurement and Results After Laparoscopic Fundoplication for Gastroesophageal Reflux Disease

Purpose: Both surgical and conservative treatments for gastroesophageal reflux disorder (GERD) are controversial. The aim of this prosepective study was to examine outcomes after laparoscopic antireflux surgery. Methods: The subjects were 143 patients who underwent laparoscopic antireflux surgery. Following diagnostic procedures 126 patients were allocated to a total fundoplication group (360°C, Nissen-DeMeester) and 17, to a posterior semifundoplication group (250–270°, Toupet). All complications were registered, and pathophysiological and outcome data were examined 3, 6, and 9 months after surgery. Results: By 6 months after surgery the mean lower esophageal sphincter (LES) pressure had improved significantly, to 14.8 mmHg in the Nissen-DeMeester group, and to 12.1 mmHg in the Toupet group, corresponding to successful prevention of esophageal reflux in both groups. Dysphagia was more common in the early postoperative period after total fundic wrap (17% vs 12%), but this difference disappeared in time. All patients reported complete relief of reflux symptoms, although two of those who underwent the Nissen-DeMeester fundoplication experienced relapse of GERD and required open reconstruction (1.4%). The laparoscopic procedure was converted to open surgery in three patients (2%). There were no associated deaths and the perioperative complication rate was 4.2%. Conclusion: Laparoscopic antireflux surgery is an effective treatment for GERD. More than 93% of the patients in this series rated their outcome as good to excellent following the operation. Received: December 10, 2001 / Accepted: May 7, 2002 Reprint requests to: K. Ludwig     

Laparoscopic Sleeve Gastrectomy: Symptoms of Gastroesophageal Reflux can be Reduced by Changes in Surgical Technique

Background

Bariatric surgery is the most effective treatment for gastro-esophageal reflux disease (GERD) in obese patients, with the Roux-en-Y gastric bypass being the technique preferred by many surgeons. Published data reporting the results of laparoscopic sleeve gastrectomy (LSG) in patients with GERD are contradictory. In a previous observational study, we found that relative narrowing of the distal sleeve, hiatal hernia (HH), and dilation of the fundus predispose to GERD after LSG. In this study, we evaluated the effects of standardization of our LSG technique on the incidence of postoperative symptoms of GERD.

Methods

This was a concurrent cohort study. Patients who underwent bariatric surgery at our center were followed prospectively. LSG was performed in all patients in this series.

Results

A total of 234 patients underwent surgery. There were no cases of death, fistula, or conversion to open surgery. All 134 patients who completed 6?C12?months of postoperative follow-up were evaluated. Excess weight loss at 1?year was 73.5?%. In the study group, 66 patients (49.2?%) were diagnosed with GERD preoperatively, and HH was detected in 34 patients (25.3?%) intraoperatively. HH was treated by reduction in three patients, anterior repair in 28, and posterior repair in three. Only two patients (1.5?%) had symptoms of GERD at 6?C12?months postoperatively.

Conclusions

Our results confirm that careful attention to surgical technique can result in significantly reduced occurrence of symptoms of GERD up to 12?months postoperatively, compared with previous reports of LSG in the literature.     

Laparoscopic Management of Persistent Strictures After Laparoscopic Sleeve Gastrectomy

Background

Laparoscopic sleeve gastrectomy (LSG) has become a common option in the management of morbid obesity. Although this procedure seems easier, many caveats remain, especially in terms of leakage. Other serious complications include strictures, bleeding, and gastroesophageal reflux disease (GERD). Strictures are related to operative technique but also to healed leaks and fistulas. To our knowledge, the literature reports on the physiopathology and management of strictures after LSG are scarce.

Methods

A retrospective analysis of our database provided a total of 16 patients who underwent laparoscopic surgery for the treatment of strictures. A comprehensive review of each case was done including their management.

Results

Sixteen patients were treated laparoscopically for strictures. There were eight females (mean age, 40.6 years). Most common complaints were dysphagia (n?=?14) and/or GERD (n?=?8). Body Mass Index was 30.5 kg/m²?±?9.3. Fourteen patients underwent a seromyotomy (SM) and two a wedge resection of the stenosis. After SM, morbidity included five leaks on the short term and five reoperations in the long-term. Of the 16 patients, 12 were treated satisfactorily, three required endoscopies and one had minimal GERD symptoms.

Conclusions

Strictures and stenosis can be managed by laparoscopic approach with acceptable results. SM can be useful but carries a high complication rate. Accurate technique with parsimonious use of coagulation and possibly with the systematic use of an omental patch might lead to better results. The wedge resection of the stomach including the stricture was performed successfully in two cases. In addition, wedge resection was used secondarily in two other cases to address a complication of the seromyotomy.     

腹腔镜胃底折叠术治疗胃食管反流病

目的探讨腹腔镜胃底折叠术治疗胃食管反流病的临床效果。方法2008年1月-2011年11月对40例胃食管反流病行腹腔镜胃底折叠术。腹腔镜单纯胃底折叠术7例（Toupt式）,腹腔镜食管裂孔疝修补加胃底折叠术33例（Nissen式5例,Toupet式28例）。结果手术均获成功,无中转开腹及死亡病例,无术后严重并发症。手术时间75～215min,平均112min;术中出血量10-350ml,平均52ml;术后住院5—10d,平均7d。40例术后随访1—24个月,平均16个月,34例临床症状完全消失,6例症状明显好转。结论腹腔镜胃底折叠术治疗胃食管反流病疗效满意。     

Symptoms of Gastroesophageal Reflux Following Laparoscopic Sleeve Gastrectomy Are Related to the Final Shape of the Sleeve as Depicted by Radiology

Background  

Laparoscopic sleeve gastrectomy (LSG) is gaining popularity as a primary procedure in selected morbidly obese patients. Like most other bariatric procedures LSG results in alterations of the upper GI anatomy that might affect gastroesophageal reflux postoperatively. The study was conducted to assess the presence of reflux symptoms in patients before and after laparoscopic sleeve gastrectomy and any possible relation of these symptoms to the postoperative gastric anatomy as depicted by gastrografin swallow studies.     

腹腔镜袖状胃切除术

患者女性，30岁，BMI36.6，诊断代谢综合征。患者平卧"大"字位，头高左侧高30°，主刀右侧站位。距幽门2 cm开始紧贴胃壁游离胃大弯，充分游离胃底，显露左侧膈肌脚及食道左侧，经口置入36 F减重胃管，沿胃管距幽门4 cm开始进行袖状胃裁剪，根据胃壁厚度应用不同钉脚高度的切割闭合钉，连续全层缝合加固胃切缘，并将胃切缘复位固定于大网膜及胰腺背膜，经主操作孔取出切除的胃组织，清理腹腔，放置引流管，缝合戳卡孔。     

Improvement in Quality of Life After Laparoscopic Sleeve Gastrectomy

Few studies have investigated changes in health-related quality of life (HRQOL) in surgical patients who have undergone a laparoscopic sleeve gastrectomy. Prospective data were obtained from 78 consecutive patients undergoing laparoscopic sleeve gastrectomy (LSG; mean age, 42.4 years; mean body weight, 131 kg; mean body mass index (BMI), 47 kg/m(2) (24.4% of superobese patients)). Two HRQOL questionnaires were administered preoperatively and 12 months postsurgery: the generic Medical Outcomes Study Short Form-36 and the weight-specific IWQOL-Lite questionnaire. Excess weight loss at 12 months was 57.18%. No mortality was recorded. HRQOL scores revealed a significant improvement in all areas of both questionnaires. However, changes in HRQOL were not associated consistently with amount of weight loss. Laparoscopic sleeve gastrectomy is an effective and safe procedure, with positive changes in health-related quality of life as well as weight reduction. A fruitful area for future research is the investigation of long-term changes in HRQOL after LSG.     

Laparoscopic Total Gastrectomy with Roux-Y Esophagojejunostomy for Chronic Gastric Fistula After Laparoscopic Sleeve Gastrectomy

Laparoscopic sleeve gastrectomy is a restrictive operation with hormonal elements that is rapidly gaining popularity. The most feared complication of the procedure is a staple line leak. The treatment of staple line leakage depends on timing and clinical and anatomical considerations. If leakage persists and transforms into a chronic fistula, a definitive surgical procedure is required. In cases where the fistula originates close to the esophagogastric junction, the surgical possibilities are limited and one treatment option is total gastrectomy with esophagojejunal anastomosis. We report a case series of four patients with chronic fistulae, who failed conservative treatment and required total gastrectomy. Their average length of hospital stay was 8.7 days (range, 5–15 days), without conversions, leaks, or other complications. In experienced hands, total gastrectomy is feasible by laparoscopic techniques and should be performed soon after the fistula is established.     

Cardiac Remodeling in Obese Patients After Laparoscopic Sleeve Gastrectomy

Background

Obesity is associated with high morbidity and represents an increasing health care problem worldwide. Laparoscopic sleeve gastrectomy (LSG) has been used effectively for weight loss and co-morbidity remission. In this retrospective study, we evaluated cardiac reverse remodeling at medium-term follow-up by echocardiography, the amount of cardiovascular medications, and the impact of co-morbidities after sleeve gastrectomy.

Methods

Altogether, 16 obese patients (4 men, 12 women; 46.4 ± 10.3 years) underwent complete clinical evaluation, laboratory tests, and color Doppler/tissue Doppler imaging echocardiography preoperatively and 12–20 months after bariatric surgery.

Results

Body weight (mean body mass index) was significantly reduced (from 44.8 ± 8.0 to 31.2 ± 7.8 kg/m²; p = 0.001). Lipid profile significantly improved: total cholesterol and triglycerides decreased (respectively: 215.5 ± 53.8 vs. 205.3 ± 46.6 mg/dl and 184.9 ± 109.3 vs. 116.1 ± 49.9 mg/dl, both p ≤ 0.05), and high-density lipoprotein increased (43.1 ± 10.9 vs. 51.4 ± 12.8 mg/dl, p = 0.005). Systolic blood pressure significantly decreased (from 133.0 ± 17.1 to 120.6 ± 13.7 mmHg; p = 0.04). Diabetes remission was complete in five of six patients (83 %) and sleep apnea in four of five (80 %). Echocardiography showed significantly reduced interventricular septum and posterior wall thickness (11.3 ± 1.8 to 9.4 ± 2.1 mm and 10.4 ± 1.7 to 8.6 ± 1.9 mm, respectively; both p < 0.007) and reduced left ventricular mass (absolute value and indexed by height, respectively: 222.41 ± 78.2 to 172.75 ± 66.3 g (p = 0.003) and 55.9 ± 14.3 to 43.8 ± 17.2 g/m^2.7 (p = 0.0004). Antihypertensive drug intake was significantly reduced (p = 0.03), as shown by the 10-year Framingham Risk Score (from 14.2 ± 9.3 to 8.3 ± 9.5 %, p = 0.003).

Conclusions

Sleeve gastrectomy is associated with marked improvement in terms of weight loss, lipid profile, type 2 diabetes, sleep apnea, hypertension, and left ventricular hypertrophy, with a significantly reduced Framingham Risk Score.     

Sugar Detection Threshold After Laparoscopic Sleeve Gastrectomy in Adolescents

Introduction

Obesity in young people is one of the most serious public health problems worldwide. Moreover, the mechanisms preventing obese adolescents from losing and maintaining weight loss have been elusive. Laparoscopic sleeve gastrectomy (LSG) is successful at achieving long-term weight loss in patients across all age groups, including children and adolescents. Anecdotal clinical observation as well as evidence in rodents suggests that LSG induces a shift in preference of sugary foods. However, it is not known whether this shift is due to a change in the threshold for gustatory detection of sucrose, or whether LSG induces behavioral change without affecting the gustatory threshold for sugar.

Aims

The objective of this study was to determine whether adolescents who undergo LSG experience a change in their threshold for detecting sweet taste.

Methods

We studied the sucrose detection threshold of 14 obese adolescents (age 15.3 ± 0.5 years, range 12–18) who underwent LSG 2 weeks before surgery and at 12 and 52 weeks after surgery. Matched non-surgical subjects were tested on two occasions 12 weeks apart to control for potential learning of the test that may have confounded the results. Seven sucrose concentrations were used and were tested in eight blocks with each block consisting of a random seven sucrose and seven water stimuli. The subjects were asked to report whether the sample contained water or not after they tasted 15 ml of the fluid for 10 s.

Results

The bodyweight of the LSG group decreased from 136.7 ± 5.4 to 109.6 ± 5.1 and 86.5 ± 4.0 kg after 12 and 52 weeks, respectively (p < 0.001). There was no significant difference after surgery in taste detection threshold of patients after LSG (p = 0.60), and no difference was observed comparing the taste detection threshold of the LSG group with the non-surgical controls (p = 0.38).

Conclusion

LSG did not affect the taste detection threshold for sucrose, suggesting that the shift in preference for sugary foods may be due to factors other than fundamental changes in taste sensitivity.