Ligamentum Teres Cardiopexy for GERD *after* the sleeve

[SleevedK 25]

I just recently found out that there is a surgical procedure that might be helpful for those of us who have a hiatal hernia and GERD after the sleeve to repair the problem without having to convert to an RNY. It is called "Cardiopexy with Ligamentum Teres" (basically they wrap part of a ligament from your liver around the esophagus to reinforce the lower esophageal sphincter)
Here is a recent article that discusses this technique if any of you want to show it to your doctor and get their thoughts.
https://www.americanjournalofsurgery.com/article/S0002-9610(20)30814-X/fulltext#gr2
And here is a video of a surgery performing it:
https://www.youtube.com/watch?v=t_SbDqhueRU

Have any of you had this done, or at least been able to talk to your surgeon about it? It seems like this is not yet being done widely, so I would welcome any info any of you have about it. If you have had this done or know someone who did, what were their results like? Thanks!

[KateinMichigan 24]

Hi Sleeved K,

I am seeing Dr.Hawasli who wrote the article on the 15th of April 2021. It seems old - so it'll be interesting to see what he says. I'll let you know.https://www.sciencedirect.com/science/article/abs/pii/S000296102030814X#!

[SleevedK 25]

I would love to hear what he says to you about it, KateInMichigan! It would be great to know if this is really a viable option.

[KateinMichigan 24]

Me too! I've also spoken with Dr. Jossart in California who has done many hiatal hernia (HH) repairs post sleeve for those with GERD. This sounds perfect for you. He said he's done 125+ repairs with a 90% success rate. Only 1 of these patients out of over 125 needed a conversion to bypass.

As someone with no energy, horrible anemia (iron infusions) and low final weight - the bypass conversion sounds like a disaster waiting to happen, so I'm praying for a HH to show up on my latest swallow test. I've had several scopes over the years, and they can never find a HH, but according to Dr. Jossart that isn't uncommon, and he feels there is a very high likelihood that it's small and the doctor's I've seen are missing it. This gives me hope - that's why I wanted to share it. Hope is everything.

I also feel I should share that new research on PPI's show that they are now linked to depression (PPI's rank #1 as OTC drug that causes depression) and eye problems (including blindness). This is new research coming out to add to the list of problems it causes. We all need to get off PPI's!

Lastly, a few surgeons are now doing the sleeve with HH repair first, and with other GERD preventative measures DURING surgery. These doctors "get it", and are being proactive because they've seen the pain that GERD causes. I would suggest that ALL sleeve pre op patients have this discussion with their surgeon before moving forward, if he downplays it, RUN. If you are in the 30% that suffer, it's severely lowers your quality of life. I've been suffering for 14 years with too many dead end Dr. Appointments to count. Stanford, UofM - I've consulted with the best "experts" over the years and found found many shake their heads with a sort of "you're on your own" attitude.

I truly believe that the only hope we have is with a bariatric surgeon who really understands what was done and who has done the surgery - but also does GERD repairs. These doctors are rare and you need to really hunt for them.

When most hear "acid reflux" as a potential side effect, they think "so what, I'll have to take a tums once in a while". It's NOT that sort of reflux. It's debilitating. It's vomiting after half a cup of Water. It's pain after every single meal. It's instant dependency of horrific drugs with a myriad of side effects - including blindness and cancer. If my doctor had told me I had a 30% chance of this version of GERD, I would have run for the hills.

If your doctor does the whole "very rare", etc. (my doctor did), he's either: not reading recent studies, not listening to his patients, not following up on them (my doctor just pawned me off to a GERD doctor), minimizing this horrific side effect, or all of the above. Don't settle of a doctor who acts like it's super rare or no big deal. Find one that is proactive and discusses HOW they avoid it.

Please share with me all your research. I'm rooting for you!

[SleevedK 25]

I am so glad that you mentioned that Dr. Jossart is experienced in dealing with this issue. I will need to look into that. Did you have to make an appointment with his office staff to talk to him?
I am sorry that you are suffering with these issues too, but I am also glad that you are here and talking about what you have learned. It is so nice to hear from someone else who is interested in this topic and taking action to try to figure it out. This is such a difficult problem because it seems like there aren't a ton of people who have dealt with it so you feel kind of alone struggling to find help with a complicated problem that even many doctors don't seem to understand very well. To be honest, I desperately wish that I had never had the sleeve, because I didn't understand at the time what trouble it could lead to, and I NEVER wanted a bypass under any circumstance. I wish I had made it more clear to my doctor at the time that I did not consider the bypass an option and maybe then she would not have done the sleeve.

Here are a couple of other leads that I have found that you might want to check into:

Dr. Kenneth J. Chang at UC Irvine is doing research into an experimental method of controlling GERD with an endoscopic procedure that can be done post-sleeve.
https://www.ucihealth.org/find-a-doctor/c/kenneth-chang
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6133678/

Dr. Olaya I Brewer Gutierrez at Johns Hopkins is apparently close to starting a clinical trial using a similar endoscopic procedure:
https://clinicaltrials.gov/ct2/show/NCT04771247

Edited March 26, 2021 by SleevedK

[SleevedK 25]

I saw this webpage for Dr. Elias Darido, who appears to be very knowledgeable about the sleeve and says that in many cases a hernia repair alone will stop the reflux. He will do virtual consults online. However, I have not yet found anyone who has actually seen him as a patient, so I don't actually know much about him.
https://houstonsleevesurgeon.com/category/acid-reflux-and-heartburn/

I also found out that Dr. Keshishian, who I know is pretty well known in the WLS world, has experience with repairing hernias after sleeves:
https://www.dssurgery.com/laparoscopic-hiatal-hernia-repair/

[SleevedK 25]

I also found some articles by Dr. Craig Chang, who seems to be very aggressive about repairing hiatal hernias in his bariatric patients and apparently has had good results. Perhaps he is worth consulting with as well?
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4754198/
https://www.sages.org/meetings/annual-meeting/abstracts-archive/sleeve-gastrectomy-with-reinforced-laparoscopic-hiatal-hernia-repair-outcomes-and-clinical-experience/

[KateinMichigan 24]

On 3/26/2021 at 7:38 PM, SleevedK said:

I also found some articles by Dr. Craig Chang, who seems to be very aggressive about repairing hiatal hernias in his bariatric patients and apparently has had good results. Perhaps he is worth consulting with as well?
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4754198/
https://www.sages.org/meetings/annual-meeting/abstracts-archive/sleeve-gastrectomy-with-reinforced-laparoscopic-hiatal-hernia-repair-outcomes-and-clinical-experience/

I sent you an email with my phone number. Please text if you get the chance. I’m seeing 3 doctors in the next 2 weeks and thought we could share research!

[KateinMichigan 24]

On 3/26/2021 at 7:33 PM, SleevedK said:

I saw this webpage for Dr. Elias Darido, who appears to be very knowledgeable about the sleeve and says that in many cases a hernia repair alone will stop the reflux. He will do virtual consults online. However, I have not yet found anyone who has actually seen him as a patient, so I don't actually know much about him.
https://houstonsleevesurgeon.com/category/acid-reflux-and-heartburn/

I also found out that Dr. Keshishian, who I know is pretty well known in the WLS world, has experience with repairing hernias after sleeves:
https://www.dssurgery.com/laparoscopic-hiatal-hernia-repair/

You are a wealth of knowledge! Loved both links. Hope!

[JRL1989 3]

On 3/29/2021 at 3:22 PM, KateinMichigan said:

I sent you an email with my phone number. Please text if you get the chance. I’m seeing 3 doctors in the next 2 weeks and thought we could share research!

How did your appointments go?

I had a scope, showed HH (recurrent, as it was apparently fixed during my sleeve) and a "patulous LES" (wide open lower esophageal sphincter), so I guess that explains my regurgitation.

I see my WLS surgeon again for follow-up next Thursday. I am pretty sure he's going to try to strong-arm me into converting to RNY.

[SleevedK 25]

Do you know if you are a candidate for Linx, JRL? That is an option for fixing the hernia and LES, *if* you have enough esophagus motility for it.
I would definitely talk to a surgeon who does Linx before I would agree to a bypass.

It is hard for me to accept the idea of being forced into a bypass when I really regret ever getting bariatric surgery to begin with. I feel like I am worse off this way than I would have been with my original stomach and the extra weight.

[JRL1989 3]

2 hours ago, SleevedK said:

Do you know if you are a candidate for Linx, JRL? That is an option for fixing the hernia and LES, *if* you have enough esophagus motility for it.
I would definitely talk to a surgeon who does Linx before I would agree to a bypass.

It is hard for me to accept the idea of being forced into a bypass when I really regret ever getting bariatric surgery to begin with. I feel like I am worse off this way than I would have been with my original stomach and the extra weight.

I had an esophageal manometry test (which I don't know the results for, will get next week when I see WLS surgeon), but regardless - I am in Canada. LINX is not approved for use here in Canada. I asked him at 3 months post-op where he told me LINX isn't approved, and that he thinks in 15 years - LINX will be the new gastric band story - lots of erosion etc. So, LINX isn't an option for me, really.

I'm going to explore alternative options with him to see what he thinks. I'll be bringing the Ligamentum Teres paper, and also the BARF paper showing hiatal hernia repair works for these symptoms too. It's not that I absolutely won't agree to getting RNY, but I really truly feel like RNY should be a last resort. Not the first-line response to non-PPI responsive GERD after sleeve.

[Bariatricwarrior 2]

I know this is a year plus after the original post but I have had the ligament wrap done . It is amazing!

[KateinMichigan 24]

Wow! I’m so glad to hear this worked for you! Could you share the results? How bad was your GERD? Are you off all PPI’s now?

[Bariatricwarrior 2]

Hi ! Yes so I am 12 days post op this surgery and i felt instant relief they always say notice a huge difference at 2 weeks post op and at 6 weeks post op you get go come off ppis and all the swelling is down!

I had a stricture, my sleeve was sliding up through my diaphragm creating a sliding hiatal hernia and severe severe severe reflux. I have been on 5 different reflux meds and was taking 120 mg a day plus pepcid twice a day . Also was npo for ten weeks from aspirating on stomach acid and not able to keep anything down not even fluids . Was on tpn via picc line and a feeding tube . So it was pretty bad . But this surgery saved my life!