36 year old male underwent Laparoscopic sleeve gastrectomy 2 year ago and his BMI was 43.4. After the surgery his BMI was 36.2 . He is Diabetic but insulin requirement did not come down significantly . For 2 years he was maintained his weight loss , but now he regained about 20 kgs. His main complaint is severe disabling GERD affecting his lifestyle .
Would you share more details about the case, please? What kind of the oesophageal lesions was found? What is the lower oesophageal sphincter pressure? How much is the Hiss angle? Condition of the gastric juice output? Any gastritis? Any hiatal hernia? Have any medical therapy been prescribed?
Anyway, I believe that a gastric bypass procedure will make things even worse than before, IMHO.
Thank you very much . Upper G.I Endoscopy done elsewhere did not showed any significant abnormality except antral gastritis ( Patient has been on PPIs) . I requested manometry , 24pH , and CECT to assess the fundus and size of the stomach .
Could you please expand IMHO ?
A gastric bypass might make things worse but in a majority of cases it will make things better because off the weight control. I would have an open discussion with the patient about this and suggest a conversion with all known problems.
PS IMHO In my honnest opinion?
Thank you for the answer, Dr.Reddy,
If the pH of the body of the stomahc is 2-4 - in case I understand correctly - I would suggest Omeprazol - 20 mg twice a day during 1 month and DeNol for the same period. The patient should be tested for Hp gastritis as well. I believe that there is most probability of success, and there is not any risk.
However, if there no improvement has achieved, I would recommend to think about the Billroth-1 procedure with or without Scopinaro's bilio-pancreatic diversion. The latter way is rather risky, IMHO.
Still, the examination of the patient is not complete...
If PPIs do not resolve his symptoms, then you are left with 2 non-medical options. One is Stretta (see literature from Duke on this) or RYGB. As long as you do a small pouch, the gastric cardia does not have parietal cells in it and does not secrete acid. Be sure to reduce any hiatal hernia during the RYGB. FYI, RYGB is the preferred procedure for MO patients that have a hx of reflux, not a sleeve.
I am agreed with Dr.Scheeres that a sleeve gastrectomy may provoke the GERD to occur. I must confess, however, that I did not understand a good half of the abbreviations from his post.
The gastric fundus (or fornix) filled with gas (believed by some to be CO2) forms the acute angle of Hiss of the cardiac notch (along with the Willis's loop of the innermost muscle fibers of the stomach, or so called 'sling fibers' otherwise) which is one of the normal occlusive mechanisms of the lower oesophageal sphincter preventing from the gastro-oesophageal reflux.
So that the sleeve gastrectomy will reduce both the fundus and this occlusive mechanism as well. Sometimes, the sling fibers might be damaged also during this procedure. On the other hand, I did not meet any reports about either frequency or severety of the GERD development after the procedure.
The Roux-en-Y gastric bypass solves gastroesophageal reflux. I just do cruroplastia if the hiatal hernia is bigger than 5 cm
By far the most effective option for this patient would be conversion to a roux-en-Y gastric bypass. My group has extensive experience (100+ patients) with this conversion with greater than 85% GERD resolution and nearly 100% improvement in GERD symptoms.
The Roux-en-Y gastric bypass is the better option actually, no doubt, but in some patients with sleeve gastrectomy, worsening of reflux is due to overfeeding, dietary care
I would go for a conversion of sleeve to RYGB. Relatively simple to perform as the vertical component of pouch is already done and it only needs one horizontal firing of the stapler to complete the pouch.
I believe it would effectively address all of this patient's problems - Weight gain, Diabetes and Reflux.
Obviously, strong dietary counselling is required, because there is always a chance that he could regain weight a few years after RYGB just as he did after a sleeve, if he does not adopt strict dietary discipline.
No doubt that in this cae the sleeve must be converted to RYGB ..it will resolve the GERD symptomes and must probabily her fiabetic will be much better. ..but i doubt id she will have wait loss ....
Is there any role for STRETTA Procedure or any other nonsurgical procedure .
Conversion to RYGB in combination with ICG vascular monitoring to make sure that there is no vascularisation issue.
No Linx, no Stretta, no HH repair.... straight to RYGB. It’s an anti-reflux and anti-diabetes procedure. Patients wake up in recovery room feeling better. Surgeons only offering sleeves and bands are not ‘Bariatric‘ surgeons
We solve the GERD in a much easier way, nothing aggressive: cardiogastropexy with the round ligament according to the technique of our school (NARBONA). Technique performed in Valencia, Alcoy, Madrid, Mexico, etc. in Sleeve Gastrectomy, without the need of a BAGUA, SADI, RYGB... The STRETTA what it gets is to increase the pressure of the SLE in an artificial way but without tensing the sphincter physiologically. This can only be achieved by lowering the esophagus-cardias 5-6 cm below the diaphragm, in order to recover the tone of the SLE. This is exactly what gardiogastropexy with the round ligament, NARBONA (open surgery), or CUSCHIERI-NARBONA, does by laparoscopy.
I am sending you a video of Prof. Carda (Madrid) practicing the CUSCHIERI-NARBONA technique. It is as simple as it is almost unknown nowadays, and it avoids the aggressiveness and risks of the other techniques.
They must add the closing of pillars if necessary, from the back or from the front (COLLIS).
http://www.pablopriego.com/gastrectomia-vertical-laparoscopica-con-tecnica-antirreflujo-de-narbona-asociada/
Dear Dr. Reddy, this is an excellent discussion you have initiated. Since your patient has both severe reflux and non-resolving diabetes, obviously conversion to bypass will solve both problems. I have to agree with Dr. Schuster. Even though Dr. Davila describes an excellent and simple technique to resolve the reflux, it will not resolve the diabetes.
May I ask what you did for him eventually?
In our experience, the sleeve gastrectomy cures diabetes in more than 60% of cases. In the remainder, the response to non-insulin treatment of diabetes has been significantly simpler and more comfortable for the patient. In 2 cases with persistent diabetes and inadequate weight loss, the bypass technique was added with a single jejunal anastomosis: in the first patient, an anthro-jejunostomy (BAGUA), and in the second patient, duodenal section with post-pyloric duodeno-jejunal anastomosis (SADI).
Simpler solutions than Bypass Roux-Y or duodenal switch. With excellent clinical evolution over 6 years.
Not all bypasses or duodenal switch cures all diabetics... They are techniques that we no longer use, which are much more complex and with some complicated and more complex post-operative follow-ups.
We seek, as in all surgery, the least aggressive techniques with the greatest efficiency.
Remember that the LES is not a pressure sphincter (like the anus), but only a response to traction.Therefore, the good anti-reflux response with the simple traction exercised by the round ligament as I indicated.
Conversion to RYGB most likely best particularly if patient remains overweight or has diabetes. It will be interesting to see the long term results of newer alternatives for GERD eg linx and stretta in these sub-groups
Sadi procedure is not my choice in this instance because it might ad bile reflux to the equation.
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