Nissen-Sleeve operation, is it an option?

Nissen-Sleeve operation, is it an option?

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.

I personally believe that a wrapped fundus is metabolically and functionally equivalent to a resected gastric fundus. In other words, A properly performed Sleeve gastrectomy is not associated with increased risk of acid reflux. In fact, I use gastric sleeve surgery to treat GERD in obese patients. Acid reflux develops or worsens following gastric sleeve surgery when the incisura angularis is narrowed, hiatal hernia is not repaired, gastric fundus is incompletely resected and gastric antrum is resected. When gastric sleeve surgery was first introduced, bariatric surgeons aggressively resected the stomach over very small bougie size. Bariatric surgeons assumed that the smaller gastric sleeve volume is the better is weight loss. These unproven assumptions mutilated the stomach and resulted in narrow high pressure gastric tubes: A recipe for acid reflux.

Gastric sleeve surgery like any successful metabolic procedure is not simply a restrictive procedure. The antrum or gastric pump should be preserved to promote gastric emptying. The incisura angularis diameter cannot be narrowed over a 32 F bougie to prevent gastric content backflow into the esophagus. The gastric sleeve cannot be exposed to negative intra-thoracic pressure as this will favor not only acid reflux but also bile reflux. Therefore, any size hiatal hernias must be repaired to prevent GERD in the setting of sleeve gastrectomy.

Accordingly, I don’t see a major role for Nissen-sleeve surgery as a primary weight loss procedure. However, in a revision scenario, Nissen-sleeve surgery can be quite useful. I have personally used the Nissen-sleeve approach in obese patients with history of Nissen fundoplication. Rather than taking down the fundoplication and resecting the gastric fundus, the wrap was preserved, and a longitudinal gastrectomy was performed between the antrum and lower part of the fundoplication. I have also performed a Toupet or 270-degree fundoplication in patients who had incomplete gastric sleeve surgery with a large retained gastric fundus and severe acid reflux. This scenario is especially common in patients who undergo lap band to sleeve revision in one setting. Lap band creates excessive scarring around the gastro-esophageal junction preventing proper dissection and sleeve resection when attempted at the same time as band removal. Typically, patients have an associated hiatal hernia, esophageal dysmotility and an incompetent lower esophageal sphincter secondary to Lap Band over-restriction. All 3 factors lead to severe GERD in the setting of morbid obesity. I typically repair the hiatal hernia and use the remaining gastric fundus to perform a partial wrap. The few cases I did had excellent acid reflux control following surgery.

In short, a properly performed gastric sleeve resection is an excellent anti-reflux procedure. Standardizing proper sleeve gastrectomy technique and increasing awareness about acid reflux management and hiatal hernia repair are better options than developing a hybrid new procedure to treat two common disorders like GERD and Obesity.