OBES SURG DOI 10.1007/s11695-013-1117-6
Improvement of Gastroesophageal Reflux Symptoms After Standardized Laparoscopic Sleeve Gastrectomy Jorge Daes & Manuel E. Jimenez & Nadim Said & Rodolfo Dennis
# Springer Science+Business Media New York 2013
Abstract Background Gastroesophageal reflux disease (GERD) is present in half of morbidly obese patients. Published data reporting the results of laparoscopic sleeve gastrectomy (LSG) in patients with GERD are contradictory. We have shown in a previous study that symptoms of GERD can be reduced for up to 12 months after LSG with careful attention to surgical technique. The present study prospectively evaluated the effect of a standardized LSG technique on the incidence of postoperative GERD symptoms in a larger sample, and followed patients for up to 22 months. Methods This was a concurrent cohort study. All patients who underwent LSG at our center completed a standard multidisciplinary preoperative evaluation and were followed prospectively. Results A total of 382 patients underwent surgery. There were no cases of death or fistula. GERD was diagnosed in 170 patients (44.5 %) preoperatively, and hiatal hernia (HH) was detected in 142 patients (37.2 %) intraoperatively. Between 6 and 22 months postoperatively, 373 patients were completely evaluated. Ten (2.6 %) had GERD symptoms 6–22 months postoperatively, and 94 % of patients with preoperative GERD symptoms were asymptomatic at follow-up 6–22 months after LSG. Only 1 patient (0.5 %) of a subgroup of 174 without HH or esophagitis at preoperative evaluation had GERD at follow-up. J. Daes (*) : M. E. Jimenez : N. Said Minimally Invasive Surgery Department, Clinica Bautista, Carrera 38 calle 71 esquina, Barranquilla, Colombia e-mail: [email protected]
R. Dennis Research Department, Fundacion Cardioinfantil; and Clinical Epidemiology Department, School of Medicine, Universidad Javeriana, Bogota, Colombia
Conclusions Our results confirm that, contrary to previous reports of LSG in the literature, careful attention to surgical technique can result in significantly reduced GERD symptoms up to 22 months postoperatively suggesting that LSG does not predispose patients to GERD during that period. Keywords Sleeve gastrectomy . Laparoscopic . Gastroesophageal reflux . Hiatal hernia . Technique
Introduction A strong association exists between obesity and gastroesophageal reflux disease (GERD). GERD is reported to be present in half of obese candidates for bariatric surgery , which seems to be the best alternative for the obese patient with GERD, and many surgeons consider Roux-en-Y gastric bypass (RYGBP) to be the technique of choice [2–4] even though a variable percentage of patients remain symptomatic [5–7]. We demonstrated in a previous prospective study that symptoms of GERD can be greatly reduced after laparoscopic sleeve gastrectomy (LSG) with careful attention to surgical technique . We found that 1.5 % of patients had GERD 6– 12 months after LSG. The results were more significant because the study did not select patients for LSG and included patients with large hiatal hernia (HH), severe reflux symptoms, and esophagitis. The present study prospectively evaluated the effect of a standardized LSG technique on the incidence GERD symptoms in 382 patients followed for 6–22 months. Other objectives were to establish the preoperative prevalence of GERD, esophagitis, and HH; morbidity associated with the LSG procedure; predisposing factors to GERD symptoms after LSG, percentage of total body weight loss (%TBWL); percentage of excess weight loss (%EWL); and outcome of a
selected group of patients without preoperative HH, or esophagitis after LSG.
Materials and Methods This is a cohort study with concurrent collection of data. All patients from April 2011 to October 2012 underwent LSG. Patients with HH and GERD were included in the study, including 1 with ultra-short-segment Barrett's disease. Two patients with gastric bands were converted to a LSG because of poor weight loss. Three patients had a re-sleeve for weight regain; all of them had a dilated fundus. All patients underwent a multidisciplinary preoperative evaluation and met Colombian Surgical Society criteria for LSG. All patients were surveyed about the presence of heartburn and/or regurgitation. A detailed explanation was made to the patients on the definition of each. Preoperative GERD was diagnosed if patients experience heartburn o regurgitation two or more times a week, or if they required antacid treatment for any symptoms for more than 2 weeks. The presence of esophagitis in any degree, Barrett's esophagus, or stricture at endoscopy was also considered GERD. All patients underwent preoperative endoscopy by an endoscopist/surgeon with extensive experience. A diagnosis of small HH was made when there was a patulous cardia or a hernia measuring 2 cm. Presence and degree of esophagitis and Barrett's disease, and any additional pathological findings, were recorded. The patient was reevaluated on the eight postoperative day; 1, 3, 6, and 12 months postoperatively; and every 6 months thereafter. We recorded symptoms of GERD using the same survey employed preoperatively. Early endoscopy was indicated if a patient had difficulty tolerating solid food, and after the sixth postoperative month in patients with GERD symptoms. We report only on patients with six or more months of follow-up because reflux symptoms in the first postoperative months may represent an adaptation to restricted stomach size. Surgical Procedure The technical aspects of our LSG procedure can be viewed at http://www.sages.org/video/details.php?id=103375. Briefly, we use five ports as follows: a 12-mm port at the umbilicus for the laparoscope and for stapling and removal of the stomach; a second 12-mm port at the left flank for devascularization of the greater curvature, as a secondary position for insertion of the laparoscope during stapling, and for suturing; and three additional 5-mm ports, one at the epigastrium for liver retraction, one at the right upper quadrant for the surgeon's left-hand working trocar, and one at the left lateral subcostal area for the assistant.
The greater curvature is devascularized using an ultrasonic device starting 3 cm proximal to the pylorus and continuing until the fundus is dissected free of the left crus of the diaphragm. We ensure that there is at least 3 cm of intra-abdominal esophagus. When HH is present, we completely free the esophageal–gastric union from the left and right crura, divide the phrenoesophageal membrane and periesophageal connective tissues, and continue the dissection well into the mediastinum to ensure a sufficient length of intra-abdominal esophagus. The HH defect is then closed with nonabsorbable monofilament sutures. Neither a calibrating bougie nor mesh, even for large hernias, is used. A 32-French bougie is introduced to the distal antrum. Division of the stomach starts 3 cm proximal to the pylorus, keeping the bougie adjacent to the lesser curvature. We fire a 60–4.8-mm staple cartridge initially, followed by three to five 60–3.5-mm cartridges, carefully avoiding relative narrowing at the junction between the vertical and horizontal parts of the stomach, which usually occurs during the first, and occasionally the second, firing of the stapler if it is inappropriately pressed against the bougie in an attempt to leave a small antrum. Narrowing can be avoided by using an articulating stapler, slightly angled to the greater curvature, to create a wide angle at the junction between the horizontal antrum and the vertical body of the stomach. When the pylorus is located in the right upper quadrant and the stomach is very curved, the only way to form a small antrum and avoid relative narrowing is to place an additional trocar through a port at the right flank to help aim the first stapler correctly. When firing the staplers, it is important not to overstretch the stomach to avoid narrowing by recoil of the stapler line. The anterior stomach wall and posterior stomach wall need to be equal and flat in order to keep the sleeve from rolling or spiraling, which may result in food intolerance or GERD. Division of the stomach, including most of the fundus, is then completed, leaving only a small portion for oversewing. We bury the staple line with continuous seromuscular to seromuscular stitches, using nonabsorbable monofilament sutures, starting at the top of the sleeve . We then retract the bougie proximally, test the sleeve with 25–35 mL of methylene blue, perform a small omental patch with a single seroserosal stitch over the top of the sleeve, and, after incising the aponeurosis, extract the stomach through the umbilical port without a bag. We instill diluted bupivacaine into the left upper quadrant and do not place drains. Trocars are removed under direct vision to ensure hemostasis and the aponeurosis sutured. The patient is discharged the following day after tolerating a liquid diet and receiving a complete set of postoperative instructions from the nurse coordinator.
OBES SURG Table 1 Characteristics of the patients who underwent LSG (total cohort) Patients
Female/male Age, mean (range) BMI, mean (range) GERD, patients (%)
262/120 38.2 (14–70) 37.7 (30–64) 170 (44.5)
Endoscopy HH, patients (%) Confirmed at surgery HH, patients (%) Large HH, patients (%) Esophagitis, patients (%)
197 (51.6) 142 (37.2) 34 (8.9) 46 (12)
BMI body mass index, GERD gastroesophageal reflux disease, HH hiatal hernia
Statistical Analysis We used an Office 2000 database (Microsoft, Redmond, WA) for data collection and Epi info 7.0 software (Centers for Disease Control, Atlanta, GA) for statistical analysis. For all comparative analysis, a two-sided P value of