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. 2021 Jan 25;33(4):e1553.
doi: 10.1590/0102-672020200004e1553. eCollection 2021.

WHEN SHOULD BE CONVERTED LAPAROSCOPIC SLEEVE GASTRECTOMY TO LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS DUE TO GASTROESOPHAGEAL REFLUX?

[Article in English, Portuguese]
Italo Braghetto  1 , Owen Korn  1 , Anamaría Burgos  1 , Manuel Figueroa  1
Affiliations

WHEN SHOULD BE CONVERTED LAPAROSCOPIC SLEEVE GASTRECTOMY TO LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS DUE TO GASTROESOPHAGEAL REFLUX?

[Article in English, Portuguese]
Italo Braghetto et al. Arq Bras Cir Dig. .

Abstract
in English, Portuguese

Background: Gastroesophageal reflux (GER) is one of the most common indications for conversion of sleeve gastrectomy (LSG) to laparoscopic Roux-en-Y gastric bypass (LRYGBP). Objective evaluations are necessary in order to choose the best definitive treatment for these patients.

Aim: To present and describe the findings of the objective studies for gastroesophageal reflux disease performed before LSG conversion to LRYGBP in order to support the indication for surgery.

Method: Thirty-nine non-responder patients to proton pump inhibitors treatment after LSG were included in this prospective study. They did not present GER symptoms, esophagitis or hiatal hernia before LSG. Endoscopy, radiology, manometry, 24 h pH monitoring were performed.

Results: The mean time of appearance of reflux symptoms was 26.8+24.08 months (8-71). Erosive esophagitis was found in 33/39 symptomatic patients (84.6%) and Barrett´s esophagus in five. (12.8%). Manometry and acid reflux test were performed in 38/39 patients. Defective lower esophageal sphincter function was observed independent the grade of esophagitis or Barrett´s esophagus. Pathologic acid reflux with elevated DeMeester´s scores and % of time pH<4 was detected in all these patients. more significant in those with severe esophagitis and Barrett´s esophagus. Radiologic sleeve abnormalities were observed in 35 patients, mainly cardia dilatation (n=18) and hiatal hernia (n=11). Middle gastric stricture was observed in only six patients.

Conclusion: Patients with reflux symptoms and esophagitis or Barrett´s esophagus after SG present defective lower esophageal sphincter function and increased acid reflux. These conditions support the indication of conversion to LRYGBP.

O refluxo gastroesofágico é uma das indicações mais comuns para a conversão da gastrectomia vertical (SG) em gastroplastia laparoscópica em Y-de-Roux (LRYGBP). Avaliações objetivas são necessárias para escolher o melhor tratamento definitivo para esses pacientes.

Apresentar e descrever os achados objetivos da doença do refluxo gastroesofágico realizados antes da conversão do SG para o LRYGBP, a fim de apoiar a indicação cirúrgica.

Trinta e nove pacientes não respondedores ao tratamento com inibidores da bomba de prótons após SG foram incluídos neste estudo prospectivo. Eles não apresentavam sintomas de refluxo gastroesofágico, esofagite ou hérnia hiatal antes da SG. Endoscopia, radiologia, manometria, monitoramento de pH 24 horas foram realizados.

O tempo médio de aparecimento dos sintomas de refluxo foi de 26,8+24,08 meses (8-71). Esofagite erosiva foi encontrada em 33/39 pacientes sintomáticos (84,6%) e esôfago de Barrett em cinco (12,8%). A manometria e o teste de refluxo ácido foram realizados em 38/39 pacientes. A função alterada do esfíncter inferior do esôfago foi observada independentemente do grau de esofagite ou esôfago de Barrett. Em todos esses pacientes, foi detectado refluxo ácido patológico com escores elevados de DeMeester e % de tempo pH<4, mais significativo nos com esofagite grave e esôfago de Barrett. Anormalidades radiológicas SG foram observadas em 35 pacientes, principalmente dilatação da cárdia (n=18) e hérnia hiatal (n=11). Estenose gástrica foi observada em apenas seis pacientes.

Pacientes com sintomas de refluxo e esofagite ou esôfago de Barrett após SG apresentam função do esfíncter esofágico inferior defeituosa e aumento do refluxo ácido. Esses sintomas e estudos objetivos apoiam a indicação de conversão para LRYGBP.

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Conflict of interest statement

Conflict of interest: none

Figures

FIGURE 1
FIGURE 1. Patients and work-up before and after SG pre conversion to LRYGBP
FIGURE 2
FIGURE 2. Endoscopic evaluation: A) esophagitis grade B after sleeve gastrectomy with small hiatal hernia; B) paraesophageal hiatal hernia, “U turn”; C) mesogastric stricture before conversion to LRYGBP
FIGURE 3
FIGURE 3. Radiologic confirmation of hiatal hernia post-sleeve gastrectomy: A) hiatal hernia with intramediastinal fundus; B) hiatal hernia with mesogastric stricture; C) dilated cardia with residual fundus
FIGURE 4
FIGURE 4. Intraoperative confirmation of hiatal hernia after sleeve gastrectomy, showing: A) dilated hiatus; B) anterior gastric fundus dissection; C) intramediastinal gastric fundus dissection; D) gastric fundus pulled down after intramediastinal dissection; E) posterior view of herniated gastric fundus; F) hiatal hernia with intramediastinal gastric fundus
See this image and copyright information in PMC

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