I read with great interest the case series published this month in Surgery for Obesity and Related Diseases, SOARD, by Yerdel et al. “Sleeve Gastrectomy in patients with previous antireflux surgery. Preliminary results of the “no-touch to posterior wrap” technique. The authors converted 14 Nissen fundoplication patients with morbid obesity to sleeve gastrectomy. Mean follow up time was around 2 years after conversion surgery. Conversion surgery preserved the posterior and right lateral aspect of the wrap. The authors took down the left side of the wrap and stapled this part off along with the rest of the gastric body to complete the sleeve gastrectomy. The main advantage of such an approach is to decrease morbidity associated with complete wrap take down. Furthermore, the risk of creating septated pouch by stapling the left aspect of the wrap is practically eliminated adopting the described approach.

At Houston Weight Loss Surgery Center, we have safely performed a number of Nissen fundoplication revisions to sleeve gastrectomy.  I have preserved the wrap in most cases and performed gastric sleeve resection below the wrap. My approach consists of complete wrap mobilization along the left crus to be able to include a good part of the posterior aspect of the wrap in the resected gastric sleeve. In most cases, the posterior aspect of the Nissen fundoplication wrap was stretched and easily resected. We did not have any ischemia of remnant wrap. Weight loss results were good at one year with most patients losing more than 50% of their excess weight. Patients with recurrent hiatal hernia underwent redo hiatal hernia repair during Nissen to sleeve conversion surgery. Patients presenting with acid reflux symptoms underwent complete GERD work-up including ambulatory pH testing and esophageal manometry. Patients with slipped Nissen fundoplication or confirmed recurrent acid reflux underwent complete wrap take down and conversion to sleeve gastrectomy. At Houston Weight Loss Surgery Center, the incidence of de novo acid reflux or worsening existing acid reflux after sleeve gastrectomy is almost zero. Our approach of preserving the antrum, preventing narrowing of incisura angularis, and properly repairing any existing hiatal hernia has resulted in excellent acid reflux control. The only reason we preserve the wrap in sleeve gastrectomy conversion cases is to decrease morbidity and mortality. I agree with the author, the most difficult aspect of Nissen fundoplication take down is dissecting posterior wrap adhesion to posterior esophagus and crura. Anterior wrap mobilization is much easier and safer. Most importantly, it allows for safer stapling of redundant gastric fundus with very low risk of pouch septation.