Bariatric Times

Sleeve Gastrectomy 2015

A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional

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A12 Bariatric Times • April 2015 • Supplement A 5 th INTERNATIONAL CONSENSUS SUMMIT FOR SLEEVE GASTRECTOMY T he number of laparoscopic sleeve gastrectomy (LSG) procedures being performed has increased such that it now represents the majority of bariatric surgeries in many states, including our state—Michigan. Although LSG continues to rise in popularity, the postoperative development of gastroesophageal reflux (GERD) remains one potential downside that needs to be taken into consideration. Rates of development of GERD vary (Table 1) and there are many factors that may result in GERD after LSG. The presence of a hiatal hernia, disruption of the sling fibers, a redundant remnant fundus, and narrowing at the incisura angularis have been suggested to be etiologic factors. This study investigates the first two factors. LITERATURE REVIEW The literature has been mixed on the impact of hiatal hernia repair (HHr) on postoperative GERD after LSG. It must be mentioned first that there are no randomized studies that compare patients with a hiatal hernia who underwent repair versus those who did not. Santonicola et al 10 documented in patients undergoing LSG+HHr the persistence of GERD in 43.3 percent and development of de novo GERD in 22.9 percent, whereas GERD persisted in 22.5 percent and de novo GERD developed in 17.1 percent in those patients who did not have a hiatal hernia. Thus, the authors concluded that HHr did not reduce GERD after LSG. 10 On the other hand, Soricelli et al 9 demonstrated a benefit to HHr by showing only 7.5-percent persistence of GERD in patients undergoing HHr and no cases of de novo GERD, whereas GERD persisted in 42.2 percent and de novo GERD developed in 22.9 percent of those who did not have a hiatal hernia. METHODS This study is a retrospective review of 503 consecutive patients who underwent LSG from May 2010 to September 2013. Of note, nearly 200 LSGs done from April 2006 until the study period were not included as different techniques were utilized. Only severe uncontrolled GERD was considered to be a contraindication to LSG. Transection began at 4cm from the pylorus, no buttressing was used, the posterior short gastric vessels were divided, the left crus was visualized, and the proximal staple line was oversewn. A 36 Fr bougie was used in most patients, while a 40 Fr bougie was used in the remainder. Hiatal hernias were repaired via the right crus using the Endo Stitch ™ suturing device (Covidien, North Haven, Connecticut, United States) using 0 Ticron (see Figure 1). RESULTS All patients underwent preoperative endoscopy (EGD). Hiatal hernias were demonstrated on EGD in only 17 of the 41 patients (41.4%) who ultimately underwent HHr. Most of the hiatal hernias were small (2 to 3cm) and only two were larger than 4cm. • Gastroesophageal reflux disease (GERD) remains one of the main downsides of laparoscopic sleeve gastrectomy. • Hiatal hernia repair, although necessary, did not improve resolution of preoperative GERD or reduce the incidence of de novo GERD. • Details related to the construction of the sleeve appear to be more important than the hiatal hernia repair itself. KEY POINTS Outcome of Hiatal Hernia Repair on Patients with Gastroesophageal Reflux Disease Undergoing Sleeve Gastrectomy TALLAL M. ZENI, MD; SHEILA K. THOMPSON, RN; and JACOB E. ROBERTS, DO Michigan Bariatric Institute, St. Mary Mercy Hospital, Livonia, Michigan, United States Bariatric Times. 2015;12(4 Suppl A):A12–A14. DISCLOSURE: The authors report no conflicts of interest relevant to the content of this article. ADDRESS CORRESPONDENCE TO: Dr. Tallal Zeni, 14555 Levan Rd., Marian Professional Bldg., Suite 311, Livonia, MI 48154; Phone: (734) 655- 2692; Fax: (734) 655-4218; E-mail: tallal.zeni@stjoeshealth.org

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