IBC Oxford University Oral Abstract 1 - Ligamentum teres cardiopexy for de novo refractory reflux following sleeve gastrectomy: a good use for a spare part

Abstract Introduction GERD is a recognized complication of sleeve gastrectomy (SG), with an incidence of up to 32% in patients without preexisting reflux. Historically, the remedy for refractory GERD following sleeve gastrectomy has been conversion to a Roux-en-Y gastric bypass (RYGB). Many patients opt for SG over RYGB due to the increased risk of short- and long-term complications associated with the more invasive bypass. In 1964, Narbona proposed a modification to the fundoplication whereby the ligamentum teres (LT), a vestige of the umbilical vein, was used to create a sling that is secured circumferentially around the gastric cardia, anchoring the stomach to the crural pillars, thereby reinforcing the LES and preventing intrathoracic migration. In recent years, several studies and case reports have demonstrated successful resolution or improvement of GERD symptoms using this technique following LSG. Methods The present study identified 40 patients who underwent sleeve gastrectomy and developed de novo GERD refractory to behavioral and medical management. Hiatal hernia (HH) was diagnosed radiographically by upper GI study in 38 patients (95%) and/or endoscopically in 13 patients (32.5%). Symptom severity was assessed pre- and post-operatively using the GERD-HRQL. Anti-reflux medication frequency was compared before and 6 months after the procedure. All patients underwent a laparoscopic HH repair with posterior cruroplasty. The LT was mobilized from the umbilicus to the liver. It was then wrapped circumferentially around the GE junction, securing it to itself, the stomach, and the crural pillars, reinforcing the LES and preventing intrathoracic migration. Data were analyzed using a one-tailed T-Test with P < 0.01 considered significant. Results All patients lost significant weight (avg. 9.0 BMI points). There was a significant (P = 7.67E−16) reduction in the GERD-HRQL from 30.2 ± 9.2 before surgery to 8.13 ± 7.9 after the procedure. Similarly, there was a significant (P = 3.56E−12) reduction in anti-reflux medication from 2.15 ± 1.1 doses per day to 0.36 ± 0.63 post-operatively. One patient developed recurrent GERD and was converted to RYGB. At surgery, the LT was found to have necrosed, and the GE junction was in the mediastinum. Conclusion It is estimated that 60% of people with morbid obesity have a HH. This study suggests that a dormant HH, perhaps resulting from central obesity but masked by adiposity around the hiatus, may manifest after significant weight loss. The absence of a fundus in those with SG poses a challenge that can be overcome by utilizing vestigial tissue from the umbilical cord in the form of an LT cardiopexy to provide an alternative to conversion to an RYGB. Moreover, this might be a consideration during the index operation to prevent subsequent development of GERD. Further study utilizing manometry and pH measurements will be necessary to fully substantiate this as an option in treating GERD following sleeve gastrectomy.