Long-term outcomes of conversion of failed Nissen fundoplication to Roux-En-Y gastric bypass

Daniel T McKenna, MD, Michael Burchett, DO, Daniel Mwanza, DO, Lori Blythe, APRN, Jen Choi, MD, Don Selzer, MD, Samer Mattar, MD

Indiana University School of Medicine

Introduction: As the prevalence of obesity rises, more patients present with a history of previous Nissen fundoplication, morbid obesity, and recurrent medically recalcitrant gastroesophageal reflux disease (GERD). Some of these patients are managed by revision of their failed fundoplication which fails to address their morbid obesity and comorbid conditions. Conversion to a bariatric procedure is believed to have increased risk of perioperative complications due to reoperative gastric surgery and decreased tissue perfusion. Analysis of this small, but growing, population is necessary to assist decision making in this challenging situation.

Methods and Procedures: Retrospective analysis was performed of a prospectively gathered database at a tertiary, university-affiliated bariatric surgical center. Patients with history of previous fundoplication were identified. The database and the patients’ charts were reviewed to determine patient characteristics, indications for surgery, comorbidities, perioperative complications, and long term outcomes.

Results: Over a 6 year period, 11 patients (10 female), underwent conversion of a failed fundoplication to a Roux-en Y gastric bypass. The average preoperative BMI was 42.7, age 51.6, and length of time from fundoplication was 108 months (24-300 months). All patients had GERD, 7/11 (63.6%) had endoscopic or radiologic evidence of recurrent hiatal hernia, 4/11 (36.4%) had type II diabetes, 11/11 (100%)had hypertension, 4/11 had asthma (36.4%), and 6/11 (54.5%) had hyperlipidemia. Of the 11 patients, 10 procedures were completed laparoscopically (90.9%). Average operative time was 236.1 minutes. Average hospital stay was 5.1 days. Perioperative complications occurred in 2/11 patients (18.2%). Both of these were reoperations. One was performed for a leak (9.1%) and the other was a negative diagnostic laparoscopy. Four patients experienced complications outside of 30 days requiring reintervention. Two patients had strictures (18.2%) and two had ulcers (18.2%)). Seven had no postoperative difficulties (63.6%).There were no perioperative deaths.
At an average of 20.6 months of follow-up, patients had lost 69.9% of their excess weight with an average weight loss of 75.4lbs and BMI of 29.3. Subjective symptoms of GERD had resolved in 10/11 patients. There was remission of all cases of diabetes and asthma. All cases of hypertension and hyperlipidemia demonstrated improvement or remission.

Conclusion: Morbidly obese patients with recurrent gastroesophageal reflux disease after a failed fundoplication can be safely managed with conversion to Roux-en Y gastric bypass with a slight increase in perioperative risk. Weight loss and comorbidity remission appear similar to expected outcomes in patients undergoing this procedure primarily.

Session: Poster Presentation

Program Number: P252

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