Case of the week: Gastric Sleeve Surgery Following Nissen Fundoplication

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.

The traditional approach to such a case is hiatal hernia repair and Nissen fundoplication conversion to gastric bypass. Ideally, the fundoplication is taken down prior to gastric pouch creation. Occasionally, the fundoplication is adherent to the esophagus and the pouch can be constructed below the fundoplication thus avoiding esophageal injuries and minimizing complications.

A newer approach entails conversion of Nissen fundoplication to Gastric sleeve surgery with hiatal hernia repair. Gastric sleeve surgery, when properly performed, is as effective as gastric bypass in terms of acid reflux control. The fundoplication is typically taken down prior to gastric sleeve resection. New reports have recently emerged about the Nissen-sleeve and Rosetti-sleeve surgeries whereby part of the gastric fundus is preserved following gastric sleeve surgery to perform a fundoplication. Weight loss results at one year were comparable to a traditional gastric sleeve procedure.

Accordingly, I started offering obese patients with previous Nissen fundoplication, a fundoplication preserving sleeve gastrectomy. The greater curvature is mobilized and gastric sleeve resection is performed up to the fundoplication level. Care is taken to resect the redundant posterior fundus to avoid a large pouch in that area. A concomitant recurrent hiatal hernia is repaired. My short-term weight loss results in a limited series of patients are similar to regular gastric sleeve weight loss outcomes. Patients report excellent appetite and portion control and no GERD symptoms.

Fundoplication preserving gastric sleeve surgery is the least invasive surgical weight loss option for obese patients with history of anti-reflux surgery. This approach is particularly suitable for patients with significant adhesions around the gastro-esophageal junction. I predict that long-term results of fundoplication preserving gastric sleeve surgery are similar to a traditional sleeve gastrectomy and this approach is likely to become the preferred revision procedure for this particular group of patients.

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