Background: Gastroesophageal reflux (GER) is one of the most common indications for conversion of sleeve gastrectomy (LSG) to laparoscopic Roux-en-Y gastric bypass (LRYGBP). Objective evaluations are necessary in order to choose the best definitive treatment for these patients. Aim: To present and describe the findings of the objective studies for gastroesophageal reflux disease performed before LSG conversion to LRYGBP in order to support the indication for surgery. Method: Thirty-nine non-responder patients to proton pump inhibitors treatment after LSG were included in this prospective study. They did not present GER symptoms, esophagitis or hiatal hernia before LSG. Endoscopy, radiology, manometry, 24 h pH monitoring were performed. Results: The mean time of appearance of reflux symptoms was 26.8+24.08 months (8-71). Erosive esophagitis was found in 33/39 symptomatic patients (84.6%) and Barrett´s esophagus in five. (12.8%). Manometry and acid reflux test were performed in 38/39 patients. Defective lower esophageal sphincter function was observed independent the grade of esophagitis or Barrett´s esophagus. Pathologic acid reflux with elevated DeMeester´s scores and % of time pH<4 was detected in all these patients. more significant in those with severe esophagitis and Barrett´s esophagus. Radiologic sleeve abnormalities were observed in 35 patients, mainly cardia dilatation (n=18) and hiatal hernia (n=11). Middle gastric stricture was observed in only six patients. Conclusion: Patients with reflux symptoms and esophagitis or Barrett´s esophagus after SG present defective lower esophageal sphincter function and increased acid reflux. These conditions support the indication of conversion to LRYGBP.

BACKGROUND: Laparoscopic Nissen fundoplication fails to control the gastroesophageal reflux in almost 15% of patients, and most of them must be reoperated due to postoperative symptoms. Different surgical options have been suggested. AIMS: This study aimed to present the postoperative outcomes of patients submitted to three different procedures: redo laparoscopic Nissen fundoplication alone (Group A), redo laparoscopic Nissen fundoplication combined with distal gastrectomy (Group B), or conversion to laparoscopic Toupet combined with distal gastrectomy with Roux-en-Y gastrojejunostomy (Group C). METHODS: This is a prospective study involving 77 patients who were submitted initially to laparoscopic Nissen fundoplication and presented recurrence of gastroesophageal reflux after the operation. They were evaluated before and after the reoperation with clinical questionnaire and objective functional studies. After reestablishing the anatomy of the esophagogastric junction, a surgery was performed. None of the patients were lost during follow-up. RESULTS: Persistent symptoms were observed more frequently in Group A or B patients, including wrap stricture, intrathoracic wrap, or twisted fundoplication. In Group C, recurrent symptoms associated with this anatomic alteration were infrequently observed. Incompetent lower esophageal sphincter was confirmed in 57.7% of patients included in Group A, compared to 17.2% after Nissen and distal gastrectomy and 26% after Toupet procedure plus distal gastrectomy. In Group C, despite the high percentage of patients with incompetent lower esophageal sphincter, 8.7% had abnormal acid reflux after surgery. CONCLUSIONS: Nissen and Toupet procedures combined with Roux-en-Y distal gastrectomy are safe and effective for the management of failed Nissen fundoplication. However, Toupet technique is preferable for patients suffering from mainly dysphagia and pain.

Laparoscopic sleeve gastrectomy can be associated with significant morbidity. Dehiscence of the staple line and gastric leak are some of the severest complications. The aim of this study was to compare three different methods of gastric suture in terms of staple line strength and leak volume/pressure of the sleeved stomach. The resected stomachs of 20 patients subjected to laparoscopic sleeve gastrectomy were evaluated for bursting volume/pressure after extraction from the abdomen. The specimens were categorized into three groups according to the staples that were used. The staple line of each specimen was divided into three groups: group A, standard green cartridge stapler [stapler closure 4.0 mm] and standard blue cartridge [stapler closure 3.5 mm] for antrum and body/fundus, respectively, with interrupted suture over the intersection of stapler suture line for reinforcement [n=10]; group B, standard green and blue loads but without reinforcement [n=4]; and group C, Tri-Stapler® mechanical [stapler closing 3.0-3.5-4.0 mm] devices without reinforcement [n=6]. Leak volume/pressure was determined by injection of methylene blue solution into the lumen of the resected stomach and by recording the pressure at which the leakage occurred. Intragastric pressure and volume of first leak and location of leak were recorded. Twenty sleeved gastrectomy specimens were included. The leak pressure was significantly higher [34.0 SD 20.7 mm Hg] in group C. The volume of the resected stomach was also greater in group C [1083.3 SD 343 cc]. Leaks were observed indistinctly in the antrum body or fundus of the stomach. We found higher burst pressure and volume in stomachs resected with Tri-Stapler®. It could be a safer device for performing sleeve gastrectomy.