Conversion of Failed Laparoscopic Nissen Fundoplication to Gastric Bypass for the Management of Recurrent Gastroesophageal Reflux Disease

Sean R Sheff, MD, Julio J Bird, MD, Shanu N Kothari, MD FACS. Gundersen Lutheran Medical Foundation, Gundersen Lutheran Health System

Introduction: Gastroesophageal reflux disease (GERD) is prevalent in approximately 20% of the population. However, in the morbidly obese population, 55-62% of patients presenting for gastric bypass (GB) complain of GERD symptoms. Standard surgical treatment of GERD is fundoplication which, in normal weight individuals, is 93% effective in controlling symptoms. In contrast, morbidly obese patients are four times more likely to experience a failed fundoplication than normal weight patients.
Methods: We present the case of a 50-year-old obese woman (body mass index (BMI) = 35 kg/m²), with a history of laparoscopic Nissen fundoplication, treated for recalcitrant GERD with laparoscopic Roux-en-Y GB. The patient presented with chronic abdominal pain and mild dysphagia 6 years after fundoplication. She initially had excellent results, but developed symptoms over the last year. Esophagogastroduodenoscopy revealed esophagitis with a mild stricture appreciated on barium esophagram. The benefits and risks of re-do fundoplication versus conversion to GB were discussed with the patient who decided to proceed with GB.
Results: Copious adhesions were noted along the stomach where the wrap was formed as well as the liver and diaphragmatic hiatus. An incarcerated gastric fat pad was found in the wrap, and believed to be the cause of the previous failure. The fundoplication was taken down using laparoscopic staplers. A 30 cc gastric pouch was created, and the tip of the fundus became ischemic due to the division of the lesser curvature mesentery. The fundus was resected and a standard retrogastric, retrocolic GB was performed. The patient is currently one year out from surgery. Her BMI is 26 kg/m², and she reports satisfaction with the procedure.
Conclusion: Conversion of laparoscopic Nissen fundoplication to GB remains a viable option for morbidly obese patients who present with recurrent GERD symptoms following Nissen fundoplication.