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Recent publications in the literature show de novo GERD in almost 60% of patients after sleeve gastrectomy in the long-term. To solve this problem, in 2013 a new technique was proposed: adding a Nissen fundoplication when performing the sleeve gastrectomy to prevent de novo GERD or treat a preexisting condition in morbidly obese patients.
Regarding the surgical technique, a fundamental step is to fix the wrap of the Nissen sleeve (N-sleeve) in the lower part of the esophagus but avoiding the gastroesophagic junction, so that the distal esophagus can be seen below the wrap. This consideration is important to avoid future dilations of the wrap. Then the sleeve gastrectomy can be performed just under the wrap. At the end of the operation, an indocyanine green test can be performed to discard ischemia of the fundoplication. Another interesting maneuver is to perform a “gastric tube test” to check if the food will follow the correct path during oral intake, avoiding its presence in the wrap which would dilate the fundoplication, in some cases resulting in future necrosis and stomach perforation..
This procedure will result in a decrease in morbidity of sleeve gastrectomy patients. Not only will postoperative GERD rates decrease, but also the rate of leaks at the level of the angle of His, solving two of the main problems associated with the sleeve gastrectomy procedure. Results of the follow-up in the mid-term show good rates of excess weight loss along with <10% rate of GERD in operated patients.