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Gore Symposium (EMEA & Australia): Meet the Experts - Obesity and the Associated Diseases

Last year, Gore sponsored a live webinar symposium for EMEA and Australian surgeons which featured a panel of EMEA experts who discussed outpatient bariatric procedures, laparoscopic ventral hernia repair in conjunction with bariatric surgery and how to manage hiatal hernia defects during a sleeve gastrectomy procedure.* This discussion, based on the approved device indications for EMEA and Australia, presented education considerations for physicians in these regions.^

The expert panel was chaired by Dr. Salvador Morales-Conde, President-elect of the European Association of Endoscopic Surgeons and Chief of the Innovation Unit, Hospital Universitario Virgen del Rocío, Sevilla, Spain. Dr. Morales-Conde began the symposium by stating that from a surgeon’s standpoint it is crucial that they have the right material when performing laparoscopic reconstruction abdominal surgery (e.g., hernia repair) or when reinforcing the staple line (e.g., laparoscopic sleeve gastrectomy).

Material matters

Prior to the clinical presentations, Thomas Mithieux, W. L. Gore & Associates, outlined some of the key properties of the company’s products for staple line reinforcement (GORE® SEAMGUARD® Bioabsorbable Staple Line Reinforcement) and hiatal hernia reinforcement (GORE® BIO-A® Tissue Reinforcement). Both these devices are designed to support tissue regeneration and are comprised of a unique biosynthetic 3D web scaffold made of 67% polyglycolic acid (PGA) and 33% trimethylene carbonate (TMC). The highly interconnected pores facilitate tissue response over six to seven months during which time the material is constantly absorbed through hydrolysis.

“This combination of material and structure make our devices unique. As physicians, users and implanters of bioabsorbable synthetic devices, it is important you know the composition and structure of the device you will implant into your patients. Not all materials are the same, and therefore, may not have the same outcomes,” he explained.

Mithieux then showed scanning electron microscopes images of two buttressing materials clearly demonstrating the structural differences between the GORE® SEAMGUARD® Bioabsorbable Staple Line Reinforcement with fibres of around 26 μm in diameter and a device that is 100 percent PGA with fibres of around 9 μm in diameter. One study reported a device that is 100 percent PGA is more likely to have a faster degradation process leading to a higher inflammation in the early stages after implantation.‡

Mithieux added that the large, interconnected pore of the GORE® BIO-A® Tissue Reinforcement encourage the creation of the robust tissue layer, which is especially important in cases such as hiatal hernia that require rapid cell migration and vascularisation.

In summary, he said that the GORE® SEAMGUARD® Staple Line Reinforcement was launched in 1996 (made of PTFE) and then in 2003, the bioabsorbable version of GORE® SEAMGUARD® Staple Line Reinforcement was launched. Over four million devices have been implanted, and there are over 60 peer-reviewed papers published. For more than 10 years, over 105,000 hiatal configured Gore BIO-A Tissue Reinforcement devices were sold. Clinical literatures cites more than 1,000 hiatal hernia repairs performed using this device with no reports of erosion or infection (Data on file 2020, W. L. Gore & Associates, Inc; Flagstaff, AZ.)

Bariatric surgery as outpatient procedures

In the first presentation, Dr. Adriana Torcivia (general surgeon), Hôpital Pitié Salpêtrière, Paris, France, explained how her centre performs bariatric surgery as an outpatient (ambulatory or day care) procedure through their enhanced recovery after surgery (ERAS) programme. She cited a paper by Surve et al. (Surve A, Cottam D, Zaveri H, Cottam A, Belnap L, Richards C, Medlin W, Duncan T, Tuggle K, Zorak A, Umbach T, Apel M, Billing P, Billing J, Landerholm R, Stewart K, Kaufman J, Harris E, Williams M, Hart C, Johnson W, Lee C, Lee C, DeBarros J, Orris M, Schniederjan B, Neichoy B, Dhorepatil A, Cottam S, Horsley B. Does the future of laparoscopic sleeve gastrectomy lie in the outpatient surgery center? A retrospective study of the safety of 3162 outpatient sleeve gastrectomies. Surg Obes Relat Dis. 2018 Oct;14(10):1442-1447), that concluded outpatient laparoscopic sleeve gastrectomy centres are a viable option for patients with minimal surgical risks after they reported a short-term complications rate of 2.5 percent and a readmission rate of 0.6 percent from 3,162 patients who underwent primary laparoscopic sleeve gastrectomy procedure at outpatient surgery centres.

An additional study (Rebibo L, Dhahri A, Badaoui R, Dupont H, Regimbeau JM. Laparoscopic sleeve gastrectomy as day-case surgery (without overnight hospitalization). Surg Obes Relat Dis. 2015 Mar-Apr;11(2):335-42) reported high levels of patient satisfaction and post-operative similar to patient in conventional hospitalisation.

GORE® SEAMGUARD® Bioabsorbable Staple Line Reinforcement

And a further study found that ERAS protocol for laparoscopic sleeve gastrectomy results in shorter length of stay, without increase in peri-operative morbidity or readmission rates, and was cost-effective (Lam J, Suzuki T, Bernstein D, Zhao B, Maeda C, Pham T, Sandler BJ, Jacobsen GR, Cheverie JN, Horgan S. An ERAS protocol for bariatric surgery: Is it safe to discharge on post-operative day 1? Surg Endosc. 2019 Feb;33(2):580-586).

She reported that her hospital has a building, specifically designed, built and dedicated to ambulatory surgery. This is one of the most important factors in the success of the programme as this avoids unnecessary postponements or cancellations of surgery.

Dr. Torcivia and colleagues established their ambulatory programme in 2017 and follow the standard inclusion and exclusion criteria for bariatric surgery (BMI, age, well-motivated patients, psychosocial context, diabetes and smoking status, immunosuppression, etc.), adding that good patient selection is one of the most important factors for favourable outcomes. In the first 30 patients, they had two re-admissions for hyperglycaemia and hypertension, as a result they decided to exclude patients who were taking more than one medication for diabetes. Due to medical and psychological issues, as well as patient refusal, the centre currently has a recruitment figure of around 15 percent.

The first stage for a patient going through the programme is surgical consultation to assess the patient’s suitability and provide them with all the information they will need, i.e., details of the programme and the postoperative objectives. The second stage is a second evaluation with a medico-social assessment and a re-explanation of the programme, delivery of explanatory notices and an assessment of any post-hospitalisation needs, which she added underpins the patient’s trust in the centre. On the day of surgery, the patient undergoes an anaesthesia evaluation to prevent hypothermia, as well as morphine and corticosteroid therapy, antibiotic prophylaxis and thromboembolic prevention.

The minimally-invasive procedure is performed with as little aggression as possible and without drains, a nasogastric tube or a urinary catheter. To minimise the risk of post-operative leaks and bleeding, they utilise the GORE® SEAMGUARD® Bioabsorbable Staple Line Reinforcement that is supported by the medical literature (Gayrel X, Loureiro M, Skalli EM, Dutot C, Mercier G, Nocca D. Clinical and Economic Evaluation of Absorbable Staple Line Buttressing in Sleeve Gastrectomy in High-Risk Patients. Obes Surg. 2016 Aug;26(8):1710-6).

Post-surgery, the patient can have water and chewing gum to accelerate intestinal transit and is allowed to return to their room whether standing, sitting or lying down. They perform standard postoperative analgesia for pain with non-steroidal anti-inflammatory drugs. The patient is discharged if their pain is controlled, they can eat without nausea or vomiting, independent mobilisation, no signs of infection, stable hemodynamic parameters and little chance of hospitalisation and if they accept discharge. The patient is also given a symptoms list (fever, pain, tachycardia, etc.) and if they develop any they are told they must return to the hospital.

The nurse calls the patient on day one and they have access to a 24/7 hot line, a home nurse administers low-molecular-weight heparin, they have a biological assessment on day two and a surgical consultation appointment is planned after day three.

Dr. Torcivia explained that the success of the centre’s outpatient programme is a highly-focused multi-disciplinary team, standard protocols, good patient selection and prioritised re-admission.

“May we dare to propose a dogma in bariatric surgery?” she asked. “When possible, ERAS surgery should be the norm.”

Laparoscopic ventral hernia repair

Next, Dr. ssa Berta Rossana Berta (bariatric and metabolic surgeon), Nuova Santa Chiara University Hospital, Pisa, Italy, examined the role of laparoscopic ventral hernia repair in bariatric patients. She began by stating that incisional and primary ventral hernias are two of almost two-hundred comorbidities of obesity, with more than 60 percent of patients with ventral hernias presenting as overweight or obese, and ventral hernias are present in 8-10 percent of patients undergoing bariatric surgery. In addition, small bowel obstruction secondary to incarcerated ventral hernia can be a fatal complication immediately after bariatric surgery causing an anastomotic leak or further fatal complications after thirty days, she added.

GORE® SYNECOR Intraperitoneal Biomaterial

There is high risk of complication and recurrence in patients with obesity who have undergone ventral hernia repair and increased BMI is associated with operative, medical and respiratory complications after ventral hernia repair surgery (Owei L, Swendiman RA, Kelz RR, Dempsey DT, Dumon KR. Impact of body mass index on open ventral hernia repair: A retrospective review. Surgery. 2017 Dec;162(6):1320-1329 and Zavlin D, Jubbal KT, Van Eps JL, Bass BL, Ellsworth WA 4th, Echo A, Friedman JD, Dunkin BJ. Safety of open ventral hernia repair in high-risk patients with metabolic syndrome: a multi-institutional analysis of 39,118 cases. Surg Obes Relat Dis. 2018 Feb;14(2):206-213).

Dr. ssa Berta Rossana Berta
Dr. ssa Berta Rossana

“We know that patients with a BMI over 40 have twice the risk of complications after ventral hernia repair and the presence of metabolic syndrome – diabetes, hypertension, etc. – is related to unfavourable outcomes and increased mortality after ventral hernia repair, compared with patients with no metabolic syndrome,” Dr. ssa Berta explained. “Although weight loss can improve outcomes, to date, there is no consensus on the best timing and treatment option for this group of patients.”

Ventral hernia repair can be performed before, during and after bariatric surgery and a review of 11 papers reported that repair during bariatric surgery was feasible and safe for a small ventral hernia defect (Andrea Lazzati, Georges Bou Nassif, Luca Paolino. Concomitant Ventral Hernia Repair and Bariatric Surgery: a Systematic Review. Obes Surg. .2018 Sep;28(9):2949-2955. doi: 10.1007/s11695-018-3366-x). No significant differences were identified between primary repair and the use of synthetic or biologic mesh in terms of mortality and morbidity, although synthetic mesh resulted in lower recurrence and mesh infection rates.

In addition, a paper published in 2019 by Krivan (Krivan MS, Giorga A, Barreca M, Jain VK, Al-Taan OS. Concomitant ventral hernia repair and bariatric surgery: a retrospective analysis from a UK-based bariatric center. Surg Endosc. 2019 Mar;33(3):705-710), reported synchronous ventral hernia repair and bariatric surgery is feasible with low recurrence rate and the laparoscopic technique had lower complication rates verses open. In addition, Shabanzadeh et al., found that laparoscopic surgery reduced the surgical site infection rate by 70-80 percent (Shabanzadeh DM, Sørensen LT. Laparoscopic surgery compared with open surgery decreases surgical site infection in obese patients: a systematic review and meta-analysis. Annals of Surgery. 2012 Dec;256(6):934-945). However, Krivan and colleagues also reported that higher BMI and a ventral hernia larger than 5 cm have a greater incidence of recurrence and wound related complications. Dr. ssa Berta suggested that such patients might benefit from deferred ventral hernia repair.

The American Society for Metabolic and Bariatric Surgery and American Hernia Society have published a consensus guideline on bariatric surgery and hernia surgery (Menzo EL, Hinojosa M, Carbonell A, Krpata D, Carter J, Rogers AM. American Society for Metabolic and Bariatric Surgery and American Hernia Society consensus guideline on bariatric surgery and hernia surgery. Surg Obes Relat Dis. 2018 Sep;14(9):1221-1232) and reported that “…in patients with severe obesity and ventral hernia, and both being amenable to laparoscopic repair, combined hernia repair and bariatric surgery may be safe; however in these patients where laparoscopic repair is not amenable, a staged approach is recommended. Weight loss prior to hernia repair is likely to improve hernia repair outcomes.”

Dr. ssa Berta’s own centre confirmed these findings – better outcomes after bariatric surgery and hernia repair after weight loss (12 BMI points) when they analysed their own data (in press) from 149 patients.

Dr. ssa Berta’s and her colleagues follow a strict algorithm to treat patients who are undergoing bariatric surgery with ventral hernias. If patients present with a hernia defect larger than 4 cm and are asymptomatic they leave the hernia undisturbed and perform laparoscopic bariatric surgery. For symptomatic patients, they perform laparoscopic bariatric surgery and treat the hernia with direct sutures. Definitive treatment of hernias occurs after sufficient weight loss. If bariatric surgery is performed by an open approach, the hernia is repaired using GORE® BIO-A® Tissue Reinforcement. If the hernia is less than 4 cm and symptomatic, they will repair the hernia and then perform bariatric surgery. If the defect is asymptomatic it is repaired at the same time as bariatric surgery.

She said the latest guidelines from the International EndoHernia Society (Bittner R, Bain K, Bansal VK, Berrevoet F, Bingener-Casey J, Chen D, Chen J, Chowbey P, Dietz UA, de Beaux A, Ferzli G, Fortelny R, Hoffmann H, Iskander M, Ji Z, Jorgensen LN, Khullar R, Kirchhoff P, Köckerling F, Kukleta J, LeBlanc K, Li J, Lomanto D, Mayer F, Meytes V, Misra M, Morales-Conde S, Niebuhr H, Radvinsky D, Ramshaw B, Ranev D, Reinpold W, Sharma A, Schrittwieser R, Stechemesser B, Sutedja B, Tang J, Warren J, Weyhe D, Wiegering A, Woeste G, Yao Q. Update of Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS))-Part A. Surg Endosc. 2019 Oct;33(10):3069-3139) recommend that for patients with obesity presenting with a ventral or incisional hernia, the laparoscopic approach is preferred because it reduces the wound infection and wound complication rates. However, as the recurrence risk for obese patients is higher, there may be a need for additional technical steps (greater mesh fixation, more overlap, suture closure of the defect) when the laparoscopic approach is indicated.

Dr. ssa Berta recommended using permanent tacks to counter the impact of mesh migration, as well as using a wide overlap – 5 cm – and new studies suggest the diameter of the mesh should be four times the diameter of the defect (Tulloh B, de Beaux A. Defects and donuts: the importance of the mesh:defect area ratio. Hernia. 2016 Dec;20(6):893-895). Therefore, if a hernia defect is 7 cm, a mesh size of 28 cm is recommended.

“The best choice for patients with hernias of less than 5 cm in diameter seems to be laparoscopic repair using a wider overlapping permanent strong mesh, such as the GORE® SYNECOR Intraperitoneal Biomaterial that is up to five times stronger than polypropylene (data on file 2016; W.L. Gore & Associates, Inc; Flagstaff, AZ), has rapid integration and lower rates of infection,” she concluded. “The material is easy-to-use and you can see the abdominal wall and vessels through the material. I believe GORE® SYNECOR Intraperitoneal Biomaterial is the right material for our complicated patients.”

In a discussion following the two presentations, Dr. Torcivia said she preferred to perform an ambulatory gastric bypass rather than sleeve gastrectomy as the complication rates were lower and there is a higher risk of post-operative bleeding after a sleeve gastrectomy.

A question from the audience asked Dr. ssa Berta whether she changes the planned procedure (sleeve gastrectomy or gastric bypass) if the patient presents with a ventral hernia. Dr. ssa Berta replied that they do not change the planned procedure but in cases of large hernias they prefer to do sleeve gastrectomy and if the hernia is located in the upper abdomen. However, if they have a large hiatal hernia and the bowel is completely involved by adherence, they prefer to do an open gastric bypass, and following weight loss, repair the hernia. She added that concomitant surgeries should be performed by experienced bariatric surgeons adding no longer than 30-40 minutes to the total time of surgery. Dr. ssa Berta noted that the paper by Krivan et al., also showed diabetes to be an associated factor for post-operative infection, whereas open and laparoscopic procedures were not.

Regarding the size of the hernia defect, Dr. Morales-Conde asked Dr. ssa Berta why she changes her strategy above 4 cm. She replied that at 4 cm, they are able to close the defect more effectively with a mesh four times greater than the defect size, but it also depends on other factors such as the height and abdominal waist size of the patient. So, for smaller defects hernia repair can be carried out safely at the same time as bariatric surgery, but for larger hernias her team prefers to wait until after bariatric surgery (weight loss). Larger hernias also add more time to the overall procedure time, she added, so it is safer to separate the two procedures.

The next question from the audience asked Dr. Torcivia if she carries out a barium swallow to assess any leaks or issues with the gastric pouch, anastomosis or bowel configuration. She replied that they do not, but prefer to detect early complications through symptoms such as fever, pain and tachycardia. Dr. Morales-Conde agreed that the literature shows little benefit for carrying out a barium swallow test. The final question from the audience asked Dr. Torcivia what percentage of ambulatory cases are bariatric procedures and what the sleeve gastrectomy versus gastric bypass split was. She replied bariatric surgery accounts for approximately 15 percent of all ambulatory procedures and they perform more sleeve gastrectomies than gastric bypass procedures, primarily due to medical complications in gastric bypass patients such as chronic diabetes as they will be taking more than one medication for this condition.

Hiatal hernia defect during sleeve gastrectomy procedure

In the final session, Dr. Ricardo Zorron (bariatric and metabolic surgeon), Ernst von Bergmann Klinikum Potsdam, Germany, and Dr. Andrea Peri (bariatric and metabolic surgeon), IRCCS Policlinico San Matteo, Pavia, Italy, evaluated whether a surgeon should always look for a hiatal hernia defect during sleeve gastrectomy procedure.

Dr. Zorron explained that sleeve gastrectomy procedures at his centre account for 15 percent of the total number of bariatric procedures. He noted that they have a high percentage of patients who have BMI over 50, so sleeve gastrectomy is often used as a two-stage procedure (Mahdy T, Emile SH, Madyan A, Schou C, Alwahidi A, Ribeiro R, Sewefy A, Büsing M, Al-Haifi M, Salih E, Shikora S. Evaluation of the Efficacy of Single Anastomosis Sleeve Ileal (SASI) Bypass for Patients with Morbid Obesity: a Multicenter Study. Obes Surg. 2020 Mar;30(3):837-845), although gastroesophageal reflux disease (GERD) is a contra-indication for sleeve gastrectomy in his centre.

GORE® BIO-A® Tissue Reinforcement
GORE® BIO-A® Tissue Reinforcement

This is because of a 5-10 percent conversion rate to gastric bypass due to reflux post-sleeve gastrectomy and his centre has reported up 30 percent de novo reflux after sleeve gastrectomy, as well as GERD and Barrett’s oesophagus, compared with 10 percent after gastric bypass (SM-BOSS Trial. Peterli et al. JAMA 2018, SLEEVEPASS Trial. Salminen P JAMA 2018, Systematic Review, Sebastianelli et al. Obes Surg 2019 and Genco A. SOARD 2017). For this reason, Dr. Zorron said, pre-operative endoscopy is mandatory in any candidate for bariatric surgery, symptomatic or asymptomatic.

He cited a study by Antonio Iannelli that reported five years after sleeve gastrectomy the rate of Barrett’s Oesophagus was 19 percent (Sebastianelli L, Benois M, Vanbiervliet G, Bailly L, Robert M, Turrin N, Gizard E, Foletto M, Bisello M, Albanese A, Santonicola A, Iovino P, Piche T, Angrisani L, Turchi L, Schiavo L, Iannelli A. Systematic Endoscopy 5 Years After Sleeve Gastrectomy Results in a High Rate of Barrett's Esophagus: Results of a Multicenter Study. Obes Surg. 2019 May;29(5):1462-1469) and suggested systematic endoscopy in these patients to rule out this condition.

A study from the Strasbourg group (Quero G, Fiorillo C, Dallemagne B, Mascagni P, Curcic J, Fox M, Perretta S. The Causes of Gastroesophageal Reflux after Laparoscopic Sleeve Gastrectomy: Quantitative Assessment of the Structure and Function of the Esophagogastric Junction by Magnetic Resonance Imaging and High-Resolution Manometry. Obes Surg. 2020 Jun;30(6):2108-2117) reported that destroying the anatomy from the cardia, the angle of His is eliminated – a primary reason for reflux after a sleeve gastrectomy and possibly hiatal hernia due to increased abdominal pressure. Dr. Zorron said he prefers to close hiatal hernias either with bioabsorbable sutures or for larger defects with the GORE® BIO-A® Tissue Reinforcement.

He explained he uses an anterior fundoplication type Dor technique to avoid postoperative reflux and said it is a feasible alternative for patients with symptomatic GERD (Del Genio G, Tolone S, Gambardella C, Brusciano L, Volpe ML, Gualtieri G, Del Genio F, Docimo L. Sleeve Gastrectomy and Anterior Fundoplication (D-SLEEVE) Prevents Gastroesophageal Reflux in Symptomatic GERD. Obes Surg. 2020 May;30(5):1642-1652. doi: 10.1007/s11695-020-04427-1. Erratum in: Obes Surg. 2021 Feb 4). However, Nissen sleeve gastrectomy for reoperation has been reported in the literature to have a 6.4 percent leak rate (Olmi S, Uccelli M, Cesana GC, Ciccarese F, Oldani A, Giorgi R, De Carli SM, Villa R. Modified laparoscopic sleeve gastrectomy with Rossetti antireflux fundoplication: results after 220 procedures with 24-month follow-up. Surg Obes Relat Dis. 2020 Sep;16(9):1202-1211. doi: 10.1016/j.soard.2020.03.029) Another option is to perform a fundoplication with the APOLLO OVERSTITCH Endoscopic Suturing System (Apollo Endosurgery), after a sleeve gastrectomy, but this procedure is still under evaluation, he cautioned.

“To answer the question, ‘should a surgeon always look for a hiatal hernia defect during sleeve gastrectomy procedure?’ In selected patients, it is an option to explore the left crus which is needed to do a perfect sleeve gastrectomy and the disadvantages of routine exploration is destroying the anatomy and eliminating the natural anti-reflux mechanisms and we are endangering the vascular supply increasing the likelihood of sleeve migration,” he concluded. “There is no evidence that treating small hernias is beneficial for patients losing a substantial amount of weight. Exploring the left crus in selected patients is my preferred option.”

In response, Dr. Peri explained his centre performs 70 percent sleeve gastrectomies and does not believe surgeons should routinely look for a hiatal hernia defect during sleeve gastrectomy procedure because performing such an exploration damages the anatomical structures that help maintain oesophageal gastric junction. Years ago, his team were more aggressive towards the left pillar of the diaphragm but now they like to examine the left pillar but are careful not to disrupt the structures. He agreed with Dr. Zorron that patients with symptomatic reflux or asymptomatic patients but with oesophagitis GERD classification using Los Angeles grading scale, more than B should not have a sleeve gastrectomy.

“But, if in surgery you explore the hiatus and there is a well visible or macroscopic hiatal hernia, that was not detected in pre-operative endoscopy, then we fix the problem and then we perform a sleeve gastrectomy,” he added.

He described the case of a young woman who had a sleeve gastrectomy and presented with complete dysphagia and they found that the upper part of the sleeve gastrectomy was integrated into the chest and the migrated sleeve gastrectomy was causing the dysphagia. He explained that sometimes if a surgeon isolates the hiatus it can lead to further unwarranted complications.

For re-do surgery, he emphasised the importance of always exploring the hiatus especially after adjustable gastric banding. Sleeve gastrectomy is a very popular re-do procedure for failed gastric band patients, although he and his team prefer to do a gastric bypass or one anastomosis gastric bypass, as the leak rate increases four to five times with a sleeve gastrectomy. If the hiatus is not explored, there is a risk of leaving the oesophageal gastric junction in the chest, resulting in severe reflux and improper sleeve gastrectomy.

He then presented three cases, the first was an incidental finding of a hiatal hernia, in such cases (even in primary surgery) they explore the hiatus and fix the hernia, and if the pillars are quite robust his team does not place a mesh, they then perform a sleeve gastrectomy. In the second case, the patient had a gastric band removed and they explored the hiatus and pulled down the oesophageal gastric junction and the angle of HIS and recreated a clean anatomy ready for a sleeve gastrectomy or gastric bypass revision procedure. The third case was the female who presented with complete dysphagia and the migration of the sleeve gastrectomy to the upper part of the chest. In this case, in order to reduce the risk of a new migration, they preferred to reinforce the hiatus with a GORE® BIO-A® Tissue Reinforcement.

“In Italy, the fundoplication type Dor technique is not used, but I had a good impression. So maybe in some cases when I am forced to perform a sleeve gastrectomy I will try the fundoplication type Dor technique in patients with moderate reflux disease. I prefer this to the Nissen sleeve, as the Dor procedure leaves a larger fundus and increased leak rate in many reports,” he concluded.

In the discussion, Dr. Morales-Conde reminded the audience that there are some situations where a sleeve gastrectomy is indicated over a gastric bypass, even if the patient has a hiatal hernia, such as chronic medication, inflammatory disease, etc., and he asked the panel what exploratory mechanisms they would undertake. Dr. Zorron commented that it was only important if the patient has a long history of reflux, as it is not only a co-morbidity of obesity. He said he would perform a manometry and a pH test, but would prefer to do a gastric bypass and explain to the patient the risks of Barrett’s and oesophagus carcinoma. He added that in patients with super-super obesity, after a sleeve gastrectomy, the second operation is a single anastomosis duodenoileal bypass. If the patient has reflux and has a sleeve gastrectomy which is not covered by the Dor technique, the second operation will be a gastric bypass, but a gastric bypass is less effective in this group of patients regarding weight loss.

Dr. Peri said manometry and a pH test could be useful but in his setting it would be difficult, adding that his centre’s policy is clear, they do not perform a sleeve gastrectomy on patients with a clear history of GERD. If the patient has no symptoms but has oesophagitis more than B, again, a sleeve gastrectomy is not performed. If a patient is more than BMI 50 with severe diabetes and reflux, they perform a one anastomosis gastric bypass (OAGB).

Dr. Morales-Conde asked in which instances they use a mesh to reinforce the repair of the hiatal hernia. Dr. Peri said he uses an absorbable reinforcement when he feels tension during the closure of the pillars or when the pillars are very thin, very little muscular tissue. Dr. Zorron agreed and said in instances of fragile tissue the GORE® BIO-A® Tissue Reinforcement is indicated.

The panel then discussed leaks rates between Nissen and the Dor procedures and Dr. Zorron explained that the leak rates will be similar as the tissue is de-vascularised and therefore a surgeon cannot assess whether the tissue will be viable or not. He added that if he were performing a Nissen sleeve he would use indocyanine green (ICG) to assess the gastric blood flow and to look for signs of ischaemia, particularly at the site of the anastomosis.

Dr. Salvador Morales-Conde suggested that to avoid cases of sleeve migration (as shown in the case study by Dr. Peri), a surgeon could perform the ‘Hill technique’ where the preaortic fascia is dissected at the root of the crura and sutures are placed approximating the gastroesophageal junction to the aforementioned fascia. Dr. Zorron commented that this in his experience the ‘Hill technique’ did not provide sufficient anti-reflux effects.

On March 30 2022, W. L. Gore & Associates will host the Gore Expert Obesity Meeting (GEOM) 2022 Virtual Symposium (2.00-4.00 CET). To see the programme and to register for this virtual international symposium, please click here

* W. L. Gore & Associates (Gore) was the financial sponsor of this educational information, and presenters have been compensated for their time. The material was independently developed by presenters, and does not include recommendations from Gore. ^ Note the use of GORE® BIO-A® Tissue Reinforcement for reinforcement of hiatal hernia defects during a sleeve gastrectomy procedure is not within the approved indications in the U.S. Refer to the applicable country specific Instructions for Use at for all indications, contraindications, warnings and precautions. Comparison of two buttressing materials for gastric sleeve resection – clinical outcome and complications, Maria Bergstrom, M.D., Ph.D., Jorge A Arroyo Vàzquez, M.D., Per-Ola Park, Professor. South Alvsborg Hospital)

Refer to Instructions for Use at for a complete description of all applicable indications, warnings, precautions and contraindications for the markets where this product is available.

Products listed may not be available in all markets.

APOLLO and OVERSTITCH are trademarks of Apollo Endosurgery.

GORE, BIO-A, SEAMGUARD, SYNECOR and designs are trademarks of W. L. Gore & Associates.

© 2021 W. L. Gore & Associates, Inc. 2156032-EN JULY 2021


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