Efficacy of Nissen Sleeve Gastrectomy on Mid-term Barrett's Esophagus Regression.

INTRODUCTION: Sleeve gastrectomy is the most commonly performed bariatric operation globally. The main complication is GERD. In the medium term, it can increase the incidence of Barrett's esophagus (BE), which is a risk factor for esophageal adenocarcinoma. Following conventional sleeve gastrectomy, BE is noted in up to 16% of patients postoperatively. Recently, Nissen sleeve gastrectomy (NSG) has been shown to reduce the frequency of postoperative GERD compared to conventional sleeve gastrectomy. This study aims to evaluate the impact of NSG on the incidence and remission of BE in the long term. MATERIAL AND METHOD: This bicentric retrospective study included 692 patients who received NSG from September 2013 to July 2021. All patients underwent preoperative upper GI endoscopy and were then scheduled to receive upper GI endoscopy between 1 and 2 years and then between 3 and 5 years postoperatively. BE was systematically confirmed by biopsies. RESULTS: Seventy-four patients had endoscopic suspicion of BE, which was confirmed on 54/692 patients by histology. The BE lesions consisted of 18.5% intestinal metaplasia and 75.9% fundal metaplasia. Among these 54 patients, 38 underwent endoscopic investigation within 2 years postoperatively. The biopsies showed healed BE in 25/38 patients (64.1%). At 5 years, two patients had proven BE. Concerning the incidence of BE post NSG: 234 performed the follow-up endoscopy within 2 years. The incidence of de novo BE is nil. CONCLUSION: The NSG is associated with healing of known BE in approximately two-thirds of patients at 2-year follow-up. This is consistent with the GERD improvement that has been shown with NSG.

Nissen Sleeve as a Redo Surgery Post Gastric Banding for Non-responders to Weight Loss and Therapy-Resistant Reflux.

Roux-en-Y gastric bypass (LRYGB) would be the procedure of choice for non-responders of weight loss and patients with reflux symptoms (GERD). However, not every patient is a candidate for RYGB, and sometimes, the patient can insist only on alternatives other than malabsorption procedures, as was the case with our patient. We report a case with symptomatic GERD who underwent a successful Nissen sleeve gastrectomy after band removal. To our knowledge, this is the first case using Nissen sleeve as a redo surgery after a previous bariatric procedure.

Efficacy of Sleeve Gastrectomy with Concomitant Hiatal Hernia Repair versus Sleeve-Fundoplication on Gastroesophageal Reflux Disease Resolution: Systematic Review and Meta-Analysis.

(1) Background: There is still disagreement over how sleeve gastrectomy (SG) affects gastroesophageal reflux disease (GERD). The debate regarding the best option for patients undergoing bariatric surgery who are also affected by GERD and/or hiatal hernia continues to divide the community of bariatric surgeons. While concomitant hiatal hernia repair (SG + HHR) has been proposed as a means of reducing the risk of GERD following SG with varying degrees of success, the addition of a fundoplication (SG + FP) has been suggested in recent years as a way to improve the lower esophageal sphincter's competency. The aim of this study is to systematically review and meta-analyze the efficacy of SG + HHR versus SG + FP on GERD remission in patients with obesity. (2) Methods: A systematic review of the literature was conducted, and studies analyzing the effects of SG + HHR versus SG + FP on postoperative GERD were included. The methodological quality of included trials was evaluated. The primary outcome was postoperative GERD rate, erosive esophagitis, and 12-month weight loss. Secondary outcomes included postoperative complications and mortality. The PRISMA guidelines were used to carry out the present systematic review (PROSPERO Registration Number: CRD42023405600). (3) Results: Fifteen articles with a total of 1164 patients were included in the meta-analysis; 554 patients underwent SG + HHR while 610 underwent SG + FP. In the SG + HHR group, 58.5 ± 28.9% of subjects presented clinical GERD symptoms compared to 20.4 ± 17.5% postoperatively (p < 0.001). In the SG + FP group, 64.8 ± 39.4% were affected by GERD preoperatively compared to only 5 ± 8.1% postoperatively (p < 0.001). SG + FP patients had a significantly greater GERD remission compared to SG + HHR (p < 0.001). Weight loss was similar between groups (p = 0.125). The rate of leaks was 0.18% and 0.33% in the SG + HHR and SG + FP, respectively (p = 0.657), while perforations were significantly higher after SG + FP compared to the SG + HHR group (3.1% versus 0%, p = 0.002). The mortality rate was significantly greater in the SG + FP group (0.5% versus 0%, p = 0.002). (4) Conclusions: This study revealed that both SG with concomitant HHR and sleeve-fundoplication are effective in terms of reflux resolution and weight outcomes, with superiority of SG + FP in terms of GERD control, despite a greater overall complication rate. Both strategies can therefore be suggested as a suitable alternative variant to a conventional SG in subjects with obesity and concomitant hiatal hernia and/or GERD. Studies with extended follow-up and direct comparisons of these surgical approaches to conventional SG are warranted.

Peri-operative Morbidity of Nissen Sleeve Gastrectomy: Prospective Evaluation of a Cohort of 365 Patients, Beyond the Learning Curve.

PURPOSE: Over the last decade, an important interest was taken to prevent the reflux following sleeve. A new variant, Nissen-sleeve, was described with the purpose to prevent GERD and to decrease the occurrence of leak. The current study reports the preliminary results of a prospective trial. MATERIALS AND METHODS: All consecutive patients who underwent a Nissen-Sleeve between January 2018 and September 2020 were included. Baseline characteristics including age, gender, weight, body mass index (BMI), GERD symptoms, and treatment were evaluated after 1 year. Operative time, length of stay, complication, and reoperation data were also collected. RESULTS: Three hundred sixty-five consecutive patients decided to undergo Nissen-sleeve: 75% females with median age of 41.2 years (+ / - 14.1) and an average BMI of 41.6 kg/m2 (+ / - 5.4). There were 16 cases (4.4%) of early postoperative complications (< 30 days): six cases of acute wrap perforation (1.6%), intraabdominal bleeding for 5 patients (1.4%), one case of wrap dilatation (0.3%), one case of acute complete aphagia, one case of incarcerated umbilical hernia, and 2 cases (0.5%) of pulmonary atelectasis/pneumonia and one venous pulmonary embolism. We recorded the following complications: 16 patients (4.4%) mild dysphagia; 3 patients (0.8%) chronic dysphagia; and 2 cases of wrap perforation that have been diagnosed 8 and 9 months respectively, after the procedure due to the use of steroids not associated with PPI intake. The mean operative time was 83 min (46-125 min). The conversion and mortality rates were nil. CONCLUSION: Following the initial learning curve and additional technical modifications, the Nissen-Sleeve appears to be a safe surgical technique with an acceptable early postoperative complication rate. CLINICAL TRIAL REGISTRATION: NCT02310178.

Effect of laparoscopic sleeve gastrectomy vs laparoscopic sleeve + Rossetti fundoplication on weight loss and de novo GERD in patients affected by morbid obesity: a randomized clinical study.

PURPOSE: To compare sleeve gastrectomy (SG) to SG associated with Rossetti fundoplication (SG + RF) in terms of de novo gastro-esophageal reflux disease (GERD) after surgery, weight loss, and postoperative complications. MATERIALS AND METHODS: Patients affected by morbid obesity, without symptoms of GERD, who were never in therapy with proton pump inhibitors (PPIs), were randomized into two groups. One group underwent SG and the other SG + RF. The study was stopped on February 2020 due to the COVID pandemic. RESULTS: A total of 278 patients of the programmed number of 404 patients were enrolled (68.8%). De novo esophagitis was considered in those patients who had both pre- and postoperative gastroscopy (97/278, 34.9%). Two hundred fifty-one patients (90.3%) had completed clinical follow-up at 12 months. SG + RF resulted in an adequate weight loss, similar to classic SG at 12-month follow-up (%TWL = 35. 4 ± 7.2%) with a significantly better outcome in terms of GERD development. One year after surgery, PPIs were necessary in 4.3% SG + RF patients compared to 17.1% SG patients (p = 0.001). Esophagitis was present in 2.0% of SG + RF patients versus 23.4% SG patients (p = 0.002). The main complication after SG + RF was wrap perforation (4.3%), which improved with the surgeon's learning curve. CONCLUSION: SG + RF seemed to be an effective alternative to classic SG in preventing de novo GERD. More studies are needed to establish that an adequate learning curve decreases the higher percentage of short-term complications in the SG + RF group.

The Nissen-Sleeve: Early Postoperative Complications.

Introduction: Nissen Sleeve (NS) was introduced in the bariatric armamentarium with the purpose to decrease the risk of reflux symptoms following sleeve gastrectomy. The aim of this study was to evaluate our personal experience with this new technique, in particular concerning early postoperative complications (<30 days). Methods: We retrospectively reviewed our prospectively collected data on consecutive morbid patients with obesity receiving NS from December 2019 to August 2020. All data pertaining to each patient, including demographic data and preoperative and postoperative clinical data, were collected. Results: A total of 28 N-sleeve procedures were performed in the considered period. All the patients had a hiatal hernia that was evaluated between 2 and 6 cm of extent in the preoperative work. Esophagitis of stage A, according to the Los Angeles classification, was detected in 71% of the patients, while 8 out of 28 patients presented a stage B esophagitis. One of the patients had a preoperative diagnosis of Barrett esophagus. A complete disappearance of gastroesophageal reflux disease (GERD) symptoms was achieved in 25 patients out of 28, while the remaining patients reported an improvement in symptoms and continued to be treated with low doses of proton pomp inhibitors. Two reinterventions (7.1%) were performed (Clavien-Dindo IIIb). Three other patients (10.7%) experienced a transient postoperative dysphagia that in one case persisted for 4 months (Clavien-Dindo II). All the patients were managed with conservative treatment, and in each case an endoscopic dilatation was necessary. Conclusions: NS appears to be a safe surgical technique with an acceptable early postoperative complication rate. NS appears to be effective in treating patients suffering from obesity and preoperative reflux, but the data are insufficient to establish whether it can reduce the long-term risk of de novo GERD in laparoscopic sleeve gastrectomy patients.

Necrosis of the Nissen-Sleeve Gastrectomy (N-SG) Wrap.

BACKGROUND: Sleeve gastrectomy (SG) is the highest performed bariatric procedure in the world. Gastro-oesophageal reflux disease (GERD) is widely debated topics after SG. Nissen-Sleeve gastrectomy (N-SG) technique was reported in 2016 as an alternative solution to this problem. They reported concern about valve ischaemia but did not report any such complication in the beginning of their experience. We would like to share video showing this complication and technique to manage it. METHOD: Data was retrospectively analysed. RESULTS: A 45-year-old female with BMI of 35.5 kg/m had an uneventful Nissen-SG. She had GERD treated with proton pump inhibitor (PPI). The preoperative gastroscopy showed peptic oesophagitis with hiatal hernia. On post-operative day (POD) 1, the patient complained of severe abdominal pain, tachycardia and fever. Inflammatory markers were raised. Diagnostic laparoscopy showed necrosis of the wrap. The wrap was carefully undone and resected with a stapler (with seamguard). Thorough wash with saline was performed. Drain was left near the new staple line. A CT scan with oral contrast 4 days later confirmed absence of a gastric leak. The patient was discharged 8 days after the revision on PPI and antibiotics. Two-years post-operatively, the patient is doing well and her GERD symptoms are controlled with PPI. CONCLUSION: Wrap necrosis is a life-threatening complication after N-SG. This case is shared to raise awareness of this complication. This was successfully managed by prompt laparoscopy and wrap resection. Ideally such complications should be referred to experts or centers with high volume of bariatric surgery.

The Nissen-Sleeve (N-Sleeve): Results of a Cohort Study.

BACKGROUND: The Montpellier bariatric team has recently proposed some technical alternatives to decrease the rate of gastroesophageal reflux disease (GERD) after bariatric surgery and also to offer patients an alternative in case of contraindication to Roux-en-Y gastric bypass (RYGBP): the Nissen-Sleeve (N-Sleeve). OBJECTIVES: We present here the results from a cohort of patients that underwent an operation with this newly designed anti-reflux bariatric procedure N-Sleeve: Nissen valve added to a standard SG. METHODS: Data from a prospective, observational, and monocentric cohort. All consecutive patients presenting to the bariatric surgery department for a laparoscopic sleeve gastrectomy between 2016 and 2018 with GERD were included in the study. The fundus was stapled with a margin from the valve, and the valve was created with tissue at a distance from the greater curvature so as to avoid a double layer stapling of the stomach. RESULTS: A total of 70 patients were included in the study. Ninety percent of the cohort presented with a hiatal hernia at the time of surgery. No mortality was observed during the follow-up period. Concerning GERD, 76% of all patients had preoperative esophageal syndromes, whereas 21% were asymptomatic with associated esophagitis. Grade A-C esophagitis was present in 99% of the cohort, but no Barrett's esophagus was present. Fifty-six (80%) patients used PPIs regularly. At 1 year of follow-up, one patient was still symptomatic. CONCLUSIONS: Comparative trials remain necessary between N-Sleeve and standard bariatric procedures to refine the specific indications of each of them and determine the eventual role of the N-Sleeve.

Roux-en-Y Gastro-jejunostomy for Complex Leak After the "Nissen" Variant of Sleeve Gastrectomy.

BACKGROUND: Recently, improvised variants of sleeve gastrectomy SG were reported as alternative bariatric options in patients suffering from both morbid obesity and GERD, including mainly additional anterior or posterior fundoplication over a partially sleeved stomach. METHODS: We present the case of a 29-year-old male patient with a body mass index (BMI) of 46.2 kg/m2 underwent laparoscopic SG with concomitant posterior fundoplication: Nissen-SG (N-SG). At postoperative day (POD) 4, he presented with epigastric pain, nausea, and 40 °C fever. The abdomen was tender with signs of peritonitis. Explorative laparotomy displayed a massive gastric leak with generalized peritonitis. Peritoneal lavage was performed. the patient was transferred to our department for the management of persistent SGL. RESULTS: Initial management comprised total parenteral nutrition and wide-spectrum intravenous antibiotics. Three weeks later, the patient underwent laparoscopic exploration. As shown in the video, at least two leaks were individualized, including one, anterior, catheterized by the pigtails, and the other one, posterior, impossible to reach endoscopically (Fig. 1). A residual abscess, located between the left crus, the pancreas, and the upper edge of the spleen, was evacuated. Eventually, Roux-en-Y gastro-jejunostomy was performed CONCLUSION: The adjunction of a posterior fundoplication may have contributed to the multiple and complex occurrence of SGL. Having an ill-vascularized redundant fundus may have increased ischemia of the GE junction. Moreover, it is more difficult to perform endoscopic treatment in a plicated and sleeved stomach as well.

Chronic Fistula Post Laparoscopic Nissen Sleeve Gastrectomy: Conversion to Roux-en-Y Gastric Bypass.

BACKGROUND: Sleeve gastrectomy (SG) is the most frequently performed bariatric intervention worldwide, and obese patients have a higher risk of developing reflux symptoms compared with the general population [1, 2]. One of the controversies of SG is to perform it in patients with gastroesophageal reflux disease (GERD). Some studies have shown that SG may exacerbate GERD symptoms or even increase the risk of "de novo" postoperative GERD [3, 4]. Laparoscopic Nissen fundoplication is an effective treatment for patients with severe GERD. In order to avoid the Roux-en-Y gastric bypass (RYGB), some authors combined the SG with the Nissen fundoplication in morbid obese patients with GERD [5]. As after SG, postoperative gastric fistula may occur after Nissen SG. Persistent fistula after Nissen SG may be treated by conversion to RYGB. METHODS: We present the case of a 35-year-old woman with long-standing morbid obesity, who presented to our institution seeking management options for her postoperative fistula. In August 2018, she underwent a laparoscopic Nissen SG in another institution. Her initial weight was 107 kg, height 172 cm, and body mass index (BMI) 36.27 kg/m2. At the 7th postoperative day, she complained of severe abdominal pain and fever. A computed tomography (CT) scan was performed showing a massive supra-mesocolic pneumoperitoneum. An explorative laparoscopy was performed with evidence of a generalized peritonitis without identification of the orifice of the leak. Peritoneal lavage of the abdominal cavity was done and the patient was transferred to our institution. An upper gastrointestinal endoscopy was performed with evidence of a fistula on the gastric longitudinal staple line (8 mm in diameter), and a stenosis of about 15 mm on the distal gastric tube. A double pig-tail was placed. After 14 days, the patient underwent a gastric pneumatic dilatation of the stenosis placed at the antro-fundic region, without complications. Three months later, the fistula was persistent; therefore, after a careful nutritional and psychological evaluation and discussion with the patient, we decided to perform a conversion to a RYGB. The valve of the Nissen fundoplication was identified and divided using a stapler. The orifice of the fistula was identified. Resection of this valve, including the orifice of the fistula and the gastric tube, was done using a blue-load stapler ECHELON FLEX™ GST (Ethicon Endo-Surgery, USA) while creating the new gastric pouch. Then, we performed a Roux-en-Y gastric bypass with a 150-cm alimentary limb and a 50-cm biliary limb. The Petersen and the mesenteric defects were closed. RESULTS: The blood loss was less than 100 cc and the operative time was 240 min. The postoperative period was smooth and uneventful; the patient was started on liquid diet on the second postoperative day and discharged at day 8. At 1 month postoperatively, the patient has lost 16 kg and the %EWL was 36.53%, %TWL 14.95% with a BMI of 30.84 kg/m2. At 6 months postoperatively, the patient lost 24 kg, with a BMI at 26 kg/m2. She does not complain of GERD, no vomiting, no abdominal pain, and no diarrhea. CONCLUSIONS: In cases of fistulas after Nissen SG, the surgery becomes more tedious and difficult. Conversion to RYGB seems a feasible and effective option to treat chronic fistula after Nissen SG.