bariatric choices for the obese patient with hiatal …...bariatric choices for the obese patient...
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Bariatric choices for the Obese patient with
Hiatal Hernia
William Richards, M.D.,FACS Department of Surgery
University of South Alabama College of Medicine,
Which operations do I do in a Patient with Obesity and Hiatal hernia
Adjustable Gastric Band
Sleeve Gastrectomy
Roux-en-Y Gastric Bypass
But always repair hiatal hernia
Even the smallest defect
Medical options GERD post Bariatric surgery
Use Purple Don’t Use Blue
Effect of sleeve gastrectomy on gastroesophageal reflux disease: a systematic review 15 reports were retrieved.
4 showed an increase in GERD
7 found reduced GERD prevalence after SG
The evidence of the effect of SG on GERD did not consolidate to a consensus.
Sharon Chiu et al SOARD, 2011
Mechanisms of GERD
Incompetent LES with TLESRs
LES is in negative intrathoracic pressure
Mechanisms of GERD
Esophageal Clearance of acid
Gastric emptying
Gastric Emptying Accelerated after LSG
87
63 61
0
10
20
30
40
50
60
70
80
90
Preop 6M postop 24 M postop
T1/2 (Min)
John Melissas et al OBES SURG (2008)
Vomiting Post LSG
(I) Inferior Pouch (S) Superior Pouch (T)Tubular
Olga Lazoura et al OBES SURG (2011)
Heartburn after LSG
(I) Inferior Pouch (S) Superior Pouch (T)Tubular
Olga Lazoura et al OBES SURG (2011)
Conclusions Operative Technique
Create symmetrical gastric tube
– Careful attention to avoid hourglass stomach
Repair all Hiatal hernias
– 50% require repair
Options for the Patients with GERD post LSG
Repair Hiatal hernia
Resect fundus to create tubularized stomach
Consider surgical options
– Links
– Stretta
LINKS can be used post LSG
The Linx reflux management system was approved by FDA on March 22, 2012.
LINKS
LINKS responds to movement of esophagus
Tunnel created between posterior esophagus and posterior vagus
Device encapsulated in fibrous material
pH results 1-3 years following LINKS
0
5
10
15
20
25
30
35
40
45
Baseline
n=44
1 year
n=39
2 years
n=20
3 years
n=20
Total % time pH<4
DeMeester score
Surg Endosc 2012
pH results 1-3 years following LINKS
0 0
77
87 9080 80
88
0
10
20
30
40
50
60
70
80
90
Baselinen=44
1 year n=39
2 years n=20
3 years n=20
% patients with pHnormalization
Satisfaction %
Surg Endosc 2012
Explantation in 3 patients
Persistant dysphagia for 226 days
Device removed in order to undergo MRI for neurologic symptoms
Continued GERD conversion to Nissen
Surg Endosc 2012
Severe GERD Post Sleeve Gastrectomy
Consider LINKS
Stretta may be another option