Evaluation of Anterior Phrenoesophageal Ligament Preservation During Hiatus Hernia Repair in Laparoscopic Sleeve Gastrectomy as an Anti-Reflux Measure.

Background: Laparoscopic sleeve gastrectomy (LSG) is the most common bariatric procedure, but it had been reported to increase the incidence of gastroesophageal reflux disease (GERD) and its consequences. Some surgeons tried to decrease that by routine hiatal dissection with hiatus hernia (HH) repair. But, hiatal dissection with HH repair is considered an important risk factor for the newly emergent complication of intrathoracic sleeve migration (ITSM). We proposed a new hiatal repair technique, which is expected to improve GERD without increasing the potential for ITSM. This study aims to evaluate the results of this technique. Methods: A prospective observational study was performed at the Ain Shams University Hospital between January 2016 and December 2019. It included patients with morbid obesity and one of the following: Clinical manifestations of GERD with endoscopic evidence of HH/laxity or esophagitis. Asymptomatic HH/laxity. LSG combined and HH repair with anterior phrenoesophageal ligament (PEL) preservation was performed for all patients. Patients were followed up for 12 months. Patients were evaluated after 1 year with an upper gastrointestinal (GI) endoscopy. Results: Thirty-two patients were enrolled in our study. After 1 year, the mean excess weight loss was 63% ± 23%. The mean GERD health-related quality of life (GERD-HRQL) score dropped to 12 ± 8. GERD-HRQL scores improved in 25 of documented esophagitis patients, worsened in 2, and did not change in 2 patients. Endoscopy showed a decrease in rate and degree of esophagitis (from 28 [87.5%] preoperatively to 8 [25%] patients after 1 year of follow-up). The improvement was better in patients with grade A and B esophagitis. Two patients were converted to gastric bypass due to persistent intractable GERD symptoms with grade C esophagitis despite medical treatment. No cases of ITSM were detected. Conclusion: Anterior PEL preserving HH repair combined with LSG is a safe and feasible technique that can control GERD manifestations without interference with the technique or outcome of LSG.

Hiatal hernia and gastroesophageal reflux: Study of collagen in the phrenoesophageal ligament.

BACKGROUND: Gastroesophageal reflux disease (GERD) is defined by the intensity and/or quality of the reflux of gastric or duodenal contents into the esophagus. Surgical treatment of GERD has shown conflicting results and unacceptable recurrence rates, mainly due to herniation of the antireflux valve into the chest. A variety of techniques has been proposed to reduce GERD recurrence, including routine use of prosthesis in cruroplasty. The prevalence of GERD in patients with hiatal hernia (HH) can reach 94 %. It is possible that the phrenoesophageal ligament (POL) engaged in the stabilization of the gastroesophageal junction in the abdomen may be an etiological factor of HH. We conducted a study to evaluate collagen in the constitution of the POL in patients with HH and cadavers without HH. METHODS: POL samples were collected from 29 patients with HH and GERD (cases) and 32 samples from cadavers without HH (controls). Total collagen was quantified through the Picrosirius red histochemical technique, and type-I and type-III collagens were quantified immunohistochemically using a monoclonal antibody. The stained slides were photographed, and images were quantified by computer software (Image Pro Plus) to count the pixels per field. RESULTS: The mean age was 49.5 (±11.5) years for the cases and 38.5 (±13) years for the controls (p < 0.01). Seventeen cases (58.6 %) and six controls (18.75 %) were female (p < 0.01). The quantity of total (p < 0.01), type-I (p < 0.01), and type-III (p < 0.05) collagens was significantly lower by about 60 % in patients with HH compared with controls. CONCLUSION: Our data indicate that the composition of POL for patients with GERD and HH includes less total, type-I, and type-III collagens than that of the POL of cadavers without HH. The quality of the POL may be an etiological factor in the development of HH.

Artificial phrenoesophageal ligament. An experimental study in dogs.

This report deals with the preparation of a 'true' artificial phrenoesophageal ligament aimed at restoring effective anchoring of the esophagus to the diaphragm, keeping the esophagogastric sphincter in the abdomen. A total of 24 mongrel dogs were assigned to four groups: (i) Group I (n = 4): the esophageal diaphragm hiatus left wide open; (ii) Group II (n = 8): the anterolateral esophagus walls were attached to the diaphragm by the artificial ligament and the esophageal hiatus was left wide opened; (iii) Group III (n = 5): in addition to the use of the artificial ligament, the esophageal hiatus was narrowed with two retroesophageal stitches; (iv) Group IV (n = 7): the only procedure was the esophageal hiatus narrowing with two retroesophageal stitches. The phrenoesophagogastric connections were released, sparing the vagus nerves. Five animals of groups III and IV, which did not develop hiatal hernia, were submitted to esophageal manometry immediately before and 15 days after surgery. In group I, all animals developed huge sliding hiatal hernias. In group II, two dogs (25%) had a paraesophageal hernia between the two parts of the artificial ligament. In group III, neither sliding hiatal hernia nor paraesophageal hernia occurred. In group IV, two animals (28.6%) developed sliding esophageal hiatus hernia. Regarding esophageal manometry, postoperative significant difference between groups III and IV (P = 0.008) was observed. Thus, the artificial phrenoesophageal ligament maintained the esophagus firmly attached to the diaphragm in all animals and the esophagogastric sphincter pressure was significantly higher in this group.

V-shaped Liver Retraction during a Laparoscopic Gastrectomy for Gastric Cancer

PURPOSE: The aim of this study was to evaluate the effectiveness of our retraction method for achieving a good operative field for the adequate lymph node dissection during laparoscopic gastrectomy in view of short term surgical outcome. MATERIALS AND METHODS: This study prospectively enrolled 19 patients who underwent laparoscopic gastrectomy for early gastric cancer. The procedure was simply performed by putting the laparoscopic sigle suture in the phrenoesophageal ligament, and then the string was pulling and tying over the sternum. Surgical outcomes of these patients were evaluated. RESULTS: Under V-shaped liver retraction, the mean operating time and mean number of retrieved lymph nodes was 166.3 minute and 31.37, respectively. And the results were satisfactory compared to open or conventional laparoscopic gastric surgery. CONCLUSIONS: V-shaped liver retraction requires no extra port or assistant's hands, and prevents additional injury to any intra-abdominal organ. And this method can easily, efficiently and safely enable to achieve a good operative field for the lymph node dissection near the lesser curvature of the stomach.