The Gastric Bypass and Fundoplication in Bariatric Surgery: the Comments on Published Papers and Our Classification of Combination Procedures

A Randomized Controlled Trial of Acid and Bile Reflux Esophagitis Prevention by Modified Fundoplication of the Excluded Stomach in One-Anastomosis Gastric Bypass: 1-Year Results of the FundoRing Trial

BACKGROUND

The advantages and disadvantages of one-anastomosis gastric bypass (OAGB) with primary modified fundoplication using the excluded stomach ("FundoRing") is unclear. We aimed to assess the impact of this operation in a randomized controlled trial (RCT) and answer the next questions: (1) What the impact of wrapping the fundus of the excluded part of the stomach in OAGB on protection in the experimental group against developing de novo reflux esophagitis? (2) If preoperative RE could be improved in the experimental group? (3) Can preoperative acid reflux as measured by PH impedance, be treated by the addition of the "FundoRing"?

METHODS

The study design was a single-center prospective, interventional, open-label (no masking) RCT (FundoRing Trial) with 1-year follow-up. Endpoints were body mass index (BMI, kg/m2) and acid and bile RE assessed endoscopically by Los Angeles (LA) classification and 24-h pH impedance monitoring. Complications were graded by Clavien-Dindo classification (CDC).

RESULTS

One hundred patients (n = 50 FundoRingOAGB (f-OAGB) vs n = 50 standard OAGB (s-OAGB)) with complete follow-up data were included in the study. During OAGB procedures, patients with hiatal hernia underwent cruroplasty (29/50 f-OAGB; 24/50 s-OAGB). There were no leaks, bleeding, or deaths in either group. At 1 year, BMI in the f-OAGB group was 25.3 ± 2.77 (19-30) vs 26.48 ± 2.8 (21-34) s-OAGB group (p = 0.03). In f-OAGB vs s-OAGB groups, respectively, acid RE was seen in 1 vs 12 patients (p = 0.001) and bile RE in 0 vs 4 patients (p < 0.05).

CONCLUSION

Routine use of a modified fundoplication of the OAGB-excluded stomach to treat patients with obesity decreased acid and prevented bile reflux esophagitis significantly more effectively than standard OAGB at 1 year in a randomized controlled trial.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04834635.

The Surgical Technique of Primary Modified Fundoplication Using the Excluded Stomach with Simultaneous Gastric Bypass

PURPOSE

The aim of this work is to demonstrate a new concept of the surgical technique "FundoRing" for the prevention of acid and bile reflux esophagitis after gastric bypass.

MATERIALS AND METHODS

A laparoscopic surgical technique of gastric bypass simultaneous with combined upper total and lower left partial fundoplication. This described case is a participant in an ongoing randomized clinical trial.

RESULTS

The patient was without complications and was discharged on the third postoperative day. Delta BMI was 14 kg/m² (38-24) at the 1-year follow-up. The patient did not have heartburn or bile reflux esophagitis after surgery. Evaluation of the mucosa of the esophagus by upper endoscopy after each of the 3 follow-up visits demonstrated that reflux esophagitis had resolved. Intraoperative fluorescence imaging technologies (NIR/ICG) (IMAGE1 S™ Rubina®) were to determine the quality of blood supply-no violation of the blood supply to the fundoplication wrap of the gastric pouch was detected. A CT scan clearly shows a fundoplication ring around the esophagus (two-thirds) and the upper part of the gastric pouch (one-third).

CONCLUSION

The surgical technique of primary modified fundoplication using the excluded stomach with simultaneous gastric bypass is feasible.

One anastomosis gastric bypass with fundoplication of remnant stomach for weight regain prevention: Case report

INTRODUCTION

Weight regain is a serious issue after bariatric surgery. Using banding for one anastomotic gastric bypass prevents weight regain, but carries the risk of band erosion. The combination of bariatric procedures and fundoplication for patients without hiatal hernia probably prevents weight regain. However, no studies are demonstrating this.

PRESENTATION OF CASE

A 38-year-old woman who underwent laparoscopic one anastomosis gastric bypass with fundoplication of remnant stomach maintained a stable body weight after 5 years.

DISCUSSION

Owing to the complications associated with the conventional methods, the combination treatment has several advantages such as prevention leak of suture line in the gastric pouch prevention.

CONCLUSION

The combination treatment could successfully prevent weight regain and thus, will be helpful in the better management of obesity.

A laparoscopic one anastomosis gastric bypass with wrapping versus nonwrapping fundus of the excluded part of the stomach to treat obese patients (FundoRingOAGB trial): study protocol for a randomized controlled trial

BACKGROUND

Laparoscopic one anastomosis gastric bypass (LOAGB) is a simple variation of gastric bypass and has gained worldwide popularity with clinical outcomes similar to laparoscopic Roux-en-Y gastric bypass (LRYGB) for weight loss and management of comorbidities. However, biliary reflux to the esophagus negates the benefits of LOAGB. In addition, weight gain after LOAGB and after LRYGB is a major problem in bariatric surgery. The aim of this article is to describe the design and protocol of a randomized controlled trial comparing the outcomes of two methods of LOAGB: experimental method with wrapping versus standard method nonwrapping fundus of the excluded part of the stomach to prevent weight regain and biliary reflux after LOAGB.

METHODS

The study was designed as a single-center prospective, interventional, randomized controlled trial. Masking: None (open label). Allocation: randomized. Enrollment: 100 obese patients. The relevant ethics committee approved the trial protocol. The endpoints (body mass index, bile reflux in the esophagus, other reflux symptoms) will be assessed presurgery and postsurgery (12, 24, and 36 months postoperatively).

DISCUSSION

With its 3-year follow-up time, this RCT will provide important data on the impact of wrapping the fundus of the excluded part of the stomach to prevent weight regain and biliary reflux after LOAGB.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04834635 . Registered on 8 April 2021.

A laparoscopic one anastomosis gastric bypass with wrapping versus nonwrapping fundus of the excluded part of the stomach to treat obese patients (FundoRingOAGB trial): study protocol for a randomized controlled trial

Background

Laparoscopic one anastomosis gastric bypass (LOAGB) is a simple variation of gastric bypass and has gained worldwide popularity with clinical outcomes similar to laparoscopic Roux-en-Y gastric bypass (LRYGB) for weight loss and management of comorbidities. However, biliary reflux to the esophagus negates the benefits of LOAGB. In addition, weight gain after LOAGB and after LRYGB is a major problem in bariatric surgery.

The aim of this article is to describe the design and protocol of a randomized controlled trial comparing the outcomes of two methods of LOAGB: experimental method with wrapping versus standard method nonwrapping fundus of the excluded part of the stomach to prevent weight regain and biliary reflux after LOAGB.

Methods

The study was designed as a single-center prospective, interventional, randomized controlled trial. Masking: None (open label). Allocation: randomized. Enrollment: 100 obese patients. The relevant ethics committee approved the trial protocol.

The endpoints (body mass index, bile reflux in the esophagus, other reflux symptoms) will be assessed presurgery and postsurgery (12, 24, and 36 months postoperatively).

Discussion

With its 3-year follow-up time, this RCT will provide important data on the impact of wrapping the fundus of the excluded part of the stomach to prevent weight regain and biliary reflux after LOAGB.

Trial registration

ClinicalTrials.govNCT04834635. Registered on 8 April 2021.