Is Roux-en-Y gastric bypass safe after previous antireflux surgery? Technical feasibility and postoperative symptom assessment

The impact of obesity on gastroesophageal reflux disease recurrence following re-operative anti-reflux surgery

INTRODUCTION

Obese patients represent a large proportion of patients experiencing recurrent reflux and re-operations after initial anti-reflux surgery. However, there is a limited data describing the impact of obesity on GERD recurrence following re-operative procedures.

METHODS

A review of patients who underwent re-operative anti-reflux surgery (Re-ARS) between 2012 and 2023. Peri-operative characteristics and post-operative Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) scores were compared across the three BMI categories: (BMI < 25 kg/m2, 25 ≤ BMI > 30 kg/m2, and BMI ≥ 30 kg/m2) over 12 IQR (9-14.9) months follow-up. Impedance planimetry measurements were included when it was utilized intraoperatively.

RESULTS

Of 718 patients who underwent robotic ARS, 84 patients (11.6%) underwent Re-ARS, of which 29.7% had a BMI < 25 kg/m2, 35.7% were ≤ 25 BMI < 30 kg/m2, and 34.5% had a BMI ≥ 30 kg/m2. The lower esophageal sphincter distensibility decreased similarly between groups with no differences in post-induction [3.2 ± 2 vs 4.5 ± 3.1 vs 3.9 ± 2.5 mm2/mmHg, p = 0.44] or post-fundoplication values [1 ± 0.6 vs 1.3 ± 0.7 vs 1.2 ± 0.6 mm2/mmHg, p = 0.46]. There was a significant improvement in GERD-HRQL scores postoperatively compared to preoperative levels across the three BMI classes (BMI < 25 kg/m2: pre 17 IQR (12-22), post 7.5 (1.5-15), p = 0.04 vs ≤ 25 BMI < 30 kg/m2: pre 26 IQR (10-34), post 8 IQR (0-17), p < 0.01 vs BMI ≥ 30 kg/m2: pre 44 IQR (26-51), post 5 IQR (3.5-14.5), p < 0.001) during 12 IQR (9-14.9) months follow-up. The rates of hiatal hernia recurrence on barium swallow [5.2 vs 15.7 vs 13.7%, p = 0.32] during 7 IQR (5.2-9.2) months follow-up, and endoscopy [13.3 vs 16.6 vs 7.1%, p = 0.74] during 11.8 (IQR 5.6-17.1) months follow-up period were also similar between groups.

CONCLUSION

GERD-HRQL scores in obese patients are expected to improve similarly compared to non-obese patients. Indicating that Re-ARS may be appropriate for patients across a range of BMIs.

Safety and efficacy of Roux-en-Y gastric bypass as revisional bariatric surgery after failed anti-reflux surgery: a systematic review

This systematic review evaluates the safety and efficacy of Roux-en-Y gastric bypass (RYGB) on weight loss and anti-reflux outcomes when used as a revisional bariatric surgical procedure after failed anti-reflux surgery. A systematic literature search next to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed for articles published by 30 Mar 2022. After examining 416 papers, 23 studies were included (n = 874 patients). Primary anti-reflux surgery included mainly Nissen fundoplication (16 studies). Reasons for revisional surgery included predominantly gastroesophageal reflux disease (GERD) (reported by 18 studies), obesity (reported by 6 studies), and hiatal hernia (reported by 6 studies). Interval to surgical revision was 5.58 ± 2.46 years (range, 1.5-9.4 yr). Upper endoscopy at revision was performed for all patients; esophageal manometry and pH monitoring were reported in 6 and 4 studies, respectively. Mean body mass index (BMI) at revision was 37.56 ± 5.02 kg/m2 (range, 31.4-44 kg/m2). Mean excess weight loss was 69.74% reported by 12 studies. Delta BMI reported by 7 studies was 10.41 kg/m2. The rate of perioperative complications was 16.7%, including mostly stenosis, leakage, ventral hernia, and small bowel obstruction. Mean improvement rate of GERD was 92.62% with a mean follow-up of 25.64 ± 16.59 months reported in 20 studies. RYGB seems to be an efficient surgical treatment option in failed anti-reflux procedures, but should be performed in experienced centers for selected patients, since the rate of perioperative and long-term complications must be minimized. Cooperation between bariatric and reflux surgeons is essential to offer patients with obesity and GERD the best long-term outcome.

Revisional One-Anastomosis Gastric Bypass (OAGB) After Intrathoracic Migration of Nissen Fundoplication

According to the latest IFSO recommendations, bariatric and metabolic surgery is the recommended treatment for patients with a BMI above 35 kg/m² (with or without associated pathology), achieving good results in terms of weight loss in the medium to long term, as well as improving a significant percentage of comorbidities in this type of patient (diabetes mellitus, arterial hypertension, dyslipidaemia, gastro-esophageal reflux disease (GERD)...). The incidence of GERD is higher in patients with obesity, with more severe symptoms. Over the years, Nissen fundoplication has been the gold standard treatment for patients with GERD who do not respond to medical treatment. However, in patients with obesity, gastric bypass is a valid option to consider. We present the case of a patient who had previously undergone anti-reflux surgery (laparoscopic Nissen) for GERD, with favorable evolution, who presented intrathoracic migration of the same after 8 years, with new onset of symptoms, and who was offered revision bariatric surgery. The video presents on the performance of OAGB in a patient who had previously undergone antireflux surgery, with intrathoracic Nissen. Performing this technique after a previous Nissen fundoplication (as well as migration of the Nissen) is a somewhat more complex procedure than primary surgery but can be performed safely with careful technique (there are often previous adhesions that hinder mobility and separation of the fundoplication) and provides good symptom control.

Efficacy and safety of laparoscopic Roux-en-Y gastric bypass in symptomatic patients following fundoplication failure: a meta-analysis

Revisional surgery may be required in a subset of patients who remain symptomatic despite undergoing laparoscopic fundoplication (LF) for gastroesophageal reflux disease (GERD). While revisional LF (RLF) is feasible in these patients, laparoscopic Roux-en-Y gastric bypass (LRYGB) may serve as an alternative, although its efficacy and safety remains unknown. This study aimed to determine the outcomes of LRYGB in symptomatic patients following failed LF for GERD. MEDLINE, EMBASE, and PubMed databases were systematically searched for studies reporting LRYGB outcomes in symptomatic adults despite undergoing LF for GERD. Postoperative symptom resolution, recurrence of heartburn and dysphagia, proton pump inhibitor (PPI) use, and body mass index (BMI) reduction were assessed to determine LRYGB efficacy. Postoperative morbidity and mortality were used to evaluate LRYGB safety. Twenty-two studies with 1523 patients were included. Pooled rates of symptom resolution, recurrence of heartburn and dysphagia, PPI use, morbidity, and mortality were 71.6% (95% CI 59.4-86.4), 15.6% (8.9-27.3), 20.7% (12.5-34.3), 29.6% (18.8-46.5), 39.5% (29.9-52.3), and 2.2% (1.2-4.0), respectively, following LRYGB. Similar rates were observed after RLF. However, BMI reduction was significantly greater after LRYGB compared with RLF (mean difference 6.1 kg/m², 4.8-7.4; p < 0.0001). LRYGB resulted in symptom relief in a majority of patients, and proved comparable to RLF regarding symptom recurrence and PPI use. Morbidity and mortality following LRYGB also did not differ from RLF. However, LRYGB was associated with considerably greater weight loss relative to RLF. Therefore, LRYGB is efficacious and an acceptable revisional procedure in symptomatic GERD patients who have previously undergone LF.

A Technique of Preserving Preexisting Fundoplication When Converting to Roux-en-Y Gastric Bypass

BACKGROUND

The standard surgical treatment of gastro-esophageal reflux disease (GERD) consists of either 360° (Nissen, NFP) or 270° (Toupet, TFP) fundoplication. On some occasions, such as recurrent GERD and/or severe overweight, patients may benefit from conversion to Roux-en-Y gastric bypass (RYGB), which is however technically difficult. Most techniques of conversion involve unwrapping of the fundoplication. We developed a laparoscopic technique that includes preservation of the wrap, while constructing a standard small-pouch RYGB. We describe the surgical technique and report the short-term outcomes of our technique.

METHODS

Consecutive patients underwent conversion of NFP to RYGB by our fundoplication preserving technique as described in surgical technique. Perioperative outcomes were assessed by analysis of the electronic patient records; progression of GERD symptoms and patient satisfaction were evaluated by an on-line questionnaire.

RESULTS

Fourteen patients underwent the conversion. There were no peroperative complications and no conversions. Short-term complications were registered in 4 patients (Clavien-Dindo grade 1, n = 2; grade 2, n = 1 and grade 3a, n = 1). No long-term complications were reported. None of the participants reported significant GERD symptoms Patient satisfaction was good.

CONCLUSION

We developed a laparoscopic technique of NFP to RYGB conversion, with preservation of fundoplication integrity, which appears to add to the safety and efficacy of the procedure.

Bariatric Surgery After Previous Antireflux Surgery Without Takedown of the Previous Fundoplication: a Prospective Study

BACKGROUND

The increased prevalence of reflux disease in obese patients, combined with widespread availability of laparoscopic antireflux surgery, has increased the likelihood that more patients will seek bariatric surgery having previously undergone fundoplication.

OBJECTIVES

This study examined our series of laparoscopic bariatric surgery after previous antireflux surgery without takedown of the previous fundoplication. We discuss our results, our technique and the tips and tricks to avoid complication after this procedure.

SETTING

Private practice.

METHODS

We operated on patients suffering from obesity who had already undergone laparoscopic Nissen. The patients were eligible for bariatric surgery according to the French National Institute of Health's criteria for bariatric surgery. The pre-operative assessment involved gastroscopy with biopsies looking for Helicobacter pylori, oesophago-gastroduodenoscopy, investigation for sleep apnoea syndrome and a full laboratory assessment. The patients took part in their choice of surgery.

RESULTS

The patients' post-operative course was uncomplicated. No patients had symptoms of gastro-esophageal reflux late after surgery and good gastrointestinal comfort was achieved (no pain, no reflux). All of the patients were satisfied. Length of stay was 3 to 5 days. All patients exhibited significant weight loss.

CONCLUSION

Bariatric surgery is possible after fundoplication without taking down the fundoplication. It appears to be a viable alternative in patients seeking weight loss surgery after fundoplication, which is currently assumed contraindicated.

Augmentation of Hiatal Repair with the Ligamentum Teres Hepatis for Intrathoracic Gastric Migration After Bariatric Surgery

PURPOSE

The augmentation of hiatoplasty (HP) with the ligamentum teres hepatis (LTA) is a new concept for intrathoracic migration of a gastric sleeve or pouch (ITGM). We retrospectively analyzed all cases of hiatal hernia repair in a single center between 2015 and 2019.

METHODS

A total of 171 patients underwent 307 hiatal hernia repairs after sleeve gastrectomy (SG) (n = 79), Roux-en-Y gastric bypass (RYGB) (n = 129), and one anastomosis gastric bypass (OAGB) (n = 99). Each hiatal hernia repair was defined as a "case" and assigned to the LTA group or the non-LTA group. The primary outcome was the recurrence of ITGM as detected by endoscopy or CT.

RESULTS

The basic characteristics in the LTA group (78 cases) and the non-LTA group (229 cases) were comparable with the exception of the rate of revisional HP (72% vs. 21%), the rate of prior conversion to RYGB (33% vs. 17%), the initial BMI (45.9 ± 8.2 kg/m² vs. 49.0 ± 8.8 kg/m²), and the follow-up (7 months (1-16) vs. 8 months (1-54)). The ITGM recurrence rate was 15% in the LTA group and 72% in non-LTA group (p < 0.001). Multivariate analysis showed that the length of ITGM and the type of surgical repair were independent risk factors. The addition of LTA to HP lowered the probability of ITGM recurrence by a factor of 0.35 (p = 0.015), but the conversion from SG or OAGB to RYGB did not reduce the risk.

CONCLUSIONS

LTA reduces the risk of early ITGM recurrence. The long-term durability, however, needs to be further investigated.

Best reoperative strategy for failed fundoplication: redo fundoplication or conversion to Roux-en-Y gastric diversion?

BACKGROUND

Failed fundoplication is a difficult reoperative challenge, with limited evidence differentiating outcomes of a redo fundoplication versus conversion to Roux-en-Y anatomy with a gastric diversion (RYGD). The aim of this study was to determine the impact of these reoperative strategies on symptom resolution.

METHODS

A retrospective single institution study of patients with failed fundoplications undergoing conversion to RYGD or redo fundoplication between 2006 and 2019 was conducted. Patient characteristics, preoperative evaluation, operative findings, and postoperative outcomes were recorded and analyzed.

RESULTS

180 patients with symptomatic, failed fundoplications were identified: 101 patients (56.1%) underwent conversion to RYGD, and 79 patients (43.9%) underwent redo fundoplication. Body mass index (BMI) was significantly higher for the patients undergoing RYGD with mean BMI of 34.3 ± 6.9 vs 27.7 ± 3.9 kg/m² (p < 0.001). Patients undergoing conversion to RYGD were also more comorbid than their counterparts, with higher rates of obstructive sleep apnea (17.8% vs 5.1%, p = 0.01), but similar rates of hypertension (54.5% vs 44.3%, p = 0.18, asthma/COPD (25.7% vs 16.5%, p = 0.13), diabetes (10.9% vs 10.1%, p = 0.87), and hyperlipidemia (29.7% vs 36.7%, p = 0.32). Mean operative times were significantly higher for the RYGD (359.6 ± 90.4 vs 238.8 ± 75.6 min, p < 0.0001), as was mean estimated blood loss (168.8 ± 207.5 vs 81.0 ± 145.4, p < 0.0001). Conversion rates from minimally invasive to open were similar (10.9% vs 11.4%, p = 0.92). The incidence of recurrent reflux symptoms was not significantly different (p = 0.46) between RYGD (16.8%) and redo fundoplication (12.8%), at an average follow-up of 50.6 ± 140.7 vs 34.7 ± 39.2 months, (p = 0.03). For the RYGD cohort, patients also had resolution of other comorbidities including obesity 35.6%, OSA 16.7%, hyperlipidemia 10.0%, hypertension 9.1%, and diabetes 9.1%. On average, patients decreased their BMI by 6.8 ± 5.5 kg/m² and lost 69.6% of their excess body weight. Mean length of stay was higher in patients undergoing RYGD (5.3 ± 7.3 vs 3.0 ± 1.9 days, p = 0.01). Thirty-day readmission rates were similar (9.9% vs 3.8%, p = 0.12). The reoperation rate was higher in the RYGD cohort (17.8% vs 2.5%, p = 0.001).

CONCLUSIONS

RYBG and redo fundoplication are equivalent in terms of resolution of reflux. RYGD resulted in significant loss of excess body weight.

Efficacy and Safety of Recurrent Paraesophageal Hernia Repair with Roux-en-Y Gastric Bypass

Roux-en-Y gastric bypass (RYGB) has been explored as a revisional option to failed paraesophageal hernia (PEH) repair with fundoplication, particularly in patients suffering from obesity. However, few studies have assessed long-term outcomes of RYGB with revisional PEH repairin regard to acid-suppressing medication use. We retrospectively identified 19 patients who underwent revisional PEH repair with RYGB between 2011 and 2018. The median operative time was 232 minutes with a median hospital length of stay of two days. The median length of follow-up was 24 months. Two patients (10.5%) had complications in the first 30 days, and five patients (26.3%) had complications within one year. Of the 12 patients on preoperative acid suppression, 6 (50%) were either off medication or on reduced dose at 12 months. The median BMI decrease was 14.4 kg/m2at 12 months and did not change significantly afterward. Although rates of acid-suppression medication use did not change overall after revisional PEH repair with RYGB, patients experienced successful long-term management of morbid obesity and sustained weight loss. Revisional PEH repair with RYGB is a safe and effective option, with a complication rate comparable with the reported rates after revisional foregut procedures such as revisional Nissen fundoplication.

Non-Bariatric Roux-en-Y Gastric Bypass

Background: Roux-en-Y gastric bypass (RYGB) is frequently performed for weight loss purposes in the morbidly obese population. The popularity and acceptance of this procedure have increased the knowledge of the physiological (anatomical and functional) changes that this technique produces in the organism. RYGB improves gastric emptying and gastroesophageal reflux symptoms. Materials and Methods: We analyzed 6 patients in whom an RYGB was performed for non-bariatric purposes. Symptom questionnaire was used to evaluate response. Results: None of the patients qualified for bariatric surgery, as all had a body mass index (BMI) <35 kg/m². Five patients were operated on for severe gastroesophageal reflux disease symptoms, and one for gastroparesis. All patients had good to excellent results, with marginal modification of their BMI. Conclusion: Non-bariatric RYGB can be considered in patients with functional diseases of the upper gastrointestinal tract, regardless of their BMI.

Laparoscopic Roux-en-Y Gastric Bypass After Gastroesophageal Reflux Disease Surgical Procedure: Analysis of 85 Consecutive Patients with Pre- and Post-Operative Endoscopy Control

Background: Most of the obese patients undergoing an anti-reflux operation experience recurrence of gastroesophageal reflux disease (GERD). Laparoscopic Roux-en-Y gastric bypass (LRNYGB) has been accepted as the bariatric surgery of choice for a previous GERD-operated obese patients. Methods: We present 85 consecutive patients from a single institution, previously submitted to antireflux surgery and then to LRNYGB. Preoperative endoscopy was carried out in all patients; 49 (57.64%) patients had findings of fundoplication failure or signs of persistent GERD, of those 20 (40.81%) with esophagitis. Results: From the bypass, per or postoperative minor to moderate complications occurred in 12 patients (14.11%): 2 (2.35%) conversions to laparotomy, 1 (1.17%) melena, 8 (9.41%) stenosis of gastrojejunostomy, treated by a simple endoscopic dilatation with a balloon, and 1 (1.17%) gastrogastric fistula. A follow-up endoscopy of 79 of 85 (92.9%) patients was carried out after 6 months of LRNYGB. Eight of 79 (10.12%) patients had persistent esophagitis that represented 40% (8 of 20 patients) of persistent reflux esophagitis even after LRNYGB. All of them were men. Conclusion: LRNYGB after laparoscopic fundoplication is a feasible procedure with an excepted higher rate of complications because of the complexity of the procedure. Nevertheless esophagitis still persisted in many of those patients.

FUNDOPLICATION CONVERSION IN ROUX-EN-Y GASTRIC BYPASS FOR CONTROL OF OBESITY AND GASTROESOPHAGEAL REFLUX: SYSTEMATIC REVIEW

Introduction:

Obesity is related with higher incidence of gastroesophageal reflux disease. Antireflux surgery has inadequate results when associated with obesity, due to migration and/or subsequent disruption of antireflux wrap. Gastric bypass, meanwhile, provides good control of gastroesophageal reflux.

Objective:

To evaluate the technical difficulty in performing gastric bypass in patients previously submitted to antireflux surgery, and its effectiveness in controlling gastroesophageal reflux.

Methods:

Literature review was conducted between July to October 2016 in Medline database, using the following search strategy: (“Gastric bypass” OR “Roux-en-Y”) AND (“Fundoplication” OR “Nissen ‘) AND (“Reoperation” OR “Reoperative” OR “Revisional” OR “Revision” OR “Complications”).

Results:

Were initially classified 102 articles; from them at the end only six were selected by exclusion criteria. A total of 121 patients were included, 68 women. The mean preoperative body mass index was 37.17 kg/m² and age of 52.60 years. Laparoscopic Nissen fundoplication was the main prior antireflux surgery (70.58%). The most common findings on esophagogastroduodenoscopy were esophagitis (n=7) and Barrett’s esophagus (n=6); the most common early complication was gastric perforation (n=7), and most common late complication was stricture of gastrojejunostomy (n=9). Laparoscopic gastric bypass was performed in 99 patients, with an average time of 331 min. Most patients had complete remission of symptoms and efficient excess weight loss.

Conclusion:

Although technically more difficult, with higher incidence of complications, gastric bypass is a safe and effective option for controlling gastroesophageal reflux in obese patients previously submitted to antireflux surgery, with the added benefit of excess weight loss.

Roux-en-Y Gastric Bypass Following Nissen Fundoplication: Higher Risk Same Reward

BACKGROUND

Roux-en-Y gastric bypass (RYGB) effectively treats obesity and gastroesophageal reflux disease (GERD). As more surgeons recommend RYGB to treat GERD in patients with obesity, there are concerns about this approach in patients with previous non-bariatric foregut surgery. This study aims to evaluate the effect of previous non-bariatric foregut surgery on subsequent RYGB.

METHODS

Retrospective review of 2089 patients undergoing RYGB between January 1985 and June 2015 was conducted to identify all patients with previous non-bariatric foregut surgery. Perioperative and postoperative data was collected by retrospective chart review.

RESULTS

A total of 11 patients with prior non-bariatric foregut surgery underwent RYGB with median time between operations of 95.6 months. Of note, 7/11 (63.6%) had previous Nissen fundoplication. Conversion to open operation was required in 3/7 (42.9%) with previous Nissen compared to 1/4 (25%) in those without previous Nissen. The average length of stay (LOS) was 3.9 ± 0.9 days, significantly longer than our institutional average for RYGB of 3.2 ± 3.2 days (p = 0.02). Mean percentage of excess body mass index loss (%EBMIL) was 64.7 ± 23.5 at 4-year median follow-up, comparable to our institution's previously reported data. No mortalities were attributed to RYGB and the overall complication rate was 18.2%, compared to our institutional complication rate for RYGB of 8.5% (p = 0.253).

CONCLUSION

Despite increased technical difficulty and increase perioperative morbidity, patients undergoing RYGB with previous non-bariatric foregut surgery had long-term symptom resolution and robust weight loss. This indicates that in the right hands, RYGB after non-bariatric foregut surgery may be performed safely and effectively.

Patients Having Bariatric Surgery: Surgical Options in Morbidly Obese Patients with Barrett's Esophagus

This article summarizes the currently knowledge and results observed in patients with obesity and Barrett's esophagus which were presented and discussed during the IFSO 2014 held in Montreal. In this meeting, the surgical options for the management after bariatric surgery were discussed. For this purpose, a complete revision of the available literature was done including Pubmed, Medline, Scielo database, own experience, and experts opinion. A total of 49 publications were reviewed and included in the present paper. The majority of authors agree that gastric bypass is the procedure of choice. Sleeve gastrectomy is not an absolute contraindication. Up to now, gastric bypass appears to be the best procedure for treatment of obese patients with Barrett's esophagus. Future investigations should give the definitive consensus.

Gastroesophageal reflux disease in the obese: Pathophysiology and treatment

Obesity is a condition that has increased all over the world in the last 3 decades. Overweight and gastroesophageal reflux disease (GERD) are related. GERD may have different causative factors in the obese compared with lean individuals. This review focuses on the proper treatment for GERD in the obese based on its pathophysiology. Increased abdominal pressure may play a more significant role in obese subjects with GERD than the defective esophagogastric barrier usually found in nonobese individuals. A fundoplication may be used to treat GERD in these individuals; however, outcomes may be not as good as in nonobese patients and it does not act on the pathophysiology of the disease. All bariatric techniques may ameliorate GERD symptoms owing to a decrease in abdominal pressure secondary to weight loss. However, some operations may lead to a disruption of natural anatomic antireflux mechanisms or even lead to slow gastric emptying and/or esophageal clearance and thus be a refluxogenic procedure. Roux-en-Y gastric bypass decreases both acid and bile reflux from the stomach into the esophagus. On the other hand, gastric banding is a refluxogenic operation, and sleeve gastrectomy may show different outcomes based on the anatomy of the gastric tube.

Reoperative antireflux surgery

Patient satisfaction with primary antireflux surgery is high, but a small percentage of patients experience recurrent reflux and dysphagia, requiring reoperation. The major anatomic causes of failed fundoplication are slipped fundoplication, failure to identify a short esophagus, and problems with the wrap. Minimally invasive surgery has become more common for these procedures. Options for surgery include redo fundoplication with hiatal hernia repair if needed, conversion to Roux-en-Y anatomy, or, as a last resort, esophagectomy. Conversion to Roux-en-Y anatomy has a high rate of success, making this approach an important option in the properly selected patient.

Roux-en-Y near esophagojejunostomy for failed antireflux operations: outcomes in more than 100 patients

BACKGROUND

Intractable gastroesophageal reflux disease (GERD) after antireflux operations presents a challenge-particularly in obese patients and patients with esophageal dysmotility-and increases the complexity of the redo operation. This study evaluated the results of Roux-en-Y near esophagojejunostomy (RNYNEJ) in the management of recurrent GERD after antireflux operations.

METHODS

We conducted a retrospective review of overweight patients with intractable GERD who underwent RNYNEJ for failed antireflux operations. We evaluated perioperative outcomes, dysphagia (ranging from 1 = no dysphagia to 5 = unable to swallow saliva), and quality of life (QOL) (assessed using the GERD health-related quality-of-life instrument (HRQOL).

RESULTS

Over a 12-year period, 105 patients with body mass index (BMI) greater than 25 underwent RNYNEJ for failed antireflux operations. Most were obese (BMI > 30; 82 patients [78%]); esophageal dysmotility was demonstrated in more than one-third of patients. Forty-eight (46%) patients had multiple antireflux operations before RNYNEJ, and 27 patients had undergone a previous Collis gastroplasty. There was no perioperative mortality. Major complications, including anastomotic leak requiring surgical intervention (n = 3 [2.9%]), were noted in 25 patients (24%).The median length of stay was 6 days. During follow-up (mean, 23.39 months), median BMI decreased from 35 to 27.6 (p < 0.0001), and the mean dysphagia score decreased from 2.9 to 1.5 (p < 0.0001). The median GERD HRQOL score, assessed in a subset of patients, was 9 (classified as excellent).

CONCLUSIONS

RNYNEJ for persistent GERD after antireflux operations in appropriately selected patients can be performed safely with good results in experienced centers. RNYNEJ should be considered an important option for the treatment of intractable recurrent symptoms after antireflux operations, particularly in obese patients.

Minimally invasive Roux-en-Y gastric bypass for fundoplication failure offers excellent gastroesophageal reflux control

Roux-en-Y gastric bypass (RYGB) may represent a superior alternative to reoperative fundoplication in patients with symptomatic failure. Our goal was to assess early outcomes of patients after RYGB for failed fundoplication. Records of patients who underwent fundoplication takedown and RYGB from March 2007 to June 2013 were reviewed for demographics, comorbidities, operative findings, and perioperative outcomes. Data are reported as medians (range). Forty-five patients who had undergone 64 prior antireflux procedures (range, one to three fundoplications) were identified. Median patient age was 56 years (range, 25 to 72 years) with a body mass index of 33 kg/m(2) (range, 22 to 51 kg/m(2)). Most patients had comorbidities: hypertension (60%), anxiety/depression (44.4%), dyslipidemia (33.3%), asthma (31%), obstructive sleep apnea (26.7%), arthritis (22.2%), and diabetes (11.1%). Median symptom-free interval was 3 years (range, 0 to 25 years). All patients had an anatomic reason for failure: 83 per cent had a hiatal hernia and 35 per cent had a slipped Nissen fundoplication. The procedures were accomplished laparoscopically in 28, robotically in 13, and open in four cases. Median operative time was 367 minutes (range, 190 to 600 minutes) and estimated blood loss averaged 100 mL (range, 25 to 500 mL). Five patients (11%) required reoperation: one for an anastomotic leak, one for anastomotic obstruction, and three for early obstruction resulting from adhesions. Two patients developed respiratory failure requiring prolonged mechanical ventilation. Length of stay averaged four days (range, 1 to 33 days) with two readmissions: one for melena and one for vomiting and dehydration; neither required intervention. There was no mortality. At 11 months of follow-up (range, 2.3 to 54 months), 93.3 per cent of patients were symptom-free. When primary fundoplication for gastroesophageal reflux disease fails, fundoplication takedown and RYGB can be accomplished safely with minimally invasive techniques. The conversion to a RYGB has an acceptable perioperative morbidity and excellent early symptom control, and, therefore, should be considered for reoperative patients gastroesophageal reflux disease.

Long-term outcomes of reintervention for failed fundoplication: redo fundoplication versus Roux-en-Y reconstruction

BACKGROUND

Redo fundoplication (RF) is the mainstay of treatment for failed fundoplication. A subset of patients with failed fundoplication requires Roux-en-Y reconstruction (RNY) for symptom relief. The aim of this study was to compare the long-term subjective outcomes between RF and RNY in patients with failed fundoplication.

METHODS

After Institutional Board Review approval, retrospective review of a prospective database identified 119 RF (mean = 54.1 years, 78 women) and 64 RNY (mean = 54.8 years, 35 women) patients who underwent reoperative surgery between December 2003 and September 2009. Data variables analyzed included demographics, esophageal manometry, 24-h pH study, type of procedure, perioperative findings, complications, pre- and postoperative symptom (heartburn, regurgitation, dysphagia, and chest pain) scores (scale 0-3), and patient satisfaction score (scale 1-10). Patients with grade 2 and 3 scores were considered to have significant symptoms.

RESULTS

Patients who underwent RNY had a significantly higher body mass index, higher mean number of risk factors, and higher preoperative severity of heartburn and regurgitation compared to the RF group. Of the 183 patients, long-term (>3 years) follow-up was available for 132 (89 RF and 43 RNY) patients. Symptom severity significantly improved after both procedures, with the exception of dysphagia in the RNY group. Overall, there was no significant difference in patients' satisfaction between the RF and RNY groups. In subset analysis, patients with morbid obesity, esophageal dysmotility, or ≥4 risk factors have better satisfaction with RNY compared to RF (p = 0.027, 0.031, and 0.045, respectively).

CONCLUSIONS

RF and RNY have equally good patient satisfaction at 3 years follow-up. RNY may have improved outcomes in patients who are morbid obese, have esophageal dysmotility, or have four or more risk factors.

Revisional bariatric surgery: perioperative morbidity is determined by type of procedure

BACKGROUND

Revisional bariatric procedures are on the rise. The higher complexity of these procedures has been reported to lead to increased risk of complications. The objective of our study was to compare the perioperative risk profile of revisional bariatric surgery with primary bariatric surgery in our experience.

METHODS

A prospectively maintained database of all patients undergoing bariatric surgery by three fellowship-trained bariatric surgeons from June 2005 to January 2013 at a center of excellence was reviewed. Patient demographics, type of initial and revisional operation, number of prior gastric surgeries, indications for revision, postoperative morbidity and mortality, length of stay, 30-day readmissions, and reoperations were recorded. These outcomes were compared between revisional and primary procedures by the Mann-Whitney or Chi square tests.

RESULTS

Of 1,556 patients undergoing bariatric surgery, 102 patients (6.5%) underwent revisional procedures during the study period. Indications for revisions included inadequate weight loss in 67, failed fundoplications with recurrent gastroesophageal reflux disease in 29, and other in 6 cases. Revisional bariatric procedures belonged into four categories: band to sleeve gastrectomy (n = 23), band to Roux-en-Y gastric bypass (n = 25), fundoplication to bypass (n = 29), and other (n = 25). Revisional procedures were associated with higher rates of readmissions and overall morbidity but no differences in leak rates and mortality compared with primary procedures. Band revisions had similar length of stay with primary procedures and had fewer complications compared with other revisions. Patients undergoing fundoplication to bypass revisions were older, had a higher number of prior gastric procedures, and the highest morbidity (40%) and reoperation (20%) rates.

CONCLUSIONS

In experienced hands, many revisional bariatric procedures can be accomplished safely, with excellent perioperative outcomes that are similar to primary procedures. As the complexity of the revisional procedure and number of prior surgeries increases, however, so does the perioperative morbidity, with fundoplication revisions to gastric bypass representing the highest risk group.

Laparoscopic treatment of obese patients with gastroesophageal reflux disease and Barrett's esophagus: a prospective study

BACKGROUND

Short-segment Barrett's esophagus (SSBE) or long-segment Barrett's esophagus (LSBE) is the consequence of chronic gastroesophageal reflux disease (GERD), which is frequently associated with obesity. Obesity is a significant risk factor for the development of GERD symptoms, erosive esophagitis, Barrett's esophagus, and esophageal adenocarcinoma. Morbidly obese patients who submitted to gastric bypass have an incidence of GERD as high as 50% to 100% and Barrett's esophagus reaches up to 9% of patients.

METHODS

In this prospective study, we evaluate the postoperative results after three different procedures--calibrated fundoplication + posterior gastropexy (CFPG), fundoplication + vagotomy + distal gastrectomy + Roux-en-Y gastrojejunostomy (FVDGRYGJ), and laparoscopic resectional Roux-en-Y gastric bypass (LRRYGBP)--among obese patients.

RESULTS

In patients with SSBE who submitted to CFPG, the persistence of reflux symptoms and endoscopic erosive esophagitis was observed in 15% and 20.2% of them, respectively. Patients with LSBE were submitted to FVDGRYGJ or LRRYGBP which significantly improved their symptoms and erosive esophagitis. No modifications of LESP were observed in patients who submitted to LRRYGBP before or after the operation. Acid reflux diminished after the three types of surgery were employed. Patients who submitted to LRRYGBP presented a significant reduction of BMI from 41.5 ± 4.3 to 25.7 ± 1.3 kg/m(2) after 12 months.

CONCLUSIONS

Among patients with LSBE, FVDGRYGJ presents very good results in terms of improving GERD and Barrett's esophagus, but the reduction of weight is limited. LRRYGBP improves GERD disease and Barrett's esophagus with proven reduction in body weight and BMI, thus becoming the procedure of choice for obese patients.

The impact of previous fundoplication on laparoscopic gastric bypass outcomes: a case-control evaluation

BACKGROUND

Gastroesophageal reflux disease (GERD) is a common comorbid condition in morbidly obese gastric bypass candidates. Unfortunately, some patients who ultimately present for bariatric surgery have previously undergone Nissen fundoplication for GERD. Many surgeons consider previous fundoplication to be a relative contraindication to subsequent laparoscopic Roux-en-Y gastric bypass (LRYGB) due to increased technical complexity and risk. We sought to compare the perioperative and long-term outcomes of a cohort of patients who had first undergone fundoplication and ultimately chose to later pursue LRYGB for morbid obesity (revision) to matched control patients.

METHODS

Data were obtained from our prospectively maintained bariatric surgery database. Patients who underwent laparoscopic takedown of a previous fundoplication and conversion to LRYGB were compared to control patients who underwent primary LRYGB. For every revision patient, two control subjects were randomly selected from the database after matching for preoperative body mass index and year of surgery.

RESULTS

From July 2002 to April 2011, 14 patients underwent laparoscopic takedown of a previous Nissen fundoplication and then underwent LRYGB. During the same interval, 673 patients underwent LRYGB as a primary procedure for obesity from which 28 were selected as controls. There were no conversions to open laparotomy in any patient. Subjects were similar demographically. Operating time and duration of hospital stay were significantly longer in revision patients. Complications were more frequent in revisions (36% revisions vs. 7% controls, P = 0.03). Excess weight loss 1-year after surgery was excellent in both groups and did not differ (69% revision vs. 69.6% controls, P = 0.93).

CONCLUSIONS

Although associated with longer operating times, longer duration of hospital stay, and complications, LRYGB after fundoplication is feasible and safe. Long-term weight loss outcomes are similar to those seen following primary LRYGB. Previous fundoplication is not a contraindication to LRYGB.

Roux-en-Y reconstruction for failed fundoplication

BACKGROUND

Redo fundoplication has acceptable outcomes in patients with failed previous fundoplications. However, a subset of patients require Roux-en-Y (RNY) reconstruction for symptom relief.

AIM

The aim of this study was to demonstrate safety and efficacy of RNY reconstruction for failed fundoplications.

METHOD

Retrospective review of data on patients who underwent short-limb RNY gastrojejunostomy (GJ) or esophagojejunostomy (EJ) between the years 2005 and 2007 was performed.

RESULTS

Twenty-two patients underwent RNY reconstructions. Fourteen (64%) patients had one, six (27%) patients had two, and 2 (9%) patients had three previous anti-reflux procedures. RNY GJ was performed in 18 patients and EJ in four patients. Gastrectomy was performed in 13 of these patients. Seven patients (32%) had ten major or minor complications within the 30-day postoperative period, without any mortality observed. At a mean follow-up of 23 months, completed in 21 of these patients (95%), the average heartburn score was 0.38 (range, 0-2). The average regurgitation score was 0.23 (range, 0 to2) and the average dysphagia score was 0.7 (range, 0-2). The mean postoperative BMI was 25.4 compared to a preoperative BMI of 31.

CONCLUSION

RNY reconstruction with GJ or EJ for failed anti-reflux procedures is a safe, valid surgical option in difficult situations, where a redo fundoplication is either non-feasible or expected to fail. However, it is associated with higher morbidity.

The association between gastroesophageal reflux disease and obesity

Nearly all epidemiologic studies have found an association between increasing body mass index (BMI) and symptoms of gastroesophageal reflux disease (GERD). Changes in gastroesophageal anatomy and physiology caused by obesity may explain the association. These include an increased prevalence of esophageal motor disorders, diminished lower esophageal sphincter (LES) pressure, the development of a hiatal hernia, and increased intragastric pressure. Central adiposity may be the most important risk for the development of reflux and related complications such as Barrett's esophagus and esophageal adenocarcinoma. Weight loss, through caloric restriction and behavioral modification, has been studied infrequently as a means of improving reflux. Bariatric surgery and its effects on a number of obesity-related disorders have been studied more extensively. Roux-en-Y gastric bypass (RYGB) has been consistently associated with improvement in the symptoms and findings of GERD. The mechanism of action through which this surgery is successful at improving GERD may be independent of weight loss and needs further examination. Current evidence suggests that laparoscopic adjusted gastric banding should be avoided in these patients as the impact on gastroesophageal reflux disease appears unfavorable.

Roux-en-Y near esophagojejunostomy for intractable gastroesophageal reflux after antireflux surgery

BACKGROUND

Intractable gastroesophageal reflux disease (GERD) after prior antireflux operation presents a difficult challenge. Our objective was to investigate the role of Roux-en-Y near esophagojejunostomy (RNYNEJ) in the management of intractable reflux symptoms after prior antireflux surgery.

METHODS

Between June 2000 and October 2005, 25 patients with GERD after antireflux surgery underwent RNYNEJ. The endpoints evaluated were improvement in GERD symptoms using the GERD-Health Related Quality of Life (HRQL) scale, overall patient satisfaction, overall patient weight loss, and improvement of comorbid conditions.

RESULTS

There were 4 men and 21 women (mean age 51 years; range, 35 to 74). Seventy two percent had a body mass index (BMI) greater than 30. Forty-four percent had more than one antireflux surgery and 40% had a previous Collis gastroplasty. The perioperative mortality was 0%. Six patients (24%) developed major postoperative complications, including anastomotic leak (n = 2) and Roux-limb obstruction (n = 1). The median length of stay was 6 days. Eighty percent of the patients reported satisfaction at mean follow-up time of 16.5 months. Their BMI reduced from 35.8 to 27.7 (p < 0.001). Seventy three percent of comorbid conditions were improved and the GERD HRQL score improved from 29.9 to 7.3 (p < 0.001).

CONCLUSIONS

The RNYNEJ for persistent GERD after prior antireflux surgery is technically challenging with significant morbidity. However, the majority of the patients reported satisfaction with significant improvement in symptoms. Many patients had associated benefits of weight loss and improvement in comorbid conditions. Roux-en-Y near esophagojejunostomy should be considered as an important option for the treatment of intractable GERD after prior antireflux surgery, particularly in the obese.

Effect of Roux-en-Y gastric bypass in obese patients with Barrett's esophagus: attempts to eliminate duodenogastric reflux

BACKGROUND

To assess the effect of Roux-en-Y gastric bypass (RYGB) at a tertiary referral Center of Excellence for bariatric surgery on the length and presence of dysplasia in morbidly obese patients with Barrett's esophagus (BE). Esophageal reflux of gastroduodenal contents (acid, bile) contributes to the development of BE and progression in the dysplasia-carcinoma sequence. Obese patients have a high prevalence of gastroesophageal reflux and might be at an increased risk of developing BE and esophageal adenocarcinoma. The effect of eliminating duodenogastroesophageal reflux on BE is not known.

METHODS

We performed a retrospective review of all patients with pre-existing, biopsy-proven, long-segment (>3 cm) BE undergoing RYGB at our institution. Only patients with >1 year of endoscopic, biopsy-controlled follow-up (mean 34 mo) were included.

RESULTS

Five patients (3 men and 2 women) were identified. The mean +/- standard error of the mean preoperative length of BE was 6 +/- 2 cm; 2 patients had low-grade dysplasia and 1 indeterminate dysplasia. At the postoperative follow-up (>1 yr) examinations, the length of BE had decreased in 4 patients; the overall length was 2 +/- 1 cm; and only 1 patient had dysplasia. All patients experienced a decrease in the length of BE (n = 4), complete disappearance of BE (n = 2), or improvement in the degree of dysplasia (n = 3). The body mass index had decreased from 43 +/- 4 kg/m(2) to 33 +/- 3 kg/m(2), and all experienced subjective improvement in reflux symptoms postoperatively. RYGB resulted in complete or partial regression of BE in 4 of 5 patients and improvement in reflux symptoms in all.

CONCLUSION

Our results suggest that RYGB might be the procedure of choice in morbidly obese patients with BE requiring surgical treatment for gastroesophageal reflux disease.

Anatomic findings and outcomes after antireflux procedures in morbidly obese patients undergoing laparoscopic conversion to Roux-en-Y gastric bypass

BACKGROUND

To report the anatomic findings and outcomes in patients undergoing laparoscopic takedown of Nissen fundoplication with conversion to Roux-en-Y gastric bypass.

METHODS

We reviewed the records of patients who underwent laparoscopic Nissen takedown with conversion to Roux-en-Y gastric bypass from January 2001 to April 2006 at the University of Minnesota Medical Center.

RESULTS

Eleven patients were identified. Nine patients had gastroesophageal reflux disease preoperatively, of whom six underwent 24-hour pH monitoring. In 2 patients, the pH study findings were negative. Eight prior procedures had been performed laparoscopically. Eight patients were women. The mean age was 44 years. The average body mass index preoperatively was 44 kg/m(2) (range 35-61). The mean follow-up was 13.8 months (range 4-39). The body mass index at follow-up was 30.2 kg/m(2). The operative time was 349 minutes (range 222-624). The hospital length of stay was 3.4 days (range 2-6). No conversions to open surgery were required. No major short-term complications developed. Minor complications included wound or drain site infection in 3 patients, with abscess in 2, pressure sore of the lateral aspect of the foot in 1, pneumonia in 2, and marginal ulcer in 2 patients. No strictures were observed. One internal hernia occurred. Of the 9 patients with gastroesophageal reflux disease preoperatively, all had 100% improvement in symptoms, with complete resolution in 7 (78%). Wrap disruption was present in 5 (45%) of 11 patients. Herniation of an intact wrap had occurred in 1 patient. One patient had both herniation and wrap disruption.

CONCLUSION

Laparoscopic conversion of Nissen fundoplication to Roux-en-Y gastric bypass is a feasible salvage operation for recurrent gastroesophageal reflux disease in the morbidly obese. The incidence of wrap disruption appears to be relatively high and the incidence of intact wrap herniation low in obese patients after failed Nissen fundoplication, suggesting that the mechanism of failure after primary antireflux surgery in obese patients may be different than that in normal-weight patients.