Surgical Management Algorithm for Intrathoracic Sleeve Migration: A Retrospective Series and Literature Review.

Background: With the increase in utilization of laparoscopic sleeve gastrectomy (LSG), intrathoracic sleeve migration (ITSM) has introduced a novel challenge for bariatric surgeons. Despite being an underreported complication, effective and safe solutions for ITSM are being sought. The aim of this study is to present our center's experience as well as a comprehensive review of the literature on ITSM. Accordingly, we propose an algorithm for the surgical management of ITSM. Methods: We conducted a retrospective chart review of 4000 patients who underwent LSG at our center. ITSM was clinically suspected with gastroesophageal reflux disease (GERD) symptoms and/or epigastric pain resistant to proton pump inhibitors. Diagnosis of ITSM was confirmed in all patients by three-dimensional computed tomography (3D-CT) volumetry. Several corrective procedures were offered based on the findings of the 3D-CT volumetry, esophagogastroduodenoscopy, and the diaphragmatic pillars' condition: cruroplasty with gastropexy, one anastomosis gastric bypass (OAGB), or Roux-en-Y gastric bypass (RYGB) with or without re-sleeve gastrectomy, omentopexy, or ligamentum teres augmentation. We conducted a literature review of ITSM using several databases. Results: Fifteen patients were diagnosed with postoperative ITSM. The most common presenting complaint was severely worsened GERD symptoms not responding to medical treatment. The mean time interval between the primary operation and diagnosis of ITSM was 38.8 ± 29.1 months. Three patients had re-sleeve gastrectomy and gastropexy, 5 patients had OAGB, and 7 patients had RYGB. The mean postoperative body mass index was 31.2 ± 4.9 kg/m2. No case of recurrent ITSM was detected during follow-up. Our electronic database search yielded 19 studies to be included in our review, which included 201 patients. Conclusion: A high index of suspicion is required to diagnose ITSM. CT volumetry with 3D reconstruction may be the most sensitive diagnostic modality. ITSM management should depend on the results of the diagnostic workup and the condition of the diaphragmatic pillars during surgery.

Evaluation of Anterior Phrenoesophageal Ligament Preservation During Hiatus Hernia Repair in Laparoscopic Sleeve Gastrectomy as an Anti-Reflux Measure.

Background: Laparoscopic sleeve gastrectomy (LSG) is the most common bariatric procedure, but it had been reported to increase the incidence of gastroesophageal reflux disease (GERD) and its consequences. Some surgeons tried to decrease that by routine hiatal dissection with hiatus hernia (HH) repair. But, hiatal dissection with HH repair is considered an important risk factor for the newly emergent complication of intrathoracic sleeve migration (ITSM). We proposed a new hiatal repair technique, which is expected to improve GERD without increasing the potential for ITSM. This study aims to evaluate the results of this technique. Methods: A prospective observational study was performed at the Ain Shams University Hospital between January 2016 and December 2019. It included patients with morbid obesity and one of the following: Clinical manifestations of GERD with endoscopic evidence of HH/laxity or esophagitis. Asymptomatic HH/laxity. LSG combined and HH repair with anterior phrenoesophageal ligament (PEL) preservation was performed for all patients. Patients were followed up for 12 months. Patients were evaluated after 1 year with an upper gastrointestinal (GI) endoscopy. Results: Thirty-two patients were enrolled in our study. After 1 year, the mean excess weight loss was 63% ± 23%. The mean GERD health-related quality of life (GERD-HRQL) score dropped to 12 ± 8. GERD-HRQL scores improved in 25 of documented esophagitis patients, worsened in 2, and did not change in 2 patients. Endoscopy showed a decrease in rate and degree of esophagitis (from 28 [87.5%] preoperatively to 8 [25%] patients after 1 year of follow-up). The improvement was better in patients with grade A and B esophagitis. Two patients were converted to gastric bypass due to persistent intractable GERD symptoms with grade C esophagitis despite medical treatment. No cases of ITSM were detected. Conclusion: Anterior PEL preserving HH repair combined with LSG is a safe and feasible technique that can control GERD manifestations without interference with the technique or outcome of LSG.