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.

Can patient symptoms reliably predict major oesophageal motility disorders assessed by conventional water perfusion manometry?

AIM

This study aimed to determine whether symptoms can reliably predict a major disorder of oesophageal motility as assessed by conventional water perfusion manometry.

METHODS

Data from patients who underwent conventional water perfusion oesophageal manometry and a pre-manometry questionnaire between October 1998 and August 2018 were extracted from a database. Clinical features (dysphagia, chest pain, regurgitation, dysphagia to a bread challenge) and combinations of these clinical features were compared to manometric diagnoses.

RESULTS

Data from 546 patients were analysed. Thirty-three (6%) patients had a major disorder of motility, and 513 (94%) had normal manometry or a minor disorder of motility. 'Any dysphagia' (dysphagia as a symptom or dysphagia to a bread challenge) or 'chest pain' was experienced by all patients with a major disorder of motility and 435 of 513 patients with normal manometry or a minor disorder of motility (p=0.009). Sensitivity was 100%, and specificity was 15%, in identifying patients with a major disorder of motility using symptom combinations and a bread challenge.

CONCLUSION

Symptoms and provoked dysphagia to bread were able to predict patients with a major disorder of oesophageal motility with a sensitivity of 100%. However, as specificity was 15%, confirmation with manometry is indicated if possible.