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

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.

To assess the safety and effectiveness of Toupet fundoplication plus re-sleeve for reflux control and weight loss after failed SG with HH.

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.

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.

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.