A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional
Issue link: https://bariatrictimes.epubxp.com/i/69664
CHECKLIST IN LAPAROSCOPIC SLEEVE GASTRECTOMY Part 3: CONSIDERATIONS GASTROESAPHOGEAL REFLUX DISEASE (GERD) The first line of treatment in patients with GERD = proton pump inhibitors EXPERT COMMENTARY Randal S. Baker MD, FACS Grand Health Partners, Grand Rapids Michigan A number of studies and the SG expert panel have indicated that sleeve gastrectomy can lead to new onset or increased GERD. Discussion of the panel revealed that many were concerned about performing the sleeve in patients with significant pre-operative GERD not caused by hiatal hernia (as worsening GERD and bile reflux has been reported after SG), but no consensus vote was taken regarding this issue. The panel agreed that Barrett's esophagus is a definite contraindication to performing a sleeve. In addition, we felt that during surgery the phreno-esophageal membrane must be explored to help identify, and subsequently repair, any hiatal hernias. It is easier to perform this after the sleeve is created and the excluded stomach is out of the way. To avoid retching and injury to the crural repair, sleeve patients, especially those with hiatal hernias, should wait at least two weeks after surgery to start solid food. GERD after a sleeve should first be treated with proton pump inhibitor medications and, during the panel meeting, many voiced the consideration of revision to Roux-en-Y gastric bypass if severe GERD is not responsive to conservative treatment. REVISIONS Last firing = green or greater think this most likely represents the heterogenous nature of the SG patient rather than ignorance of outcomes. For example, a patient with initial body mass index (BMI) of 65 kg/m2 R might be best served by conversion to duodenal switch for inadequate weight loss; whereas, a patient with 80-percent excess weight loss (EWL) with intractable gastroesophageal reflux disease (GERD), would be better off converted to gastric bypass. [JUNE 2012, SUPPLEMENT B] Bariatric Times B7 LSG is acceptable to convert a successful, but complicated, gastric band evisions continue to be controversial, as evidenced by the lack of consensus reached by the SG panel on the topic of what to do after a laparoscopic sleeve gastrectomy fails. I When converting from gastric banding to LSG, the operation can be done in 1 or 2 steps EXPERT COMMENTARY Kelvin Higa, MD, FACS, FASMBS University of California, San Francisco; Fresno Heart and Surgical Hospital; Advanced Laparoscopic Surgery Associates, Fresno, California Gregg H. Jossart, MD, FACS California Pacific Medical Center, San Francisco, California without a hiatal hernia repair. It is well known that preoperative studies, such as endoscopy and upper gastrointestinal (GI) contrast, can fail to diagnose a hiatal hernia. Hence, the recommendation of intraoperative examination of the hiatus anteriorly and along the left crus in all patients undergoing a sleeve gastrectomy. I think that opening the pars flaccida to probe for a hernia along the right crus may be the most sensitive technique. In my experience, hiatal hernia repair should always include circumferential dissection and mobilization of the distal esophagus, suture approximation of the posterior and anterior crus, as well as attachment of the cardia to the insertion point of the left phrenoesophageal ligament on the left diaphragm. This may restore the Angle of His and reduces recurrence rate. R eflux and hiatal hernias are common in the morbidly obese and often, as noted in the SG consensus statement, exacerbated by a sleeve gastrectomy