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SIPS with LF can treat GERD in bariatric patients

SIPS with LF has effective early weight loss and a satisfactory anti-reflux effect

Stomach intestinal pylorus sparing surgery (SIPS) with laparoscopic fundoplication (LF) for treating gastroesophageal reflux disease (GERD) in bariatric patients, has concluded that SIPS with LF is a technically feasible procedure can have good anti-reflux effects and substantial weight loss during the short term follow up. The paper, 'Stomach intestinal pylorus sparing surgery (SIPS) with laparoscopic fundoplication (LF): a new approach to gastroesophageal reflux disease (GERD) in the setting of morbid obesity', was published in the journal SpringerPlus.

In their paper the research team, led by Dr Daniel Cottam from the Bariatric Medicine Institute, Salt Lake City, UT, state that laparoscopic fundoplication (Nissen or Toupet) alone does not give satisfactory results when used for GERD in morbidly obese patients. Therefore, they decided to their data involving both LF and SIPS, which they state has the potential to provide optimal weight loss and optimal anti-reflux characteristics while limiting complications associated with laparoscopic gastric bypass (LRYGBP) for GERD in the setting of morbid obesity

The study is a retrospective analysis of the initial experience from a single surgeon at single institution and the primary objective of this study was to evaluate the SIPS procedure along with LF in terms of weight loss, operative complications, and GERD resolution.

All the patients included in the study were experiencing GERD symptoms before surgery and underwent esophagogastroduodenoscopy (EGD) and a transnasal endoscopy (TNE) to assess GERD symptoms and erosive esophagitis (EE).

SIPS technique

The researchers explain that each case begins with placement of four trocars and a liver retractor, and the short gastric vessels are taken down to facilitate the dissection of the para-oesophageal hernia repair. The entire sac is removed using blunt and sharp dissection using an ultrasonixs dissector (Covidien). This dissection is carried superiorly until approximately 5cm of intra-abdominal length is achieved. The hernias are all repaired posterior to the oesophagus with a two layer running technique with an endostich and 2.0 surgidac sutures.

The first layer is a deep layer that starts where the crus meets inferiorly and goes up to the base of the oesophagus. Once the oesophagus is reached they check to make sure there is no anterior defect, the suture line is run down back to the starting point and tied to the end of the stitch. This repair is reinforced with a PTFE felt mesh or Pariatex mesh (Covidien). Then a 40 French Bougie is placed. Depending on the patient, the wrap is created in a fashion described by Toupet or Nissen.

Next a Sleeve Gastrectomy is performed. The lesser sac is entered 4–6cm from the pylorus. Then an Endo GIA (Covidien) stapler is fired along the previously placed sizing tube. Once the staple line reaches the prior LF, the staple line deviates laterally attempting to resect as much of the fundus as possible. Blood vessels to the lesser curve are persevered ensuring adequate blood supply.

The next step is to divide the duodenal bulb. This is done by taking down all the gastro-epiploic vessels from the end of the sleeve dissection to past the pylorus. A band passer is then placed towards the liver under the duodenum, and a window is made through the duodenal-hepatic ligament. Once the window is created, an Endo GIA (Covidien) stapler is passed around the duodenum and divides the duodenum 3cm from the pylorus circumferentially. The distal duodenal stump is then sewn over with absorbable suture.

Next the ileo-cecal valve is located and traced retrograde to 300cm and that point is brought up and sewn to the proximal duodenal staple line. The loop limb is sewn to the proximal duodenal stump using 2.0 Polysorb (Covidien). Enterotomies are made in both the limbs and 3.0 Polysorb is used to do another posterior row and anterior row (Figure 1).

Figure 1: Diagrammatic representation of SIPS with Nissen Fundoplication

The anastomoses are tested intra-operatively with pressurized air to check for leaks. The resected portion of the stomach is taken out of the abdominal cavity. Antibiotics and deep vein thrombosis (DVT) prophylaxis are used in all patients. The patients were discharged the next day if they did not exhibit nausea, vomiting or any other discomfort.

All the patients had a post-operative upper gastro-intestinal (UGI) series before leaving the hospital to assess for leaks and obstructions and the adequacy of the wrap. All patients were seen back in clinic for follow up at one week, one month, three months, six months, and one year. They assessed typical GERD symptoms via the GERD-HRQL questionnaire.


The study incuded a total of five patients aged between 18-85 years. The mean operative time overall was 115min and the mean post-operative hospitalisation stay was 2.4±1.14 days. Two patients (40%) had perioperative complications; one patient had an ileus, while the other had low oxygen saturation on day two (both the complications were mild and patients recovered uneventfully).

With regard to weight loss, excess weight loss (%) at six months was 47.9±8 and 84.2±3.4 at 12 months, whilst excess BMI loss (%) at six months was 56.8±11.5 and 102.2 ± 6.4 at 12 months. In addition, GERD-HRQL questionnaire revealed patient satisfaction with a mean patient score of 6.2.

“According to our short-term follow up after SIPS with LF, we clearly demonstrate that it has effective early weight loss and a satisfactory anti-reflux effect…” they conclude. “Additional long term follow ups and larger study populations would be required to further evaluate the outcomes of this novel technique to see if it is applicable to all bariatric GERD patients or should be reserved for special circumstances like we presented in this paper.”

To access this paper, please click here

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