Question of the week: Sleeve surgery after Fundoplication surgery

Question of the Week:

Hello,

I am a 54-year young woman. I am 5’6″ and 244 lbs. I had fundoplication surgery approximately 18 years ago in Cincinnati, Ohio.

I would like to have the sleeve surgery and I’m told that I can’t have it due to the fundoplication surgery. This is such devastating news for me.

I have osteoarthritis, low thyroid, asthma. I’m taking metformin 500 mg/2 x daily along with a Trulicity injection 1x weekly for weight loss.

I am a flight attendant and I can feel the stress on my body from my weight. I would give anything to not have the joint pain that I do. I do not want to become a diabetic. I also want to feel better about myself.

I would appreciate any help that can be provided to me.

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Dear Patti,

Fundoplication surgery is not a contraindication for weight loss surgery in the form of gastric bypass or sleeve gastrectomy. Weight gain with age is common and while fundoplication surgery is an excellent solution for GERD it does not protect against obesity. Typically, we perform a wrap take down prior to sleeve gastrectomy or gastric bypass surgery. In certain cases, the wrap is adherent to surrounding tissue and it is difficult to safely dissect it. In such cases, gastric bypass can be performed with excellent weight loss outcomes while preserving the wrap. The gastric pouch is simply created below the fundoplication. In the case of Sleeve gastrectomy, stomach resection can be performed up to the level of the fundoplication. However, we don’t have any long-term data in terms of weight loss outcomes with such an approach. Complete gastric fundus resection is crucial when it comes to proper sleeve resection. Whether a wrapped fundus is equivalent to a resected gastric fundus in terms of weight loss remains to be determined. Few months ago, a French group of surgeons reported on their experience with the N-Sleeve. The study was published in SOARD (Surgery of Obesity and related Disorders). N-Sleeve is a Nissen fundoplication added to sleeve gastrectomy procedure offered to patients with severe GERD. The authors reported short-term weight loss results comparable to a traditional gastric sleeve surgery. Additional studies are needed to confirm these findings. I personally think that a wrapped gastric fundus like a resected fundus is functionally inactive. Gastric fundus invagination, a novel weight loss procedure I have developed, functions along the same line of thought. An invaginated gastric fundus is incapable of stretching and dilating to accommodate a meal. In an obese mouse model, Ghrelin did not increase following gastric fundus invagination in response to weight loss indicating an inactive fundus. Should these results be confirmed, gastric fundus invagination is a less invasive approach to weight loss than sleeve gastrectomy. Sleeve gastrectomy mechanism of action remains to be determined. Until we do so, we can only rely on outcome studies and statistics to determine whether a wrapped fundus is equivalent to a resected fundus in the setting of gastric sleeve surgery.

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