Obesity is currently a major health problem. 2% of the French adult population is
morbidly obese (BMI>40kg/m²). In this case, the only effective treatment is bariatric
surgery. More than 50,000 acts of bariatric surgery were performed in 2018 in France.
Three main operations are considered: Sleeve Gastrectomy (SG), Roux en Y Gastric Bypass
(RYGB) and Gastric Banding.
SG was validated by the Haute Autorité de Santé (HAS) in 2008 and is the most widely used
procedure in France (35,580 operations in 2018). It consists of a 2/3 partial
gastrectomy. Long-term weight loss of 61 ± 23% is expected, with significant improvement
in obesity-related comorbidities.
However, this technique is associated with postoperative complications. Gastric fistula
(2%), most often located at the upper end of the stapling line, bleeding from the gastric
section (2%) and gastric stenosis (1%) are the most frequent early postoperative
complications that may require reoperation. In addition, gastroesophageal reflux disease
(GERD) is very common (30-57%), and can have serious consequences for the esophageal
mucosa (esophagitis, Barrett's esophagus, cancer). Alarmingly high rates of Barrett's
esophagus (17-18%) after SG have recently been described in the long term, causing
concern in the medical community. This may be an exacerbation of preoperative GERD
symptoms or "de novo" postoperative GERD. Medical treatment is generally effective
(proton pump inhibitors (PPIs)). However, the long-term safety of PPIs has not been
demonstrated. What's more, these patients' quality of life may be considerably reduced,
and re-intervention (gastric Y-bypass) may be necessary to treat refractory GERD.
The classic surgical treatment for GERD, independently of bariatric surgery, is
fundoplication, which can be partial (180°: Toupet technique) or total (360°: Nissen
technique). The gastric fundus is wrapped around the esophagus to reinforce the
esophageal sphincter.
Nissen-Sleeve Gastrectomy (Nissen-SG) is an innovative technique performed in expert
centers in France. It consists in creating a total anti-reflux fundoplicature (Nissen)
before performing a SG.
A prospective non-comparative pilot study of 25 patients who underwent Nissen-SG in 2014
at Montpellier University Hospital, showed that while 92% of patients had symptoms of
GERD preoperatively, 24% were symptomatic at 3 months after Nissen and SG, only 12% had
clinical GERD at 6 months and 1 year postoperatively. Excess weight loss at 1 year was
59%, similar to the efficacy of conventional SG, although a larger gastric residual
volume was left after Nissen-SG but used as plication. The 5-year results were presented
at the SOFFCO 2020 congress and at the International Federation of Obesity Surgery (IFSO)
congress. Excess weight loss (EWL) was 70.87% (112 patients) and 58.32% (31 patients) at
2 and 5 years follow-up. Less than 7% of patients had GERD symptoms at 5 years.
Our hypothesis is that the creation of a total anti-reflux fundoplicature prior to
performing SLEEVE could significantly reduce the rate of postoperative GERD observed with
standard SLEEVE.
What's more, the creation of a Nissen fundoplicature means that a gastric section is made
away from the HIS angle (the area most at risk of fistula (90%)), which could reduce this
complication almost definitively (no gastric fistula on the staple line in this pilot
study).
Quality of life and socio-economic impact could be significant if such hypotheses are
confirmed. However, complications specific to the Nissen sleeve, such as dilatation and
perforation of the envelope, were also reported in this prospective trial. A 3.9% rate of
perioperative complications after Nissen Sleeve was described after the learning curve of
the procedure on 301 patients (2018-2020).
Our aim in this study is to highlight that there are no more complications when
performing Nissen-SG than SG (taking published PMSI data) and to show a decrease in
post-operative GERD after Nissen-SG. To achieve this, data will be collected on patients
undergoing Nissen-SG surgery in 2022 until 2024 in 18 French hospitals. For these
patients, any post-operative complications and the presence/evolution of GERD will be
collected and compared with SG data available in the literature.