Question of the Week from Tina

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.

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