Surgery for Obesity and Related Diseases ] (2014) 00–00
Editorial comment
Comment on: Subjective assessment of gastroesophageal reflux in laparoscopic sleeve gastrectomy: hiatal findings and their management influence outcome The study by Lyon et al. is interesting and timely because it addresses one of the main concerns about what has become the most popular bariatric procedure, the laparoscopic sleeve gastrectomy (LSG), namely the possibility that this procedure induces gastroesophageal reflux disease (GERD). The condition may be elicited by reduction of the pressure at the lower esophageal sphincter (LES) because of the partial resection of the sling fibers at the gastroesophageal junction [1]. Moreover, after LSG the intragastric pressure is increased [2], a condition that may facilitate gastric stasis and reflux. [3]. Concerns about LSG led a panel of experts [4] to the consensus that GERD constitutes one of the few contraindications to LSG. Recently, however, Petersen et al. reported that LSG may actually enhance rather than impair the LES pressure, hence improve reflux [5]. The study by Lyon et al. concludes that preexisting GERD indeed improves after LSG and that LSG should no longer be withheld from patients suffering from reflux, provided that even the smallest hiatal defect is repaired. This conclusion appears to be premature because of the following reasons. First, the study is not based on objective data but rather on circumstantial evidence consisting of the self-reported progression of the Visick score, the perception of number and severity of reflux episodes, and the use of proton pump inhibitors. Second, the data were obtained by telephone interview and included the patients' recollection of their preoperative reflux symptoms and proton pump inhibitors intake, which makes the study substantially sensitive to bias. Third, and most importantly, the follow-up is too short. Even though the authors mention midterm results, 76% of the patients had been followed for 2 years or less, and only 7% of the patients (a mere 18 patients) had been followed for more than 36 months. In our experience, in agreement with the findings of Lyon et al., the number of patients suffering from GERD significantly dropped after LSG over the short term (i.e., within 3 years) [6], and a considerable number of sleeve patients started complaining of reflux beyond 3 years [7]. Their patients also appeared to
deteriorate with time in terms of reflux (even within a time frame of 3 years). The authors sutured the omentum to the new greater curvature in the belief that this would prevent the development of GERD over the long term. There is, however, no scientific evidence in this particular study or elsewhere that this technique is actually helpful in preventing stenosis or torsion of the stomach and subsequent reflux. Moreover, the consideration of omentopexy to allegedly prevent reflux somehow invalidates the philosophy of the authors that aggressive hiatal repair during LSG is a key factor in curing mild to moderate preoperative reflux. In addition, moderate to severe reflux appeared to improve after LSG, independently from hiatoplasty. Nevertheless Lyon et al. must be commended for their policy of observing a low threshold to dissect the hiatus and to fix even the smallest hernia (the authors performed either anterior hiatal suturing or posterior full repair in as many as 65% of the cases). Hiatal dissection undoubtedly allows for a thorough dissection of the angle of His and subsequent adequate resection of the fundus, thereby avoiding the later development of a neo-fundus, a known cause of GERD and weight regain. Actually, rather than reserving thorough and circumferential dissection of the hiatus in the patients who present with a sizable hiatal defect, as was the policy in the study analyzed here, we believe that dissection of the posterior aspect of the hiatus should be performed in all patients submitted to LSG. More often than not, a lipoma indicative of a concealed hernia will be found. Hiatal dissection in an obese subject is not straightforward, however, especially in the heavier male patients. Technical issues might explain why the authors, who obviously were at the beginning of their experience, performed hiatal repair more frequently (even though not significantly so) in women than in men as body mass index (BMI) increased and why the BMI overall was significantly lower in the patients who did undergo full hernia repair. In conclusion, the Lyon et al. study does not bring enough support to state that patients suffering from reflux should be freely allowed to undergo LSG. Until real evidence concerning GERD and LSG is presented, patients
http://dx.doi.org/10.1016/j.soard.2014.09.012 1550-7289/r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
J. Himpens / Surgery for Obesity and Related Diseases ] (2014) 00–00
2
suffering from GERD will continue to be treated by RYGB in our practice. Jacques Himpens, M.D., Ph.D. European School of Laparoscopic Surgery, Brussels, Belgium References [1] Braghetto I, Lanzarini E, Korn O, Valledares H, Molina JC, Henriquez A. Manometric changes of the lower esophageal sphincter after sleeve gastrectomy in obese patients. Obes Surg 2010;20:357–62. [2] Yehoshua RT, Eidelman LA, Stein M, et al. Laparoscopic sleeve gastrectomy—volume and pressure assessment. Obes Surg 2008;18: 1083–8.
[3] Frankhuisen R, Van Herwaarden MA, Scheffer RCh, Hebbard GS, Gooszen HG, Samsom M. Increased intragastric pressure gradients are involved in the occurrence of acid reflux in gastroesophageal reflux disease. Scand J Gastroenterol 2009;44:545–50. [4] Rosenthal RJ, the International Sleeve Gastrectomy Expert Panel, Diaz AA, et al. International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of 412,000 cases. Surg Obes Relat Dis 2012;8:8–19. [5] Petersen WV, Meile T, Küper MA, Zdichavsky M, Königsrainer A, Schneider JH. Functional importance of laparoscopic sleeve gastrectomy for the lower esophageal sphincter in patients with morbid obesity. Obes Surg 2012;22:360–6. [6] Himpens J, Dapri G, Cadière GB. A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: results after 1 and 3 years. Obes Surg 2006;16:1450–6. [7] Himpens J, Dobbeleir J, Peeters G. Long-term results of laparoscopic sleeve gastrectomy for obesity. Ann Surg 2010;252:319–24.
Editorial comment
Comment on: Subjective assessment of gastroesophageal reflux in laparoscopic sleeve gastrectomy: hiatal findings and their management influence outcome The study by Lyon et al. is interesting and timely because it addresses one of the main concerns about what has become the most popular bariatric procedure, the laparoscopic sleeve gastrectomy (LSG), namely the possibility that this procedure induces gastroesophageal reflux disease (GERD). The condition may be elicited by reduction of the pressure at the lower esophageal sphincter (LES) because of the partial resection of the sling fibers at the gastroesophageal junction [1]. Moreover, after LSG the intragastric pressure is increased [2], a condition that may facilitate gastric stasis and reflux. [3]. Concerns about LSG led a panel of experts [4] to the consensus that GERD constitutes one of the few contraindications to LSG. Recently, however, Petersen et al. reported that LSG may actually enhance rather than impair the LES pressure, hence improve reflux [5]. The study by Lyon et al. concludes that preexisting GERD indeed improves after LSG and that LSG should no longer be withheld from patients suffering from reflux, provided that even the smallest hiatal defect is repaired. This conclusion appears to be premature because of the following reasons. First, the study is not based on objective data but rather on circumstantial evidence consisting of the self-reported progression of the Visick score, the perception of number and severity of reflux episodes, and the use of proton pump inhibitors. Second, the data were obtained by telephone interview and included the patients' recollection of their preoperative reflux symptoms and proton pump inhibitors intake, which makes the study substantially sensitive to bias. Third, and most importantly, the follow-up is too short. Even though the authors mention midterm results, 76% of the patients had been followed for 2 years or less, and only 7% of the patients (a mere 18 patients) had been followed for more than 36 months. In our experience, in agreement with the findings of Lyon et al., the number of patients suffering from GERD significantly dropped after LSG over the short term (i.e., within 3 years) [6], and a considerable number of sleeve patients started complaining of reflux beyond 3 years [7]. Their patients also appeared to
deteriorate with time in terms of reflux (even within a time frame of 3 years). The authors sutured the omentum to the new greater curvature in the belief that this would prevent the development of GERD over the long term. There is, however, no scientific evidence in this particular study or elsewhere that this technique is actually helpful in preventing stenosis or torsion of the stomach and subsequent reflux. Moreover, the consideration of omentopexy to allegedly prevent reflux somehow invalidates the philosophy of the authors that aggressive hiatal repair during LSG is a key factor in curing mild to moderate preoperative reflux. In addition, moderate to severe reflux appeared to improve after LSG, independently from hiatoplasty. Nevertheless Lyon et al. must be commended for their policy of observing a low threshold to dissect the hiatus and to fix even the smallest hernia (the authors performed either anterior hiatal suturing or posterior full repair in as many as 65% of the cases). Hiatal dissection undoubtedly allows for a thorough dissection of the angle of His and subsequent adequate resection of the fundus, thereby avoiding the later development of a neo-fundus, a known cause of GERD and weight regain. Actually, rather than reserving thorough and circumferential dissection of the hiatus in the patients who present with a sizable hiatal defect, as was the policy in the study analyzed here, we believe that dissection of the posterior aspect of the hiatus should be performed in all patients submitted to LSG. More often than not, a lipoma indicative of a concealed hernia will be found. Hiatal dissection in an obese subject is not straightforward, however, especially in the heavier male patients. Technical issues might explain why the authors, who obviously were at the beginning of their experience, performed hiatal repair more frequently (even though not significantly so) in women than in men as body mass index (BMI) increased and why the BMI overall was significantly lower in the patients who did undergo full hernia repair. In conclusion, the Lyon et al. study does not bring enough support to state that patients suffering from reflux should be freely allowed to undergo LSG. Until real evidence concerning GERD and LSG is presented, patients
http://dx.doi.org/10.1016/j.soard.2014.09.012 1550-7289/r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
J. Himpens / Surgery for Obesity and Related Diseases ] (2014) 00–00
2
suffering from GERD will continue to be treated by RYGB in our practice. Jacques Himpens, M.D., Ph.D. European School of Laparoscopic Surgery, Brussels, Belgium References [1] Braghetto I, Lanzarini E, Korn O, Valledares H, Molina JC, Henriquez A. Manometric changes of the lower esophageal sphincter after sleeve gastrectomy in obese patients. Obes Surg 2010;20:357–62. [2] Yehoshua RT, Eidelman LA, Stein M, et al. Laparoscopic sleeve gastrectomy—volume and pressure assessment. Obes Surg 2008;18: 1083–8.
[3] Frankhuisen R, Van Herwaarden MA, Scheffer RCh, Hebbard GS, Gooszen HG, Samsom M. Increased intragastric pressure gradients are involved in the occurrence of acid reflux in gastroesophageal reflux disease. Scand J Gastroenterol 2009;44:545–50. [4] Rosenthal RJ, the International Sleeve Gastrectomy Expert Panel, Diaz AA, et al. International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of 412,000 cases. Surg Obes Relat Dis 2012;8:8–19. [5] Petersen WV, Meile T, Küper MA, Zdichavsky M, Königsrainer A, Schneider JH. Functional importance of laparoscopic sleeve gastrectomy for the lower esophageal sphincter in patients with morbid obesity. Obes Surg 2012;22:360–6. [6] Himpens J, Dapri G, Cadière GB. A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: results after 1 and 3 years. Obes Surg 2006;16:1450–6. [7] Himpens J, Dobbeleir J, Peeters G. Long-term results of laparoscopic sleeve gastrectomy for obesity. Ann Surg 2010;252:319–24.
