TOUPET-SLEEVE: A HYBRID APPROACH TO MANAGE GERD IN PATIENTS WITH OBESITY
Luis Poggi, MD; Harold Guerrero, MD; Alessandra Rodriguez, MD; Rodrigo Rojas, MD; Bianca Brosset; Mateo Borja; Luciano Poggi, MD; CIFCAD / British American Hospital

Introduction and importance: Sleeve gastrectomy (SG) frequently leads to de novo or worsened GERD due to disruption of the angle of His, loss of fundus compliance, increased intragastric pressure, and impaired lower esophageal sphincter tone. These anatomical changes create a high-pressure, reflux-prone environment. This report presents a case where Toupet fundoplication was performed before SG to mitigate GERD risk in an obese patient.

Case presentation: A 49-year-old female with obesity and chronic GERD symptoms refractory to medical treatment was evaluated. Upper endoscopy revealed esophagitis. High-resolution manometry and pH-metry confirmed ineffective esophageal motility and abnormal acid exposure. The patient underwent laparoscopic Toupet fundoplication and partial gastrectomy. The postoperative course was uneventful, and the patient showed significant weight loss and sustained resolution of reflux symptoms at six-month follow-up.

Clinical discussion: This hybrid approach addresses GERD before SG, minimizing reflux risk while preserving the benefits of restrictive surgery. Staging the procedures allows for symptom resolution and improved esophageal motility prior to SG. Literature supports the role of anti-reflux procedures prior to or combined with bariatric surgery in select patients

Conclusion: Toupet fundoplication prior to SG may be a viable option to manage GERD in obese patients, offering symptomatic relief and weight loss without worsening reflux.

High-Resolution Manometry results
Parameter Normal values Preoperative 6 Months Postoperative
Esophageal Pressure - Supine
30-180 mmHg

90.7-80.3-8 99.1-89.8-71.1
LES Pressure - Supine 13 - 43 mmHg 44.6 25.3
DCI - Supine 500-800 mmHg/cm/seg 2905.3 1873.2
Peristaltic Reserve DCI - 3965.0 1259.8
IRP - Supine < 15 10 6.6
Lower Esophageal Sphincter - Supine 3-4 cm, 50% abdominal component 3.5 cm - 0.5 cm abdominal 4.7 cm -2.1 cm abdominal
Gastric Pressure 10 mmHg basal - 50 mmHg post 200 cc 25.5 basal - 31.7 post 200 cc 38.6 basal - 56.9 post 200 cc

24-Hour pH-Metry results
Parameter Normal values Preoperative 6 months postoperative
DeMeester Score < 14.72 33.1 4.6
AET (Acid Exposure Time) < 6% 8.3 % 1.2%