Management of Refractory GERD after Sleeve Gastrectomy: Robot-Assisted Conversion to Bypass

Raquel Gonzalez-Heredia, Md, PhD, Pablo Quadri, Mario Masrur, MD, Lisa Sanchez-Johnsen, PhD, Enrique Elli, MD, FACS. UIC

Introduction: Sleeve Gastrectomy (SG) distorts the gastroesophageal anatomy and it could lead to symptoms of gastroesophageal reflux disease (GERD) after the surgery. Medical management of GERD symptoms is the first choice of treatment. For patients with refractory GERD symptoms, conversion to bypass may be an option. We present a case of refractory GERD after SG.

Material and Methods: Patient is a 45-year-old woman with history of HTN, hypothyroidism and sleep apnea who underwent a SG 2 years ago. Her BMI decreased from 41 to 34 kg/m2. However, She started to have symptoms of GERD. The patient received medication for 6 months but her symptoms persisted. An EGD showed mild gastritis in the antrum but no ulceration. Manometry showed low pressures at the LES but normal peristalsis. After failed long term therapy with PPI, the patient consented to convert her surgery to gastric  bypass.

Results: The procedure started with a diagnostic laparoscopy that showed adhesions to the previous sleeve and a hiatal hernia of about 3 cm diameter defect. Using the monopolar hook, adhesions were taken down and the esophagus was dissected from the mediastinus. Once it was finished, the pillars of the hiatus were approximated with interrupted stitches of 0 nonabsorbable suture. After that, the lesser curvature was dissected and the gastric tube was mobilized. Then the gastric pouch was created transecting the sleeve at 5 cm from the hiatus. After that, the transverse colon was retracted and the angle of Treitz identified. The small bowel was run 50 cm and at this point, the bowel was transected using a load. Then the alimentary limb was run up to 120 cm and a 2 layers jejuno-jenunal anastomosis using a 3-0 PDS was performed. Then the alimentary limb was advanced cranially towards the gastric pouch using the 3rd arm and a 2 layers gastro-jejunostomy was performed with a running suture of 3-0 PDS. An intraoperative endoscopy was performed in order to rule out intragastric bleeding or strictures. There were no intra- or post-operative complications. The estimated blood loss was minimal. The patients’ symptoms improved dramatically after surgery, being discharged on POD 2. At 1 month follow-up, the patient reported improvement of her symptoms of GERD.

Conclusions: Aggressive identification of hiatal hernia intraoperatively is appropriate. Still evidence of SG’s effect on LES and presence of GERD is inconsistent. Gastric bypass appears to be an alternative option for bariatric patients with GERD after sleeve gastrectomy.