Combined partial posterior fundoplication with laparoscopic sleeve gastrectomy for morbid obese patients with symptomatic GERD. Video case report
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Abstract:
Gastroesophageal reflux disease (GERD), which can be seen in up to 30% in postoperative series, is perhaps the most important complication of sleeve gastrectomy(SG). The general trend for patients who are planning to have bariatric surgery and have symptomatic GERD, Roux-en-Y gastric bypass is the most common choice. A 42-year-old female patient with a body mass index of 36 kg/m2 presented to our clinic with obesity and symptomatic GERD. She had been using proton pump inhibitör (PPI) regularly for 1 year. Preoperative endoscopy showed hiatal hernia but no esophagitis. The patient underwent ambulatory pH study and GERD was confirmed. The patient was scheduled to have laparoscopic hiatal hernia repair plus combined partial posterior fundoplication and sleeve gastrectomy. Hiatal hernia was repaired, gastric fundus was passed behind the esophagus and partial posterior fundoplication was performed, and than SG was completed. She stopped using PPI in the early postoperative period and her reflux symptoms disappeared completely. The patient lost 20 kg in the 3rd month (%40 ewl) and underwent controlled ambulatory pH moniterization and no reflux was detected. İn some cases this technique can be proposed to obese patients with GERD as a primary treatment modality. High numbers of patients and longer follow up care are needed to assess the long term efficacy and safety of this technique.Keywords:
Hiatal Hernia
Sleeve gastrectomy
Esophagitis
Abstract Gastroesophageal reflux disease (GERD), a prevalent problem among obese individuals, is strongly associated with obesity and weight loss. Hence, bariatric surgery effectively improves GERD for many patients. Depending on the type of bariatric procedure, however, surgery can also worsen or even cause a new onset of GERD. As a consequence, GERD remains a relevant problem for many bariatric patients, and especially those who have undergone sleeve gastrectomy (SG). Affected patients report not only a decrease in physical functioning but also suffer from mental and emotional problems, resulting in poorer social functioning. The pathomechanism of GERD after SG is most likely multifactorial and triggered by the interaction of anatomical, physiological, and physical factors. Contributing factors include the shape of the sleeve, the extent of injury to the lower esophageal sphincter, and the presence of hiatal hernia. In order to successfully treat post‐sleeve gastrectomy GERD, the cause of the problem must first be identified. Therapeutic approaches include lifestyle changes, medication, interventional treatment, and/or revisional surgery.
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Belching disorder (BD) is clinically distinct from gastroesophageal reflux disease (GERD) with belching. Supragastric belching (SGB) is closely associated with reflux episodes. This study investigates belch characteristics in association with reflux, compared between patients with BD and those who had GERD with belching.Impedance pH monitoring data from 10 patients with BD and 10 patients with GERD who exhibited belching were retrospectively analyzed. Belches were considered "isolated" or "reflux-related" and acidic/non-acidic. Belch characteristics were compared between patients with BD and those with GERD.Symptomatic belches were more frequent in patients with BD than in patients with GERD (median, 160.5 vs 56.0, P < 0.05). SGB was the most common type in both groups; common subtypes comprised "isolated" in patients with BD and "isolated during the reflux period" in patients with GERD. Reflux-related SGB was more common in patients with GERD than in BD (78.3% vs 45.2%, P < 0.005). Both "preceding belching" including the reflux period and acidic SGB were more common in patients with GERD than in BD (31.8% vs 8.6% and 38.1% vs 8.9%, both P < 0.05). Supragastric belch number positively correlated with all reflux episodes in patients with GERD (adjusted R2 = 0.572, P = 0.007).BD is characterized by more belching, compared to GERD. SGB is more frequently associated with reflux in GERD than in BD; acidity may be related to GERD. In BD, SGB is typically non-acidic and unrelated to reflux. Distinct SGB characteristics may reflect different pathogenic mechanisms of reflux and associated symptoms.
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Obesity is one of the most important health problems in developed and developing countries. Morbid obesity is defined as having a body mass index (BMI) of more than 40 kg/m2. Obesity does not only predispose to gastroesophageal reflux, but is also an important independent risk factor for the development of hiatal hernia (HH). There are articles advocating about half of obese patients have a hiatal hernia. Hiatal hernia not only exacerbates reflux symptoms, but may also lead to incomplete removal of the gastric fundus during laparoscopic sleeve gastrectomy (LSG). When hiatal hernias are seen preoperatively or intraoperatively for bariatric surgery, surgical correction should ideally be made with mesh reinforcement to prevent further clinical progression.
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We performed this study to evaluate the prevalence of reflux esophagitis and/or hiatal hernia in patients referred to a medical center and to examine the relationship between endoscopic reflux esophagitis and hiatal hernia. The study was carried out in 1,010 patients referred to Yong Dong Severance Hospital for upper gastrointestinal endoscopy because of symptoms related to the gastrointestinal tract from September 1994 to March 1996. The presence of hiatal hernia was defined as a circular extension of the gastric mucosa of 2 cm or more above the diaphragmatic hiatus. Reflux esophagitis was found in 5.3% of patients, hiatal hernia in 4.1%, duodenal ulcer in 7.2% and gastric ulcer in 8.2%. The prevalence rates of reflux esophagitis and hiatal hernia in males were significantly higher than those in females. Thirty-two percent of patients with reflux esophagitis had hiatal hernia. In patients without reflux esophagitis, hiatal hernia was found in only 2.5% (p<0.01). There was no significant association between the presence of hiatal hernia and the degree of esophagitis on endoscopy. Duodenal ulcer was the second most common endoscopic abnormality found in patients with reflux esophagitis. The prevalence rate of reflux esophagitis and/or hiatal hernia at a medical center is relatively low compared to peptic ulcer disease and other reports from the Western countries. Our study confirms the close association between reflux esophagitis and hiatal hernia.
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