Post-laparoscopic sleeve gastrectomy, intrathoracic sleeve migration and its management: A case series and review of literature

Abstract

De novo or persistent gastro-oesophageal reflux disease which may or may not be associated with injury of the oesophageal mucosa is now a known complication in post-sleeve gastrectomy patients. Repair of hiatal hernias to avoid such circumstances has been commonly performed, although recurrences may occur resulting in migration of gastric sleeve into the thorax, which is now a well-known complication. We report four cases of post-sleeve gastrectomy patients who presented with reflux symptoms, with their contrast-enhanced computed tomography abdomen showing intrathoracic sleeve migration and had hypotensive lower oesophageal sphincter with normal body motility on their oesophageal manometry. A laparoscopic revision Roux-en-Y gastric bypass surgery with hiatal hernia repair was performed for all four of them. No post-operative complications were seen at 1-year follow-up. Laparoscopic reduction of migrated sleeve with posterior cruroplasty and conversion to Roux-en-Y gastric bypass surgery can be safely performed for patients presenting with reflux symptoms in cases of intra-thoracic sleeve migration with good short-term outcomes.

INTRODUCTION

Laparoscopic sleeve gastrectomy is a commonly performed procedure for patients with morbid obesity. Although less commonly reported almost 25%–75% of patients are found to have de novo or persistent gastroesophageal reflux disease (GERD) which may be associated with injury of the oesophageal mucosa.[1] Repair of hiatal hernias to avoid such circumstances has been commonly performed, although recurrences may occur resulting in migration of gastric sleeve into the thorax.[2,3]

This complication, which is now a well-known entity, is often managed by conversion to a Roux-en-Y gastric bypass surgery.[4]

CASE REPORT

In all, four cases were included in this study, of which two were male and two females, between 48-65 years of age. Their complaints consisted of intermittent burping, belching, volume reflux and occasional vomiting episodes post meals, none of them had any complaints of dysphagia. All of them had undergone a laparoscopic sleeve gastrectomy in the past (2011–2019) and the onset of these symptoms was 3–5 years after the surgery, pre-operative upper gastrointestinal scopy was normal, no signs of gastro-oesophageal reflux disease were seen before the sleeve gastrectomy surgery. Post-sleeve gastrectomy, a contrast-enhanced computed tomography, upper gastrointestinal endoscopy and oesophageal manometry were performed in all these cases along with the routine pre-operative work-up.

Contrast-enhanced computed tomography of the abdomen of all patients showed features of sliding hiatus hernia (intrathoracic sleeve migration) with herniation of gastro-oesophageal junction [Figure 1a and b], gastric fundus with omentum into the posterior mediastinum, separation between right and left crura 23–30 mm, the terminal oesophageal portion was dilated with mild circumferential mural thickening. Upper gastro-intestinalscopy showed changes of gastro-oesophageal reflux disease in all four patients with changes of Barrett’s with low-grade dysplasia in one case [Figure 2b]. Oesophageal manometry [Figure 2a] showed hypotensive lower oesophageal sphincter with normal body motility in all four cases.

Figure 1.

(a and b) CECT showing migration of gastric sleeve into the posterior mediastinum. (Blue arrows). CECT: Contrast-enhanced computed tomography

Figure 2.

(a) Oesophageal Manometry report showing hypotensive LES with normal body motility. (b) OGD scopy report showing Barrettes oesophagus with hiatus hernia. OGD: Oesophago Gastro Duodenoscopy

Patients then underwent an elective laparoscopic revision surgery. Intraoperatively, reduction of the gastric sleeve [Figure 3a] was made after meticulous adhesiolysis around the sleeve, full mobilisation of the distal oesophagus with a length of 5 cm and mobilisation of gastric sleeve were achieved. The diaphragmatic hiatus defect was closed with polyester suture 2-0 [posterior cruroplasty was performed - Figure 3b]. A 7 fr Fogarty catheter was inserted to check the adequacy of hiatal closure, intraoperatively [Figure 4a]. Sleeve was transected 3 cm below the gastro-oesophageal junction [Figure 4b]. Bilio-pancreatic limb marked 50 cm distal to the DJ flexure and an antecolic gastro-jejunal anastomosis [Figure 5a] was performed using staplers creating a 2.5 cm stoma. Enterotomy was closed with PDS 3-0 and additional sero-muscular sutures were taken with prolene 2-0.

Figure 3.

(a) Laparoscopic view of the migrated sleeve (green arrow) being reduced into the abdominal cavity. (b) Laparoscopic view of posterior cruroplasty (yellow arrow) being performed

Figure 4.

(a) 7 French Fogarty catheter (green arrow) being used to check the adequacy of hiatal closure intro-operatively. (b) Laparoscopic view of sleeve being transected 3 cm below GE junction (blue arrow). GE: Gastroesophageal

Figure 5.

(a) Laparoscopic gastro-jejunal anastomosis being performed (blue arrow). (b) Laparoscopic bowel measurement being done

Roux limb marked at 100 cm [Figure 5b] and jejuno-jejunal anastomosis [Figure 6a] done with a linear stapler and enterotomy closed with 3-0 PDS. BPL divided with endo stapler just proximal to gastro-jejunal anastomosis. Mesenteric and petersons defect closed with 2-0 prolene.

Figure 6.

(a) Laparoscopic jejuno-jejunal anastomosis being performed (green arrow). (b) Intra-operative leak test being performed

The intraoperative leak test was found to be negative [Figure 6b]. The post-operative stay was for 3–4 days and was uneventful. At 1-year follow-up, none had dysphagia and none of the patients required proton-pump inhibitors.

DISCUSSION

Laparoscopic sleeve gastrectomy is being frequently done as it is technically simpler to perform when compared with other bariatric procedures with equally good weight loss outcomes.[5] In the recent literature, there have been several instances and case reports of it accelerating pre-existing or causing new-onset gastro-oesophageal reflux disease.[6,7] In patients with pre-existing reflux who underwent SG, some authors have reported resolution of reflux post-SG in 75% of patients, while others reported the presence of reflux in 78% of patients, and new-onset reflux or de novo reflux was seen in 22% of patients.[8,9] A case of acute obstruction has also been reported, where the hiatal hernia had got incarcerated, causing acute obstruction of the oesophageal outlet.[10] Debate still remains whether the hiatal repair should be performed or not with laparoscopic sleeve gastrectomy. A study published by Baumann et al. showed 37% migration of sleeve into posterior mediastinum 1–10 months post-sleeve gastrectomy, in which 40% had reflux symptoms and 60% were asymptomatic.[11] A case series of six patients in which hiatal hernia repair was performed with laparoscopic sleeve gastrectomy, showed recurrence in only one patient on follow-up.[12]

The factors most likely to be responsible for intrathoracic sleeve migration include sudden weight loss post-sleeve gastrectomy causing enlargement of the diaphragmatic hiatus, muscle depletion of the diaphragm, dissection of the hiatal ligaments-phreno-oesophageal and phrenogastric, tubular shape of gastric sleeve, angle of his dissection, high-pressure zone due to intact pylorus, dilatation of gastric tube, leading to increased intragastric pressure, difficulty in anchoring the sleeve to the surrounding structures.[13]

The management of such complications such as GERD and hiatal hernias associated with LSG is now a topic of concern which makes it imperative to consider various procedures such as conversion to Roux-en-Y gastric bypass, hiatal hernia repairs, LINX magnetic sphincter, laparoscopic ligament teres cardiopexy and fundoplication. In laparoscopic ligament teres cardiopexy, wrapping of the ligament augments lower oesophageal sphincter pressure and its pulling effect of gastro-oesophageal junction, leading to control of reflux.[14,15] Conversion to Roux-en-Y gastric bypass surgery for the management of such complications remains the most commonly done procedure. Conversion to Roux-en-Y gastric bypass is not preferred by some patients due to its associated malabsorptive complications as well as the operative risks involved.[16,17]

A few authors have used bio-absorbable mesh for hiatal repair during laparoscopic sleeve gastrectomy, while some have used fixation of the gastric sleeve to the mesocolon near the edge of the pancreas to avoid intra-thoracic sleeve migration.[18] LINX magnetic sphincter is another alternative but is expensive and not covered by most insurance companies.[19] Fundoplication is difficult to perform due to the lack of sufficient fundus post-SG. Laparoscopic ligament teres cardiopexy is a newer alternative with few reported complications.[19]

The role of conversion to Roux-en-Y gastric bypass in the control of reflux includes the traction created by the small intestine, which is anastomosed to the gastric pouch which prevents intra-thoracic sleeve migration and it has a low-pressure system unlike laparoscopic sleeve gastrectomy.[20] The resolution of reflux post-sleeve gastrectomy by conversion to Roux-en-Y gastric bypass is approximately 80%.[21]

CONCLUSION

Laparoscopic reduction of migrated sleeve with posterior cruroplasty and conversion to Roux-en-Y gastric bypass can be safely performed for patients presenting with reflux symptoms in cases of intrathoracic sleeve migration and have resulted in relief of symptoms in short follow-up.

However long term follow up and a study of larger number of patients is required. Similarly, comparative studies with other options are desirable to establish the standard of care.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.