A New Hybrid Procedure for GERD: Anterior Fundoplication-Sleeve
I read with interest the article titled “Safety and effectiveness of anterior fundoplication sleeve gastrectomy in patients with severe reflux”. The study is recently published in the current issue of SOARD (Surgery for Obesity and Related Disorders) by M.A. Jawad et al. The authors claim that bariatric surgeons are hesitant offering sleeve gastrectomy for patients with severe GERD. To avoid performing gastric bypass surgery to achieve weight loss in the setting of severe GERD, the authors have come up with a new approach; Anterior fundoplication is added to sleeve gastrectomy to reinforce the anti-reflux barrier. Part of the gastric fundus is preserved during sleeve gastrectomy. The remnant fundus is then used to construct an anterior fundoplication. It is sutured to the right crus, arcuate ligament and left crus. A total of 31 patients were enrolled in the study and 21 of them underwent concomitant hiatal hernia repair. Most patients showed improvement in their GERD score analysis. The authors do not use pre and post operative ambulatory pH testing and upper endoscopy to objectively evaluate acid reflux disease.
This is a limited study and solid conclusions cannot be made. However, the concept itself of using a small remnant fundus to reinforce the anti-reflux barrier is worth discussing. Does fundoplication stop acid reflux when part of the stomach was resected? Does a fundoplication work when most of the gastric fundus has been resected and a small remnant is used to fold over the anterior distal esophagus?
The answer to these questions is difficult because the exact mechanism of action fundoplication for treatment of GERD remains poorly understood. The common belief of mechanically reinforcing the lower esophageal sphincter with a stomach wrap is a simplistic explanation of a complex problem. Indeed, narrowing the distal esophagus by any means does not resolve GERD. Concomitantly, the fundoplication itself does not increase resting lower esophageal sphincter pressure as it is evident on post-Nissen fundoplication esophageal manometry. Rather, a floppy and short fundoplication that does not mechanically restrict the distal esophagus is the recommended surgical technique.
An alternative mechanism of action is related to inhibition of transient lower esophageal sphincter relaxation (TLESR) events. TLESR events are believed to be the cause of GERD. Gastric fundus anatomy, physiology and motility affect TLESR event frequency and duration. Nissen, toupet or Dor fundoplication alters gastric fundus wall tension, distention, and motility and consequently it inhibits TLESR events leading to GERD resolution. I have previously hypothesized that gastric fundus resection may be partly equivalent to fundoplication in terms of TLESR control. Therefore, a properly performed sleeve gastrectomy resulting in complete gastric fundus resection without narrowing of the incisura angularis is associated with GERD resolution. Therefore, leaving a small remnant fundus to fold over the anterior esophagus in the setting of gastric sleeve surgery may be a useless step.
I agree with the authors that a concomitant hiatal hernia repair must be performed to re-establish the intra-abdominal position of the lower esophageal sphincter. I also agree with the idea that if the lower esophageal sphincter resting pressure is low, sleeve gastrectomy and hiatal hernia repair by themselves are not enough to fully control acid reflux disease. Roux- en-Y gastric bypass in this case may be a better option.