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Sphincter Augmentation and Management …
Fig. 17 Positioning of the
Linx device between the
posterior vagus nerve and
the esophagus at the gastro
esophageal junction
Fig. 18 Locking the Linx
device in place using two
locking sutures attached to
the device. I properly locked
device will resist opening and
will sit in a relaxed position
on the distal esophagus
305
Fig. 19 Proper orientation of
the Linx device in place
Fig. 20 The device is relaxed
and there is only gentle
compression on the lower
esophageal sphincter
Fig. 21 The device should
not appear tight when in the
proper position and should
rest at the gastroesophageal
junction on the distal most
position of the esophagus
Fig. 22 Final completed
positioning of the Linx
device. The Linx passes
between the posterior vagus
nerve and the esophagus. The
posterior crural defect has
been closed and there is no
tension on the esophagus at
the site of the implant
H. T. Billy et al.306
Fig. 23 Completed
implantation of a Linx
sphincter augmentation device
at the lower esophageal
junction following sleeve
gastrectomy
9 Discussion
The controversy of worsening reflux following post sleeve gastrectomy and GERD
is now well established [23]. Development of new-onset GERD following LSG is
observed in as many as 8.6–22% of patients [24, 25]. The increasing rate of reflux
following sleeve gastrectomy is alarming and some authors have reported unacceptable and high rates of reflux related transition to Barrett’s esophagus.
Sphincter Augmentation and Management …
Fig. 24 The proper position
and appearance of a Linx
device following implantation
after sleeve gastrectomy
307
The LINX® gained FDA approval in 2012. Magnetic sphincter augmentation is
now an important option to consider among patients who have undergone sleeve
gastrectomy who subsequently develop severe and pathologic reflux disease. The
division and injury of sling fibers comprising the major anti reflux mechanism at
the gastroesophageal junction result in anatomic changes that are not favorable for
performing a Nissen or Toupet fundoplication. As a result, fundoplication following sleeve gastrectomy is nearly impossible to perform due to the limited amount
of fundus tissue remaining. Implantation of a LINX® device occurs at the gastroesophageal junction, through tissue and operative planes that are typically undisturbed during sleeve gastrectomy. This may be a more favorable less complicated
approach to the problem of post sleeve gastrectomy reflux than the current recommendation of conversion to gastric bypass.
Conversion to a gastric bypass following sleeve gastrectomy produces a reduction in acid exposure-related symptoms with high success rates but comes with the
increased morbidity associated with revision surgery [26, 27]. The routine conversion of patients to Roux-Y gastric bypass creates an unnecessary risk of internal
hernia, marginal ulceration, reactive hypoglycemia and other complications which
are entirely avoidable with the implantation of a sphincter augmentation device.
Surgical options that attempt to address the mechanism of postoperative reflux
have historically been limited to the repair of a hiatal hernia as fundoplication is
typically impossible after sleeve gastrectomy. Magnetic Sphincter augmentation
can also be used in patients following sleeve gastrectomy with no clinical evidence of hiatal hernia or who do not desire conversion to a bypass procedure [28,
29]. Magnetic sphincter augmentation is an underutilized procedure and may be
the most exciting and straightforward treatment option for the patient developing
Fig. 25 Proper location
and positioning of Linx
device on post operative
barium swallow. There is
a gentle narrowing at the
gastroesophageal junction
and no evidence of reflux
following placement
H. T. Billy et al.308
GERD after sleeve gastrectomy. MSA is the only procedure that restores LES
function after sleeve gastrectomy. Roux Y gastric bypass does not create an anti
reflux mechanism, rather it provides a drainage function that decreases reflux
related incidents but does not nothing to improve or restore the antireflux function of the lower esophageal sphincter. Roux Y gastric bypass is well documented
to have its own rate of postoperative GERD, does not restore LES function and
is at best an unpredictable procedure for the treatment for reflux following sleeve
gastrectomy.
There are now several series demonstrating improved outcomes following magnetic sphincter augmentation following sleeve gastrectomy. Device erosions and
other complications following magnetic sphincter augmentation are rare and erosion rates of less than 0.5% are well established [30, 31]. Magnetic sphincter
augmentation achieves at least 50% improvement in reflux related symptoms in
patients undergoing implantation for routine reflux related symptoms and medical
therapy can be discontinued in up to 90% of patients [24]. Magnetic sphincter augmentation after sleeve gastrectomy for GERD has the potential to be a less morbid
solution with better short and long term outcomes for the difficult problem of reflux
following sleeve gastrectomy. MSA is well tolerated and can be performed on an
Sphincter Augmentation and Management …
Fig. 26 The contrast flows
easily through the Linx device
with no significant delay of
contrast transiting through the
device. There is no evidence
of esophageal pooling or
delay clearing the distal
esophagus
309
outpatient basis with immediate results. The risk of anastomotic leakage and postoperative staple line bleeding associated with conversion to Roux-Y gastric bypass
is completely avoided. Magnetic sphincter augmentation is a safe and effective procedure with a low complication rate. MSA achieves complete restoration of LES
function and is completely reversible should postoperative dysphagia result in difficult eating or discomfort [32, 33]. Conversion to Roux-Y gastric bypass can and
should be preserved as a last resort option for the majority of successful sleeve gastrectomy patients who have developed post-operative reflux symptoms.
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311
Omentopexy in Laparoscopic Sleeve Gastrectomy
Mohanned-Al-Haddad
1 Background
Sleeve gastrectomy (SG) was first performed by Hess in 1988 as part of a as a
component of the malabsorptive procedure, the biliopancreatic diversion with duodenal switch [1]. The promising results of SG in terms of weight loss and resolution of comorbidities as a first stage, combined with a low rate of complications,
has encouraged the global emergence and monumentally rapid spread of SG as a
standalone procedure. In 2009, the American Society for Metabolic and Bariatric
Surgery (ASMBS) issued a position statement recommending laparoscopic sleeve
gastrectomy (LSG) as a standalone bariatric procedure [2]. Currently, LSG and
Roux-en-Y gastric bypass are the most commonly performed bariatric procedures
in United States and Asia/Pacific regions [3]. However, despite having a comparatively lower morbidity rate among bariatric procedures, LSG has several postoperative complications, both acute and chronic. Moreover, the alteration of gastric
anatomy, a loss of ligamentous fixation, and the progressive rotation of the stable line associated with this procedure are widely believed to be the reasons for
the formation of a twisted or spiral stomach in a condition similar to organoaxial
gastric volvulus [4]. The resulting functional narrowing, despite a fairly normal
luminal diameter, has been linked with a wide range of postoperative gastrointestinal symptoms, such as nausea, vomiting, and gastroesophageal reflux disease
(GERD). In response, the use of omentopexy during LSG is believed by many bariatric surgeons to play a major role in solving this problem [4], and this approach
is used routinely in an attempt to regain the normal anatomic fixation of the new
Mohanned-Al-Haddad (*)
Jaber Al-Ahmed Al-Sabah Hospital, Kuwait, Kuwait
e-mail: dr.moq8@hotmail.co.uk
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer
Nature Switzerland AG 2021
S. Al-Sabah et al. (eds.), Laparoscopic Sleeve Gastrectomy,
https://doi.org/10.1007/978-3-030-57373-7_31
313
Mohanned-Al-Haddad314
greater curvature of the sleeved stomach to the gastrocolic and gastrosplenic
ligaments.
2 Clinical Benefits of the Omentum
Various surgical specialties uses the omentum in their practices. Due to its intrinsic features, the omentum not only inhances the healing process in the setting
of inflammation, it also has the ability to halt bleeding through direct pressure
and acceleration of the formation of fibrin clots [5]. Considering these remarkable properties, surgeons are using the omentum to close perforations in the
gastrointestinal tract and to reinforce gastrointestinal anastomosis. Also, it has
been shown that the omentum has a role in heart repair following myocardial
infarction because of its capability for angiogenesis and smooth muscle production [6]. In addition, a recent study concluded that laparoscopic placement of a
peritoneal dialysis catheter using omentopexy minimise catheter obstruction and
migration [7].
3 Omentopexy in Sleeve Gastrectomy
3.1 Definition
The neutral orientation of the stomach is maintained by four anchoring ligaments:
gastrophrenic, gastrosplenic, gastrocolic, and gastrohepatic. Use of the omentum by omentopexyin LSG entails the suturing the free end of the greater omentum—the gastrocolic and gastrosplenic ligaments—to the gastric suture line on the
new greater curvature of the sleeved stomach to resume its normal anatomic position in an effort to improve postoperative food tolerance, slow gastric emptying
(GE), and reduce symptoms of GERD.
3.2 Operative Technique
The patient is positioned in the 30-degree reverse Trendelenburg position with legs
abducted. A 5-port technique is used, including a 5-mm port inserted in the epigastrium for liver retraction, a 10-mm port inserted supraumbilicaly slightly to the left
for the camera, a 12-mm right hypochondrial midclavicular port and a 15-mm left
hypochondrial midclavicular port, and a 5-mm left anterior axillary line port for
the assistant surgeon.
Once all the steps for LSG are completed, the integrity of the stable line is
confirmed by the methylene blue test and hemostasis of the staple line is secured.
Then the divided free edge of the omentum—the gastrocolic and gastrosplenic ligaments—is identified and sutured it to the stable line of the sleeved stomach in a
continuous fashion. Using polydioxanone sutures (PDS) 2–0, the suturing starts
Omentopexy in Laparoscopic Sleeve Gastrectomy
2 cm distal to gastroesophageal junction to the antrum, until approximately 2 cm
proximal to the pylorus, leaving 1 cm distance between each suture line to avoid
ischaemia.
315
4 Effect on Food Intolerance and Gastroesophageal
Reflux Disease
Although the relationship between LSG and GERD is still a matter of discussion, several studies have correlated LSG with worsening GERD. In a study by De
Groote et al. In which they performed a systemic review to compare various bariatric procedures and their effect on GERD, LSG was found to aggravate postoperative GERD [8]. Loss of efficacy of the antireflux barrier, twisting of the gastric
remnant, decreased gastric compliance, and decreased lower esophageal sphincter
pressure have all been suggested as possible factors associated with the development of postoperative GERD [9–13].
Various surgical techniques have been suggested to reduce the postoperative
food intolerance and symptoms of GERD, most of which are proposed to minimise gastric malposition resulting from loss of ligmentous fixation. A study by
Daes et al. demonstrated that the correct alignment of the gastric sleeve is maintained by equidistant stapling of the anterior and the posterior walls to prevent
coiling [14]. However, asymmetrical staples leading to the formation of twisted
sleeve is always a possibility, and therefore omentopexy of the gastric remnant is
believed to counteract such a twist.
In 2015, the first randomised study ofomentopexyin LSG compared 2 patients
groups (omentopexy vs. no-omentopexy) in terms of decreased postoperative
food intolerance and gastrointestinal symptoms, and no significant difference was
found between groups [15]. In contrast, growing evidence suggests that the impact
of omentopexy on the reduction of postoperative gastrointestinal symptoms has
been observed in many recent studies. A retrospective study by Arslan E et al. concluded that omentopexy can in fact reduce the incidence of gastric volvulus by
reducing the gastric mobility and restoring the stomach back to its natural anatomic position [15]. Currently, the association of omentopexy in the reduction of
food intolerance and GERD symptoms is still controversial, and increasing evidence supports the key role of this surgical technique on reducing the incidence of
postoperative GERD.
5 Effect on Gastric Emptying
Unsurprisingly, small gastric volume is believed to be associated with rapid GE
because of rapid gastric distension. Acceleration of GE for food and liquid following SG has been shown on scintigraphy [16, 17]., Fixation of the omentum to
the new greater curvature of the stomach to restore the natural anatomic position
has been observed to slow GE [15]. However, data are insufficient to support this