LSG and intractable GERD: how to prevent? How to treat? Jacques M Himpens, the European School of Laparoscopic Surgery, Brussels, Belgium

Transcription

1 LSG and intractable GERD: how to prevent? How to treat? Jacques M Himpens, the European School of Laparoscopic Surgery, Brussels, Belgium

2 Jacques Himpens is a consultant with Ethicon Endosurgery and With Medtronic. There is no conflict of interest in the material presented here.

3 LSG and GERD GERD worsened Unsure GERD improved Himpens J Oor J Rawlins L Hutter MM DuPree C Casella J Keren D Leivonen M Chiu S Arman G Barr A Rebecchi Petersen Himpens J et al. Ann Surg 2010;252 (2): Hutter MM et al. Ann Surg 2011;254 (3): Keren D et al. Obes Surg 2011;21(12): Leivonen M et al. Obes Surg 2011:21(8): Chiu S et al. SOARD 2011;7(4): Arman G et al. SOARD Dec;12(10): Oor J et al. Am J Surg 2016;211(1): DuPree C et al. JAMA Surg 2014;149(4): Rawlins L et al. SOARD 2013;9(1):21-25 Casella J et al. SOARD 2016;12(4): Barr A et al. Surg Endosc 2017;31(1):410-5

4 GASTRO-ESOPHAGEAL REFLUX OCCURS IN UP TO 40% OF THE CASES AFTER LSG Braghetto I et al. Surg Laparosc Endosc Percutan Tech Tai CM et al. Surg Endosc Gautier T et al Obes Surg van Rutte PW et al. Obes Surg Weiner RA et al. Obes Facts Howard DD et al. Surg Obes Relat Dis Abdemur A et al. Surg Obes Relat Dis Gorodner V et al. Surg Endosc 2014 Boza C et al. Surg Obes Relat Dis Sheppard C et al. Obes Surg 2014

5 Variation in PPI use before and 1 year after LSG No PPI preop 22% use at 1 yr PPI preop 37% D/C at 1 year LSG is the bariatric procedure that induces most GERD Varban O et al. SOARD 2014

6 Variation in PPI use before and 1 year after LSG No PPI preop 22% use at 1 yr PPI preop 37% D/C at 1 year LSG is the bariatric procedure that induces most GERD Varban O et al. SOARD 2014 PPI preop 58% increase dosage at 1 year 42% same dosage at 1 year 0% D/C PPI Sheppard et al. Obes Surg 2014

7 LSG and GERD before and 1 year postop (BOLD study) GERD preop 84% persistence at 1 yr No GERD preop 8.6% at 1 year Preop GERD increases postop complications, revisional surgery and decreases weight loss (n=4832) DuPree CE et al. JAMA Surg 2014;149(4)

8 Rebecchi F, et al. Ann Surg Nov;260(5): LSG improves existing GERD and does not induce GERD de novo N=71, prospective 2 years Ph-metry Petersen W et al. Obes Surg Mar;22(3): LSG increases LES pressure and may protect against GERD N=37, prospective 8 months Endoscopy, manometry

9 Can Postop GERD be avoided?

10 No statistically significant difference between the 2 surgical techniques in terms of GERD incidence was demonstrated in any individual study or on meta-analysis (RR.69; CI ; I2 = 3.6%). Michalsky D, et al.obes Surg 2013;23(4): Abdellah E, et al. Obes Surg. 2014; 24: Obeidat F et al. Obes Surg. 2015; 25:

11 Prospective non randomized study n= 67: Volume evaluation by 3-D CT reconstruction tight sleeve n=22 (vol ml) loose sleeve n=45 (vol ml) Follow-up 18 months

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16 Three included studies reported the incidence of GERD among patients A random effect model showed that there was no significant difference in the incidence of GERD (OR 0.77, 95% CI , P =.476) between the two groups.

17 retrospective chart review 210 patients who underwent SG from postoperative upper gastro- intestinal (UGI) study

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20 N= 85 GERD symptoms evaluated up to 1 year postoperatively Anatomy evaluated by gastrograffin swallow

21 Tubular pattern least improvement in GERD

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23 A sleeve gastrectomy produces an important decrease in LES pressure

24 From: Braghetto I et al. Obes Surg 2010; 20:356-62

25 Appropriate to the Laplace law, the radius at the gastro- esophageal junction declines.

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27 Group 1= controls; group2= morbidly obese patients 6 months postop Group 3=morbidly obese patients 1 week postop

28 The protective effect of LSG for GERD depends on the increase of LESP with regard to the stapler position in relation to the angle of His. In LSG, the stapler line captures the great curvature-sided sling fibers (Fibrae obliquae), which exhibit a fundamental contingent on valve mechanism of the LES. Appropriate to the Laplace law, the radius at the gastro- esophageal junction declines. Interpr: since no difference in LESP between group 2 and 3: change not Explainable by weight loss

29 Consecutive morbidly obese patients selected for LSG included in a prospective clinical study. Gastroesophageal function was evaluated using a clinical validated questionnaire, upper endoscopy, esophageal manometry, and 24-hour ph monitoring before and 24 months after LSG. 2 year Outcomes available for 28 with preoperative abnormal findings (A) 37 with preoperative normal findings (B)

30 No significant changes in lower esophageal sphincter pressure and esophageal peristalsis amplitude were found in both groups. Group A: significant improvement in De Meester score and total acid exposure (ph<4) significant clinical improvement of GERD Group B: significant worsening (de nove GERD) in 2/37 patients

31 Is hiatal repair + LSG a GERD preventive procedure? YES NO UNCLEAR Soricelli E et al Dakour Aridi K et al. Snyder B et al. Gibson SC et al. Santanicola A et al. El Chaar M et al. -Soricelli E, et al. (2013) Sleeve gastrectomy and crural repair in obese patients with gastroesophageal reflux disease and/or hiatal hernia. SOARD 9(3): Gibson SC, et al. (2013) Laparoscopic sleeve gastrectomy: review of 500 cases in single surgeon Australian practice. A-NZ J Surg doi: /ans El Chaar M et al. (2016) Short-Term Results of Laparoscopic Sleeve Gastrectomy in Combination with Hiatal Hernia Repair: Experience in a Single Accredited Center.Obes Surg 26(1): Dakour Aridi K et al.(2017) Gastroesophageal Reflux Disease After Laparoscopic Sleeve Gastrectomy with Concomitant Hiatal Hernia Repair: an Unresolved Question. Obes Surg. 27(11): Santanicola A et al. (2014) The effect of laparoscopic sleeve gastrectomy with or without hiatal hernia repair on gastroesophageal reflux disease in obese patients. SOARD 10(2): Snyder B et al. (2016) A randomized trial comparing reflux symptoms in sleeve gastrectomy with or without hiatal hernia repair. SOARD 12(9):1681-8

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35 GSRS: gastrointestinal symptom rating scale

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38 More often than not, what the patient experiences as GERD is actually stasis of food over-eating (exceeding the volume and voiding capacity of the sleeved stomach) Symptoms occur during the day, (postprandially) not at night (Del Genio et al. Obes Surg 2014) Some relief from PPI (Fujiwara et al. Digestion 2011;253(2)

39 True de novo Reflux after LSG

40 True de novo Reflux after LSG LES? (manometry) functional stenosis of the sleeve? (Ba swallow, CT reconstruction) organic stenosis? (endoscopy) retained fundus (Ba swallow)

41 True de novo Reflux after LSG LES? functional stenosis of the sleeve? corkscrew? organic stenosis? retained fundus Surgical condition

42 N=53 37 pts not converted 10 (38%) GERD (PPI)

43 Gastroscopies revealed de novo hiatal hernias in 45% of the patients and Barrett s metaplasia in 15%. Felsenreich et al. Obes Surg 2017

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46 REOPERATIONS FOR GERD AFTER SLEEVE LES: Hiatal Hernia Wedge resection Seromyotomy RYGB Plication Re-sleeve STENOSIS FUNDUS REGROWTH/ Retained Fundus

47 Hiatal Hernia

48 López-Ambriz G, Domínguez-Carrillo LG. Ligamentum teres Cardiopexy with Ligamentum Teres in Patients with Hiatal Hernia and Previous (GERD) Sleeve Gastrectomy: An Alternative Treatment for Gastroesophageal Reflux Disease. Obes Surg May 20. [Epub ahead of print] Ligamentum teres released and hernia reduced by manual traction, freeing the last 3-5 cm of esophagus in the abdomen. Distal ligamentum teres is fixed one stitch to the apex of the angle of His, one at the gastroesophageal junction, one joining the gastric fundus to the esophagus. Ligamentum teres is fixed over itself with four to six stitches, forming a necktie Procedure concludes with diaphragmatic crus closure. RESULTS: N=15, post LSG BMI= kg/m2 After 6 months, 13 patients (86.6 %) successful in terms of resolution of GERD, (no PPI, LES>12 mmhg). 2 patients (13.3 %) continued PPI.

49 Hiatal Hernia + Retained fundus

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51 N=19 2 leaks (10.5%) 1 stenosis PPI stopped in all

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53 Stenosis

54 Dapri G, Cadière GB, Himpens J. Obes Surg 2009;19(4)

55 Wedge Resection

56 Wedge Resection for corkscrew deformity Vilallonga R, Himpens J, van de Vrande S. Obes Surg 2013;23(10)

57 1 st postoperative day

58 oooooooooooooooooooooo

59 Outcome of seromyotomy versus wedge resection

60 Number of patients treated 16 Gender (M/F) 8/8 Age (min max; mean) (years) 28 62; 41 BMI at treatment of stricture (kg/m2) 18 43; 31 (min max; mean) Cause for revision - Dysphagia: 16 - GERD: 8 - Cachexia: 1 - Eructations: 1 Vilallonga R, Himpens J, van de Vrande S. Obes Surg 2013;23(10) Kalaiselvan R, et al. SOARD 2015; 11(2):474-7 Location of the stenosis - Incisura angularis: 13 - Cardia/fundus: 2 - Body: 1 Procedure performed - Wedge Resection: 2 - SeroMyotomy (SM): 14 - Conversion SM to WR: 2 - Conversion SM to GBP: 3 Complications - None: 11 - Leak: 5 (all SM) (3 reop, 2 cons. management) Final outcomes (mean follow-up: 599 days) - No symptoms: 12 - Minimal GERD: 2 - Patients with recurrent stenosis (dysphagia): 2

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63 RYGB

64 Conversion Sleeve to RYGB Weiner RA, Theodoridou S, Weiner S. Obes Facts. 2011;4 Suppl 1-42 Hamdan K, Somers S, Chand M. Br J Surg Oct;98(10):

65 RYGB Considered by many as best option for postoperative GERD Abdemur A et al. SOARD 2012;8(5) Tutuian R. Gastroenterol Rep 2011;13(3) Cottam D et al. Surg Endosc 2006;20(6)

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67 Re-sleeve

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69 Multidetector computed tomography (MDCT) for sleeve patients with GERD Rengo M et al. Obes Surg Dec;23(12):

70 Author N Follow-up mean EWL mean Iannelli months 71.4% - Complications Dapri* 7 23 months 44% 1 leak (14.3%) Nedelcu months 58.5% - Nett 17 (DS) 37.2 months 47.2% 3 conversions 1 leak Vilallonga* 4 Wedge 811 days NA - Alsabah 24 1 year 57% - Iannelli A et al. Obes Surg 2011;21(7):832-5 Dapri G et al.* SOARD 2011;7(1):38-43 Nedelcu M et al. SOARD 2015;11(6): Vilallonga R et al.* Obes Surg 2013;23(10): Alsabah S et al. Obes Surg 2016;26(10): * Authors include presenter

71 WWWWWWWWW WWWWWWWWW WWWW

72 Re-sleeve procedure Dapri et al. SOARD 2016

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74 SLEEVE STENOSIS Endoscopy Seromyotomy Segment Resection Gastric Bypass

75 CONCLUSIONS -GERD prevention during LSG: no clear anatomic link no clear advantage to fix hiatal hernia -GERD treatment post LSG rule out intrathoracic migration; if present: hiatal hernia repair In case of stenosis: RYGB