Toupet Fundoplication With Re-sleeve for Hiatal Hernia Associated With Failed Sleeve Gastrectomy.

Abstract

<h4>Background</h4>Sleeve gastrectomy (SG) may induce or worsen gastroesophageal reflux disease (GERD), especially with coexisting hiatal hernia (HH). Evidence on combining Toupet fundoplication with re-sleeving is limited.<h4>Objective</h4>To assess the safety and effectiveness of Toupet fundoplication plus re-sleeve for reflux control and weight loss after failed SG with HH.<h4>Methods</h4>Prospective single-center series of 20 adults (30-60 years) with failed SG (≤50% excess weight loss at one year and/or BMI >35 kg/m²) and medically refractory GERD. Preoperative workup included endoscopy and contrast imaging. Surgery entailed complete hiatal dissection, posterior cruroplasty, 270° (Toupet) fundoplication using residual fundus with fixation to the crura, and re-sleeve over a 36-Fr bougie. The outcomes considered were: GERD resolution, complications, excess weight loss (EWL%) at three, six, and 18 months, and changes in comorbidities.<h4>Results</h4>The mean age of the patients was 42.8 years, 65% of the total patients were females, and the follow-up period was 18 months. HH was confirmed perioperatively in 55%; all had symptomatic GERD. The mean operative time was 100±22.6 minutes, and the hospital stay was 40±18.7 hours. No leaks, bleeding, reoperation, or mortality were observed; transient nausea in 40% resolved conservatively. GERD was resolved in 65% of the patients, 25% required proton pump inhibitors (PPIs) for three months, and 10% for six months, then as needed. No HH recurrence was observed. The excess weight loss percentage (EWL%) observed was as follows: 21% (three months), 42% (six months), 63.2% (18 months). Antihypertensives were discontinued. Diabetes remitted in 10% patients with dose reduction in one additional patient.<h4>Conclusion</h4>Toupet fundoplication with re-sleeve appears to be a safe and effective option for controlling GERD and promoting weight loss after failed SG with HH. Larger comparative studies are needed.