Felsenreich et al. recently published in the journal of Obesity Surgery a very interesting study on gastric sleeve surgery long-term outcomes. The study is titled: “Update: 10 years of sleeve gastrectomy-the first 103 patients” and includes all patients who had gastric sleeve surgery prior to 2006 at participating bariatric centers in Austria. Continue reading “Does Gastric Sleeve Surgery Cause Barrett’s Esophagus?”
Gastric sleeve surgery is currently the most commonly performed weight loss procedure in Houston. With this increase in gastric sleeve popularity, we have witnessed a rising number of patients with insufficient weight loss following gastric sleeve surgery. Continue reading “Insufficient Weight Loss after Gastric Sleeve Surgery”
I read with great interest the study published in Surgery for Obesity and Related Diseases by DeMaria et al. It is a retrospective review of 96 gastric bypass patients who underwent conversion of to distal gastric bypass between 2010 and 2016. The Roux or alimentary limb is cut at the jejuno-jejunostomy and transposed distally leaving a common channel between 150 to 200 cm in length. Continue reading “Gastric Bypass and Sleeve Gastrectomy Revision Surgery”
David Nocca, MD, head of Bariatric Surgery department at the University of Montpellier in France is currently conducting an international bariatric workshop about a new weight loss procedure: Nissen-Sleeve operation. The French team have already published a pilot study in SOARD in 2016 demonstrating Nissen-sleeve surgery feasibility and safety in 25 patients. The authors advocate that this approach eliminates acid reflux following gastric sleeve surgery with comparable weight loss outcomes to the traditional sleeve gastrectomy. A secondary advantage of Nissen-sleeve surgery is a decrease in the risk of staple line leak at the angle of His. The authors further advocate that the risk of remnant gastric fundus ischemia in Nissen-sleeve surgery is low given the rich blood supply of the stomach. Continue reading “Nissen-Sleeve operation, is it an option?”
The Journal of the American Medical Association, JAMA, current issue is entirely devoted to the medical problem of obesity. I was particularly interested by two published randomized studies comparing gastric sleeve to gastric bypass surgery with a 5-year follow-up. The Swiss Multicenter Bypass or Sleeve Study, SM-BOSS, and the Finnish Sleeve vs Bypass, SLEEEPASS, study showed similar weight loss and type 2 diabetes remission rate at 5 years. Reoperation rate was similar to both gastric sleeve and bypass patients in both studies. Repeat surgery was mainly for GERD in gastric sleeve patients and internal hernia for gastric bypass patients. Continue reading “JAMA Obesity Theme Issue: Gastric Sleeve Surgery Is Here to Stay”
I read with great interest the commentary on evaluating the feasibility of phrenoesophagopexy during hiatal hernia repair in sleeve gastrectomy patients. The commentary was recently published in SOARD by Dr. Jose Ferrer from the Bariatric and Metabolic Surgery Center in Valencia, Spain. The author reports his concern about the development of GERD, severe reflux esophagitis, and Barrett’s esophagus following gastric sleeve surgery. Ferrer recommends hiatal hernia repair during gastric sleeve surgery. However, herniorrhaphy alone is not enough sometimes. Additional techniques have been developed such as phrenoesophagopexy, Hill gastropexy, Teres ligament pexy, and different forms of fundoplications to augment the anti-reflux barrier. Continue reading “Gastric Sleeve Surgery and GERD”
Question of the Week from Tina:
I’m planning on having VSG in the next three months. I had the Nissen funoplication 3 yrs ago for severe Gerd. My consult will be sometime next month. It seems that there is no contraindication for gastric sleeve after the nissen procedure, according to this article which is a relief to me. It seems nissen reversal prior to VGS would be a much riskier procedure. Will there be enough of the “hunger hormone” side of the stomach to surgically remove and can this side of stomach grow back? Or does it just stretch itself back out if one tends to over eat?
Excellent question Tina. Ghrelin or hunger hormone is mostly secreted by gastric fundus. Ghrelin blood level decreases following gastric sleeve surgery as the gastric fundus is resected. Decreased ghrelin levels contribute to hunger control, increased satiety and weight loss. We don’t have any study evaluating Ghrelin blood level following Nissen Sleeve surgery. I think that a plicated gastric fundus is metabolically equivalent to a resected fundus. Therefore, I expect Ghrelin level to decrease following Nissen Sleeve surgery. Nissen fundoplication is associated with weight loss and a recent study published in 2015 demonstrated decreased Ghrelin levels following fundoplication surgery. Gastric fundus invagination, a weight loss procedure I developed few years ago, prevents Ghrelin level increase with weight loss. I demonstrated this finding in an obese rat model. In humans, gastric fundus invagination has not been studied but I predict that Ghrelin levels will also decrease.
Ghrelin, however, is not the only hormone change responsible for weight loss. Many other signals are equally important like GLP-1 (Glucagon like peptide). GLP-1 decreases following Nissen fundoplication and is likely to decrease following Nissen Sleeve surgery. Increased gastric emptying is thought to contribute to GLP-1 increase and Nissen fundoplication is associated with increased gastric emptying. I have noticed on post-operative contrast studies that Nissen Sleeve procedure increases gastric contrast emptying.
Overall, I think that the plicated fundus is functionally equivalent to a resected fundus. When properly performed, fundus presrving gastric sleeve surgery, in obese patients with history of Nissen fundoplication, results in excellent weight loss results.
The patient is a 54-year-old female with morbid obesity presenting for weight loss surgery evaluation. She is particularly interested in gastric sleeve surgery. The patient underwent hiatal hernia repair and Nissen fundoplication 14 years ago for severe GERD. She reports excellent acid reflux symptom control but recently she has been experiencing heartburn, bloating, excessive belching. An upper endoscopy showed a Hill grade 3 hiatal hernia with 5 to 6 cm diaphragmatic opening and 8 cm axial displacement. The Nissen fundoplication appeared intact and has herniated along the rest of the upper stomach into the chest. Continue reading “Case of the week: Gastric Sleeve Surgery Following Nissen Fundoplication”
Laparoscopic sleeve gastrectomy combined with Rossetti fundoplication (R-Sleeve) for treatment of morbid obesity and gastroesophageal reflux by Stefano Olmi is a new study published online in SOARD (Surgery for Obesity and Related Disorders). 40 patients suffering from morbid obesity and acid reflux confirmed by either upper endoscopy or ambulatory pH testing were retrospectively analyzed. All patients underwent sleeve gastrectomy that spared part of the gastric fundus. the remnant fundus was used to perform a 1.5 cm, two suture, floppy fundoplication. Interestingly, hiatal hernia repair was only performed for large defects. The authors describe an unusual technique of opening the space between the esophagus and left crus to reduce small hiatal hernias without any suture repair.
Patients underwent an upper endoscopy at 12 months after surgery. Patients with preoperative esophagitis showed improvement and those without mucosal inflammation showed no new onset esophagitis. Repeat ambulatory pH testing was not performed. All patients were off proton pump inhibitors and 95% of them acid reflux related symptom free. Excess weight loss percent at 12 months was around 62%.
At Houston Weight Loss Surgery Center, we perform a formal hiatal hernia repair for all obese patients with GERD presenting for sleeve gastrectomy. We have found that a properly performed sleeve gastrectomy with distal esophageal mobilization and posterior hiatal hernia repair result in excellent reflux control. In my opinion, a resected gastric fundus is equivalent to a plicated fundus around the esophagus (fundoplication) in terms of preventing reflux. The assumption that a fundoplication works by reinforcing the lower esophageal sphincter (LES) is naïve. Fundoplication mechanism of action is much more complicated than LES reinforcement. Indeed, repeat esophageal manometry does not show increased LES pressure and most GERD patients undergoing Nissen fundoplication surgery have normal LES pressure. Acid reflux disease is a multifactorial problem. Gastric fundus wall compliance, relaxation and motility affect transient lower esophageal relaxation events and reflux episodes. Fundoplication surgery alters these factors in favor of reflux control. Similarly, fundus resection in sleeve gastrectomy prevents reflux and promotes gastric emptying. There is no need to add a fundoplication to a properly performed sleeve gastrectomy and hiatal hernia repair.
Sleeve gastrectomy is a simple and straightforward surgery to perform. The stomach is mobilized along the greater curvature and cut longitudinally with a linear stapler. The purpose of surgery is to modify the interaction between ingested food and stomach to alter certain neuro-hormonal signals. Signals as Ghrelin, GLP-1 and PYY affect metabolism, appetite, satiety and ultimately result in weight loss. Many bariatric surgeons have difficulty accepting the fact that metabolic surgery is more about altering these neuro-hormonal signals than mechanically restricting the stomach. Consequently, when gastric sleeve surgery was first introduced several years ago, the debate about bougie size dominated our metabolic and bariatric surgery field. Whole sessions in Obesity Week and other bariatric surgery conferences were devoted to discussing the optimal sleeve lumen diameter. The assumption, of course, was that the smaller the bougie diameter the better is weight loss. This assumption was proven wrong. Many published studies have shown that the smaller the bougie size the higher is the leak rate with no improvement in percent excess weight loss.
Knowledge about sleeve gastrectomy mechanism of action, predictors of weight loss and optimal surgical technique is still not established. As John Naisbitt said: “We Are Drowning in Information but Starved for Knowledge”. We will continue to be bombarded by studies that will not advance our practice or improve our skills. This newly published article: “Is a retained fundus seen on postoperative upper gastrointestinal series after laparoscopic sleeve gastrectomy predictive of inferior weight loss?” is a perfect example. It is a single center, retrospective study that includes 149 sleeve gastrectomy patients. Patients were divided into 4 groups depending on the ratio of fundus to more distal sleeve lumen diameter, measured on postoperative upper gastrointestinal series (UGI). The authors found no difference in mean percent excess weight loss at one year following sleeve gastrectomy in all 4 groups. Of note, a single surgeon performed all 149 sleeve gastrectomies using a 34 French bougie. A 1 cm distance from GEJ was left at the angle of His.
I should mention that a postoperative UGI is not an accurate measure of sleeve lumen. The resected stomach is edematous, blood clots may be present along the staple line and sleeve lumen contrast filling is not homogeneous. Accepting this limitation, the study doesn’t show a difference in weight loss even when comparing the most optimally resected gastric fundus to the severely retained fundus. So how much gastric fundus should be resected to achieve the best weight loss? The answer to this question depends on the sleeve mechanism of action. If pure restriction is the dominant mechanism of action then the smaller the sleeve volume the better is weight loss. This however is not the case. Indeed, I preserve most of the antrum to prevent narrowing at the incisura angularis and to maintain the gastric pump that promotes gastric emptying. Most importantly, I preserve the antrum to maintain the Magenstrasse gastric emptying pathway. I believe that sleeve gastrectomy mechanism of action relies on restoring the Magenstrasse pathway of gastric emptying. This allows for rapid delivery of ingested food particles into the distal intestines stimulating the neuro-hormonal signals that result in weight loss. The Magenstrasse emptying pathway depends on antral wave contractions. Accordingly, mutilating the gastric antrum along a 34 French bougie is not necessarily associated with the best weight loss results. Discussing optimal gastric fundus resection in the setting of a resected antrum is not likely to yield any meaningful results. Preserving the antrum and optimally resecting the gastric fundus seem to be the best approach for sleeve gastrectomy. But what is optimal gastric fundus resection? The fundus can be completely resected flush at the GEJ. Part of the fundus may also be left unresected leaving a gastric bubble. At Houston Weight Loss Surgery center, we have found that aggressive gastric fundus resection is not associated with better long-term weight loss results. Rather, aggressive gastric fundus resection results in severe restriction and very limited gastric capacity. Patients typically reports uncomfortable restriction during the first 6 months of surgery without the benefit of increased weight loss. I have learned from observing such patients that mechanical restriction is not the dominant mechanism for weight loss. Excessive restriction following sleeve gastrectomy is not associated with better weight loss. I leave one cm of gastric tissue at the GEJ to prevent narrowing in that area and avoid patient discomfort. I resect most of the posterior gastric fundus by applying proper retraction during surgery. does leaving a larger unresected fundus lead to poor weight loss? The answer to this question maybe a yes but the cause is not poor restriction. Leaving a larger fundus may result in slower gastric emptying and poor Magenstrasse wave formation. Studies are needed to prove or disprove these observations. One thing for sure, we have had plenty of studies demonstrating that mechanical restriction by itself is not the underlying cause for weight loss. Yet, many still believe, like the authors of this article that “restriction is considered to be one of the most important mechanisms for weight loss in stapled procedures”.