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Comment on: laparoscopic sleeve gastrectomy combined with Rossetti fundoplication (R-sleeve) for treatment of morbid obesity and gastroesophageal reflux
Surgery for Obesity and Related Diseases ] (2017) 00–00
Editorial
Comment on: laparoscopic sleeve gastrectomy combined with Rossetti fundoplication (R-sleeve) for treatment of morbid obesity and gastroesophageal reflux The authors describe a small series of obese patients with gastroesophageal reflux disease (GERD) who underwent a sleeve gastrectomy (SG) and a fundoplication, in this case the Rosetti variety. The authors demonstrate that their procedure is safe and is effective in reducing GERD in patients with either esophagitis seen on Esophagogastroduodenoscopy (EGD) or patients with a positive pH study. There were no leaks despite the fact that a fundoplication would strengthen the lower esophageal sphincter, which in theory would create a higher pressure sleeve that may contribute to a leak. Also, the patients had durability of their fundoplication as their symptoms seem to be well controlled up to 1 year after surgery. Their results should be viewed with some skepticism before consideration is given to performing this technique for all obese patients with GERD. First, the best practices indicate that reflux disease is only contraindicated in patients with Barrett’s esophagitis [1]. In this series’ patients with EGD-proven esophagitis, 50% of the patients were considered Class A or mild GERD. These patients would have likely done well with an SG alone, especially if the reason for their GERD were their obesity. In the patients with a positive pH study, the obesity alone may be the cause, suggesting again that these patients likely would have had similar outcomes with an SG alone [2]. In the case of the patient with Barrett’s esophagitis, complete regression was reported by 12 months, but this would represent a supernormal response to fundoplication. This is
not likely to be the typical response to the outcome from this procedure. Also, the study is not applicable to patients with atypical symptoms of GERD as these patients were not included in the study. Finally, the study only continued for 1 year. Most failures from fundoplications occur within 2 years, so the Rosetti addition may only be delaying the development of recurrent GERD to beyond 1 year. While the authors should be praised for their innovation, this operation may not be needed in patients with mild GERD. Ultimately, this modification of the traditional SG may be best for obese patients with moderate to severe GERD who have contraindications to a Roux-en-Y gastric bypass. Robert B. Lim, M.D., F.A.C.S., F.A.S.M.B.S. Tripler Army Medical Center Uniformed Services University of Health Sciences Metabolic and Advanced Laparoscopic Surgery Honolulu, Hawaii References [1] Rosenthal RJ, International Sleeve Gastrectomy Expert Panel, Diaz AA, et al. International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of 412,000 cases. Surg Obes Relat Dis 2012;8(1):8–19. [2] Crowell MD, Bradley A, Hansel S, et al. Obesity is associated with increased 48-h esophageal acid exposure in patients with symptomatic gastroesophageal reflux. Am J Gastroenterol 2009;104(3):553–9.
http://dx.doi.org/10.1016/j.soard.2017.09.522 1550-7289/Published by Elsevier Inc. on behalf of American Society for Metabolic and Bariatric Surgery.
Editorial
Comment on: laparoscopic sleeve gastrectomy combined with Rossetti fundoplication (R-sleeve) for treatment of morbid obesity and gastroesophageal reflux The authors describe a small series of obese patients with gastroesophageal reflux disease (GERD) who underwent a sleeve gastrectomy (SG) and a fundoplication, in this case the Rosetti variety. The authors demonstrate that their procedure is safe and is effective in reducing GERD in patients with either esophagitis seen on Esophagogastroduodenoscopy (EGD) or patients with a positive pH study. There were no leaks despite the fact that a fundoplication would strengthen the lower esophageal sphincter, which in theory would create a higher pressure sleeve that may contribute to a leak. Also, the patients had durability of their fundoplication as their symptoms seem to be well controlled up to 1 year after surgery. Their results should be viewed with some skepticism before consideration is given to performing this technique for all obese patients with GERD. First, the best practices indicate that reflux disease is only contraindicated in patients with Barrett’s esophagitis [1]. In this series’ patients with EGD-proven esophagitis, 50% of the patients were considered Class A or mild GERD. These patients would have likely done well with an SG alone, especially if the reason for their GERD were their obesity. In the patients with a positive pH study, the obesity alone may be the cause, suggesting again that these patients likely would have had similar outcomes with an SG alone [2]. In the case of the patient with Barrett’s esophagitis, complete regression was reported by 12 months, but this would represent a supernormal response to fundoplication. This is
not likely to be the typical response to the outcome from this procedure. Also, the study is not applicable to patients with atypical symptoms of GERD as these patients were not included in the study. Finally, the study only continued for 1 year. Most failures from fundoplications occur within 2 years, so the Rosetti addition may only be delaying the development of recurrent GERD to beyond 1 year. While the authors should be praised for their innovation, this operation may not be needed in patients with mild GERD. Ultimately, this modification of the traditional SG may be best for obese patients with moderate to severe GERD who have contraindications to a Roux-en-Y gastric bypass. Robert B. Lim, M.D., F.A.C.S., F.A.S.M.B.S. Tripler Army Medical Center Uniformed Services University of Health Sciences Metabolic and Advanced Laparoscopic Surgery Honolulu, Hawaii References [1] Rosenthal RJ, International Sleeve Gastrectomy Expert Panel, Diaz AA, et al. International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of 412,000 cases. Surg Obes Relat Dis 2012;8(1):8–19. [2] Crowell MD, Bradley A, Hansel S, et al. Obesity is associated with increased 48-h esophageal acid exposure in patients with symptomatic gastroesophageal reflux. Am J Gastroenterol 2009;104(3):553–9.
http://dx.doi.org/10.1016/j.soard.2017.09.522 1550-7289/Published by Elsevier Inc. on behalf of American Society for Metabolic and Bariatric Surgery.