Given the history of significant reflux that prompted a Nissen fundoplication, conversion to a sleeve gastrectomy for morbid obesity would be a bad option.  The sleeve is a very high pressure system with a relative obstructing point at the incisura and reflux would potentially worsen.  Your best option is usually a complete takedown of the fundoplication, repair of hiatal hernia which is almost certainly there, and conversion to a roux-en-Y gastric bypass.

Thanks Dear Schuster, Yes, best option for bariatric surgery in patient with Nissen fundoplication is gastric bypass. But I read a case report. In this report surgeons performed sleeve gastrectomy and hernia repair, at follow up they didn't see any reflux symptoms. Does anybody have any experience about this situation?

I have done this many times.  It works well for mild and/or intermittent reflux.  In patients with severe, PPI-resistant daily reflux symptoms, I would still only offer gastric bypass.  If you convert a Nissen to sleeve, make sure you completely take down the fundoplication to ensure proper removal of ALL of the fundus.

Thanks dear Schuster for answering and sharing your experiences

With a large experience of sleeve gastrectomy I would say dont perform sleeve after nissen procedure. It can be done for I performed it but you'll not get the same quality of the technique and leave a too large part of stomach. I took in charge a transfert for fistula after sleeve on nissen : in this case the gastric section was across the valve explaining the fistula. So a patient with nissen procedure will be treated by by-pass.

In some way, I have to agree with both previous answers by Dr. Schuster and Dr. Verhaeghe: the most recommended operation in such scenario would be to reoperate the patient and convert his surgery to a gastric bypass.

However, I have converted some Nissen fundoplications to a sleeve gastrectomy (at least 3 patients) and I have found not an increase in GERD symptoms. My decision was based in the fact that those patients were already obese (BMI>33) when they got their Nissen operation and the indication for it was persistent heartburn only during the day and not because of nigh-time symptoms.

Therefore, I recommend you to deeply investigate the preoperative GERD symptoms of your patient before the Nissen, particularly the 24-hour symptoms pattern, as well as other GI functional disorders, and make your decision based on those findings. Also, please talk to your patient through these controversies and let him be part of the decision making process.

Best of luck to you and all the readers!  

I performed sleeve gastrectomy for this patient because patient refused gastric by pass. (most performed operation for obesity is sleeve gastrectomy in our country, so most of patients choose this operation). At postoperative 25 day, patient has no GERD symptoms. Thanks for all answers