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Dr.Weight // Bariatric surgery // Operations aimed at narrowing the stomach // Laparoscopic Anti-Reflux Sleeve Gastroplasty (ASG)

Anti-Reflux Sleeve Gastroplasty

Laparoscopic Anti-Reflux Sleeve Gastroplasty (ASG)

Bariatric Surgery - Ц 2008

We developed a new bariatric operation that we call Anti-Reflux Sleeve Gastroplasty. It combines the principles of two bariatric procedures, namely sleeve gastrectomy and the Magenstrasse-and-Mill operation. Both are relatively new surgical options in the treatment of morbid obesity, with most surgeons reporting 50% to 80% loss of excessive weight.

At the same time, it is known that 30% of patients complain of heartburn after the procedure, necessitating administration of omeprazole (a drug reducing gastric acid production). This is because the original sleeve gastrectomy procedure destroys the valve mechanism of the junction between the esophagus and the stomach, converting it into a direct tube. If a sleeve gastrectomy is performed as the first stage of gastric bypass, then after the second stage (gastrojejunal bypass) the heartburn disappears. But if a sleeve gastrectomy is planned as a sole operation, then persistent heartburn might be a serious problem for the patient.

In order to avoid this, we speculated that a possible solution would be a combination of a very long and narrow vertical gastroplasty (resembling the Magenstrasse-and-Mill operation) and a well-known antireflux procedure, Nissen fundoplication. During a Nissen operation the fundus of the stomach is wrapped around the esophagus, restoring the normal valve function of this anatomic region.

Unlike the original sleeve gastrectomy, our operation does not involve the removal of any part of the stomach. In the beginning, the stomach is stapled and divided along a 1cm bougie, creating a narrow 20 cm tube. Then the divided fundus is passed behind the esophagus and a 360-degree wrap made. To date we have performed 11 such procedures.

Laparoscopic Anti-Reflux Sleeve Gastroplasty (ASG). Left Ц original state. Right Ц after operation.

Figure 7 Laparoscopic Anti-Reflux Sleeve Gastroplasty (ASG). Left Ц original state. Right Ц after operation.

Of course, our experience is not yet such as to permit a final conclusion, but the preliminary results are highly promising: none of the eleven patients who underwent this operation developed heartburn, and some lost more than 50 kg.

We believe that this technically simple operation could be an attractive form of bariatric surgery. The level of weight loss seems similar to Sleeve Gastrectomy and the Magenstrasse-and-Mill operation. The wrap, if made tight, could act not only as an antireflux mechanism, but also to some extent work similarly to a gastric band.

Furthermore, if the level of weight loss is not satisfactory in any particular patient, this operation can be easily converted to a more complex procedure, a gastric bypass, during which it would not be necessary to destroy the wrap.

In conclusion, the operations mentioned above (gastric banding, sleeve gastrectomy and Antireflux Sleeve Gastroplasty) are similar in their subsequent function but different in operative technique: during gastric banding the gastric wall is not cut, whereas during the latter two it is cut and sutured. But the main difference is that after gastric banding we can control the degree of gastric narrowing. After sleeve gastrectomy and ASG this is impossible and unnecessary.