Laparoscopic Gastroplasty and Dor Fundoplication for Gastric Sleeve Stenosis with a Proximal Dilated Sleeve.

Luciano Poggi, MD1, Daniel Pita, MD2, Luis Poggi, MD2. 1Oklahoma University Health Science Center, 2Clinica Anglo Americana

Introduction: Obstructive symptoms and Gastroesophageal reflux (GERD) after Gastric sleeve remain severe problems.  There is no consensus on the best management of this condition, some author have advocated endoscopic versus surgical management specially in refractory cases, most of the time proceeding with gastric bypass. Most of the patients present with dilated proximal segment or “neofundus” that seems to play a role in patient symptoms, specifically in reflux.  The objective of this study is to describe a surgical option to manage the gastric sleeve stenosis and the dilated proximal sleeve performing a gastroplasty and a Dor fundoplication when gastric bypass is not option and ballon dilatation has failed.

Methods: We present 3 patients referred to our institution due to severe GERD associated occasionally with nausea, vomiting and weight loss after Sleeve Gastrectomy. Extensive preoperative evaluation was obtained including Abdomen and Pelvis CT scan, esophagogastroduodenoscopy, upper gastrointestinal series, 24 hrs. Esophageal Ph study and manometry.  Prior to surgery all patients underwent endoscopic balloon dilatation up to 35mm, however resolution of symptoms would be temporary.  All patients underwent laparoscopic Gastroplasty along the area of stricture, hiatal hernia repair and a Dor fundoplication.

Results: Patients presented between 3 to 12 months after sleeve gastrectomy. The mean body mass index pre and postoperative were 31 and 20 kg/m2 respectively.  None of the patients had GERD symptoms prior to Gastric sleeve. All three patients were found to have a small hiatal hernia. None of our patients had esophageal dismotility. 

A standar vertical incision was performed along the stricture segments to subsequently close it transversely. The stricture was found consistently in the proximity of the incisura angularis. The length of the stricture was as an averaged of 5 cm. Hiatal hernia was repaired primarily and reinforced with biologic mesh. The proximal dilated segment was use to create an anterior fundoplication. Operative time was an average of 180 minutes.

Postoperatively patients have been follow at least 6 months (6-18months), 2 patients had resolution of GERD symptoms and one significant improvement. All patient have gain weight.

Conclusion: Laparoscopic gastroplasty and Dor fundoplication is a feasible and safe option for patient with Gastric sleeve stenosis and severe reflux associated with a dilated proximal sleeve.  This option should be consider in patients in which a seromyotomy is not able to be perform or morbidity of converting to gastric bypass or gastric resection with another type of reconstruction is not desirable.

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