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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April 2015 • Supplement A • Bariatric Times A13 5 th INTERNATIONAL CONSENSUS SUMMIT FOR SLEEVE GASTRECTOMY Esophagitis was present in 10 patients (24.4%). One patient had s evere esophagitis and another had an esophageal ulcer requiring treatment with healing demonstrated on repeat endoscopy. No patient had Barrett's esophagitis i n this series. Forty-one patients (8.1%) underwent HHr. HHr included posterior repair in 32 patients (78%). No use of mesh was required. No leaks developed. No strictures at the incisura angularis developed, although one patient developed adhesions that required adhesiolysis four months postoperatively with subsequent resolution. In patients undergoing HHr, 60.9 percent had persistence of their GERD, while 44 percent developed de novo GERD. In those who did not have a hiatal hernia and only underwent LSG, 171 patients had preoperative GERD (36.6%). One- hundred twenty five of those patients (73%) had persistence of their GERD. In the 296 patients who did not have preoperative GERD, 55 (18.5%) developed de novo GERD. HHr did not result in a statistically significant reduction in postoperative GERD (p=0.23) nor did it reduce de novo GERD development (Figure 2). In fact, patients undergoing HHr had a significantly higher risk of developing de novo GERD (p=0.013). Of note, there was no significant difference in GERD resolution between patients who underwent anterior HHr alone versus patients who underwent anterior and posterior repair, although this analysis is limited by the small number of patients. Disruption of the sling fibers is also postulated to be influential. Patients who had preoperative GERD and underwent stapling (with a 36 Fr bougie) lateral to the gastric fat pad (GFP [n=62]) versus takedown of the GFP (n=256) were compared. Stapling lateral to the GFP resulted in a significantly lower development of de novo GERD—6.1 versus 22.6 percent (p=0.03). Lateral stapling, however, did not lead to a higher likelihood of improvement or resolution of preoperative GERD. One patient (0.2%) had worsening of preoperative GERD after LSG. EGD was performed and revealed esophagitis, which was graded B according to The Los Angeles Classification of Gastroesophageal Reflux Disease. An upper gastrointestinal (UGI) series demonstrated reflux to the level of the cervical esophagus. The patient ultimately underwent revision to gastric bypass 34 months after LSG with resolution of her GERD. No hiatal hernia was present either at the time of primary LSG or revision to gastric bypass. CONCLUSION Repair of hiatal hernias in this study does not appear to improve resolution of preoperative GERD nor does it appear to reduce the risk of developing de novo GERD. Most hiatal hernias in this study were small and, therefore, results must be interpreted in that light. It may also be that the right crus approach to HHr (rather than left) impacted the results. Stapling lateral to the gastric fat pad appears to reduce the incidence of de novo GERD, but it does not appear to improve the resolution of preoperative GERD. The effect of TABLE 1. Studies evaluating de novo GERD incidence after LSG STUDY YEAR # PATIENTS GERD INCIDENCE Almogy et al 1 2004 21 13.0% Himpens et al 2 2006 40 21.8% Cottam et al 3 2006 126 20.0% Hamoui et al 4 2006 118 12.7% Melissas et al 5 2007 14 22.7% Nocca et al 6 2008 163 11.8% Frank et al 7 (2nd ICSSG) 2009 NA 14.3% Daes et al 8 2012 234 1.5% Soricelli et al 9 2013 378 22.9% Santonicola et al 1 0 2014 62 17.7% Varban et al 11 (Michigan BSC) 2014 1,567 21.6% Pallati et al 12 (BOLD) 2014 585 9.2%

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