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.