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Hernias and LSG

Hiatal hernias must be closed in most sleeve gastrectomies

Stapling closer to LES improves reflux after sleeve
Increased bougie size leads to reduction in leakage rates
Additional data needed to support sleeve + band/ring
Dr Michel Gagner

Surgeons must find and close most hiatal hernias during sleeve gastrectomy operations to prevent gastro-oesophageal reflux disease (GERD), claims Professor Michel Gagner, clinical professor of surgery, Herbert Wertheim College of Medicine, Florida International University.

During a presentation at the Minimally Invasive Surgery Symposium, in Las Vegas, Nevada, Gagner said the weight of evidence for treating hiatal hernias was confirmed with the publication of a consensus statement from the International Sleeve Gastrectomy Expert Panel, more than 70% of whom agreed that it was essential to identify and treat hiatal hernias when performing a sleeve procedure.

More recently, Soricelli et al confirmed the benefits of treating hiatal hernia when they reported that GERD symptoms appeared for the first time in 22.9% of the patients undergoing sleeve alone, compared with 0% of patients undergoing sleeve and hiatal hernia repair. The paper concluded that “providing good management of GERD in obese patients with reflux symptoms…a careful examination of the crura is always recommended intraoperatively.”

Gagner began his presentation by highlighting a systematic review on the effect of sleeve gastrectomy on GERD which reported differing outcomes. Four of the 15 studies reported an increase in symptoms after a sleeve, while seven showed a reduction.

He then cited a study by Braghetto et al that showed important pressure changes occur at the lower oesophageal sphincter following sleeve gastrectomy procedures. Crucially, this study also highlighted that stapling away from the sling fibres (1-2 cm from the GE junction) during the gastrectomy can lead to the appearance of reflux symptoms and oesophagitis post-procedure.

He said that Carter el al also reported that sleeve gastrectomy correlated with the persistence of GERD symptoms in patients with pre-operative symptoms. Patients who did not have pre-operative GERD also had an increased risk of postoperative GERD symptoms.

Furthermore, Peterson et al demonstrated that laparoscopic sleeve gastrectomy significantly increased lower oesophageal pressure independent of weight loss, and suggested that a sleeve gastrectomy may protect obese patients from GERD.

Gagner added that one future addition to a surgeon’s armamentarium to treat GERD after sleeve gastrectomy is the Linx reflux management system, which at four years has shown that 100% (23/23) of the patients had improved quality of life measures for GERD and 80% (20/25 were no longer using proton pump inhibitors to alleviate their reflux.

Bougie size

During his presentation, Gagner also addressed the importance of using a larger bougie when creating the sleeve, in order to reduce leakage rates, and called for additional data to support procedures using both a sleeve and a band or ring.

Most recently, Parikh et al. reported in their systematic review, which involved 112 studies and 9,991 sleeve patients, that the risk of leakage decreased with bougie sizes equal or over 40 Fr (p=0.0009) with no difference in excess weight loss between bougies under 40 Fr and over 40 Fr up to 36 months (p=0.273).

They also noted that the distance from the pylorus does not impact leak or weight loss and buttressing does not seem to impact leak.

With regards to using a band or ring during a sleeve gastrectomy, Gagner said that although there is little longterm evidence to support the procedure in gastric bypass, the evidence is limited by few published cases, too-short follow up, and some experience of band erosion and migration.

He also commented on a study by Merchant et al. that reported para-oesophageal hernia repair with a sleeve gastrectomy reduces the recurrence of hernias and GERD compared with just repairing the hernia, and is a useful alternative to fundoplication or gastropexy when treating obese patients with complex para-oesophageal hernias.

Conclusion

“Incompetent lower oesophageal sphincter with Barret’s is the only known contraindication for sleeve,” concluded Gagner. “However, If the patient has a competent lower oesophageal sphincter, GERD is often improved after sleeve.”

He emphasised that if a hiatal hernia is present it should be repaired simultaneously, although if GERD persists beyond 12 months then a second stage Roux-en­Y gastric bypass should be considered.

Gagner added that the data for fundoplication and sleeve is non-existent in the literature, and cannot be recommended, although he added that Linx is promising and he hoped that present contraindications will be lifted in the near future.

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