Reconstruction of the phreno-esophageal ligament (R-PEL) prevents the intrathoracic migration (ITM) after concomitant sleeve gastrectomy and hiatal hernia repair

Abstract

Background Laparoscopic Sleeve Gastrectomy (LSG) is the most attractive bariatric procedure, but the postoperative intrathoracic gastric migration (ITM) and “de novo” GERD are major concerns. The main objective of our study was to evaluate the efficiency of the concomitant HHR with or without partial reconstruction of phreno-esophageal ligament (R-PEL) to prevent ITM after LSG. The secondary objectives focused on procedure’s metabolic and GERD-related outcomes. Patients and method Consecutive patients who underwent primary LSG and concomitant HHR were included in a single-center prospective study. According to the HHR surgical technique, two groups were analyzed and compared: Group A included patients receiving crura approximation only and Group B patients with R-PEL. The patients’ evolution of co-morbidities, GERD symptoms, radiologic, and endoscopic details were prospectively analyzed. Results Two hundred seventy-three patients undergoing concurrent HHR and LSG were included in the study (Group A and B, 146 and 127 patients) The mean age and BMI were 42.6 ± 11.3 and 43.4 ± 6.8 kg/m 2 . The 12-month postoperative ITM was radiologically found in more than half of the patients in Group A, while in group B, the GEJ’s position appeared normal in 91.3% of the patients, meaning that R-PEL reduced 7 times the rate of ITM. The percentage of no-improvement and “de novo” severe esophagitis (Los Angeles C) was 4 times higher in group A 3.4% vs. 0.8% with statistical significance, and correlated to ITM. The GERD symptoms were less frequent in Group B vs Group A, 21.3% vs 37%, with statistical significance. No Barrett’s esophagus and no complication were recorded in any of the patients. Conclusion Concurrent LSG and HHR by crura approximation only has a very high rate of ITM in the first postoperative year (over 50%). R-PEL is an innovative technique which proved to be very efficient in preventing the ITM after HHR.

¿Cuáles fueron los beneficios de preservar la membrana frenoesofágica y la fascia transversalis diafragmática durante la realización de la funduplicatura Nissen laparoscópica? Un estudio comparativo

“…Proponen este procedimiento como una técnica innovadora, segura, eficiente y relativamente simple de realizar. 4 Al preservar la membrana frenoesofágica durante la funduplicatura de Nissen, se minimiza el trauma alrededor del esófago y, por lo tanto, se reduce el riesgo de sangrado durante y después de la cirugía. La membrana frenoesofágica tiene una rica vascularización (suministro de sangre), y cualquier daño a esta estructura durante la cirugía podría causar sangrado.…”

Multidisciplinary combined treatment based on bariatric surgery for metabolic syndrome: a review article

“…Based on SG, researchers utilized several intestinal exclusion techniques to obtain additional blood glucose management and a better weight reduction result 107 – 113 . In addition, given that obese patients are often accompanied by a variety of diseases, including gastroesophageal reflux, it is reported that concurrent hernia repair during bariatric surgery should be performed and a satisfactory result can be achieved 114 – 117 . In conclusion, it is frequently difficult for a single treatment to remain effective because obesity and associated metabolic diseases are chronic conditions with a variety of underlying causes.…”