Laparoscopic sleeve gastrectomy after previous pyloromyotomy for infantile hypertrophic pyloric stenosis. Case report and discussion of LSG-mediated weight loss mechanism

Edward J Hannoush, MD, Sebastian Eid, MD, Douglas R Ewing, MD, Hans J Schmidt, MD. Hackensack University Hospital.

Introduction: The mechanism of the laparoscopic sleeve gastrectomy (LSG)-mediated weight loss remains a topic of active investigation. Considered a restrictive procedure, LSG is thought to limit the amount of food that can be consumed and induce weight loss. This requires preserved gastric emptying. Foregut pathology and surgery, in particular infantile hypertrophic pyloric stenosis (IHPS) and pyloromyotomy, have a significant impact on gastric motility. However, the impact of previous pyloric drainage procedures on restrictive bariatric surgery has not been investigated. We report a case of a LSG performed in a patient who underwent a previous pyloromyotomy for IHPS as an infant and offer insight into the LSG-mediated weight loss mechanism.

Methods: The patient is a 32-year-old female, 5 feet 6 inches tall with a weight of 343 pounds and a body mass index (BMI) of 55.4 kg/m2. Relevant past medical history included asthma, sleep apnea, gastroesophageal reflux disease, hypertension, hypercholesterolemia and polycystic ovarian syndrome. Abdominal past surgical history included laparoscopic cholecystectomy and pyloromyotomy as an infant for IHPS. She denied smoking and reported occasional alcohol ingestion. A LSG over a 34-french bougie was performed. On postoperative day number one a routine esophogram was performed, which was unremarkable and the patient was discharge home.

Results: Postoperatively, weight loss was excellent following the procedure. Her weight at nine-month follow up visit after her surgery was 235 pounds (net weight loss: 108 pounds, excess weight loss: 50.7%). At her latest follow up visit she was tolerating solid foods without difficulty with no adverse symptoms following the surgery.

Conclusion: The pylorus plays an important role in the regulation of gastric emptying by acting as a brake to the passage of food. The potential impact that the gastric resection in LSG might have on pyloric function and gastric emptying in patients who underwent pyloromyotomy in infancy is unknown. The patient presented had excellent weight loss comparable to patients without pyloromyotomy and no adverse symptoms following surgery. We review the literature and discuss the mechanistic explanation of the successful LSG-mediated weight loss in this setting. The present is the first report suggesting that pyloromyotomy is clinically insignificant when considering LSG.

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