Simon C Chow, MD1, Emily Speer, MD2, Amber Shada, MD2, Valerie J Halpin, MD1, Lee L Swanstrom, MD2, Kevin M Reavis2. 1Legacy Good Samaritan Medical Center, 2Providence Portland Medical Center
Introduction: The symptoms of gastroesophaeal reflux disease (GERD) are frequently improved following roux-en-Y gastric bypass, however 10 to 30% of patients have persistent or new GERD post bypass. Traditional fundoplication is not an option due to surgical disconnection of the fundus from the esophagogastric junction. Endoluminal solutions are restricted to radiofrequency treatments and efficacy of this treatment is often compromised by anatomic issues including hiatal hernia. The laparoscopic Hill repair is an anti-reflux procedure with proven durability for long-term relief of gastroesophageal reflux disease which utilizes anatomy within a few centimeters of the esophagogastric junction. We present clinical outcomes of patients with refractory GERD post-gastric bypass who underwent Hill repair.
Methods: A retrospective review of prospectively collected data was performed. Data collection was approved by the institutional IRB. Data including age, gender, pre- and post-gastric bypass weight and body mass index (BMI), excess weight loss (EWL), details of the surgeries, time between gastric bypass and Hill repair, gastric acid suppression medication use, and preoperative esophageal physiology tests including esophagogastroduodenoscopy (EGD), manometry, upper gastrointestinal radiologic studies, and BRAVO or impedance pH results was analyzed. A GERD symptom questionnaire with Likert scale was administered to the patients preoperatively and 1 month postoperatively. Morbidity and mortality data at 30 days was also collected.
Results: There were 3 patients who had undergone Hill repair after gastric bypass for refractory GERD. All patients were treated with maximum dose proton pump inhibitors and had refractory symptoms (heartburn, volume regurgitation). Mean BMI prior to gastric bypass was 43.2. The mean time between gastric bypass and Hill repair was 3.7 years, during which they had a mean EWL of 59.1%. At the time of Hill repair they had a mean age of 54.4 years and mean BMI of 32.2. Pre-operative manometry revealed: baseline lower esophageal sphincter (LES) pressure 19.8, residual LES pressure 4.3 (mmHg), integrated relaxation pressure (IRP) 8.4 [mean values]. Two of the patients underwent impedance pH testing and the mean distal catheter results were: 18.5 acidic episodes, 17 non-acidic episodes and a composite DeMeester score of 43.5. The 3rd patient underwent Bravo pH testing and had 146 reflux episodes with an overall DeMeester score of 39.2. All three patients had small (2-3cm) hiatal hernias which were concomitantly repaired at the time of Hill repair. Two patients also underwent truncal vagotomy, 1 patient had a revision of the gastrojejunostomy anastomosis with partial gastrectomy for pouch dilatation, and 1 patient had esophageal balloon dilation for gastrojejunostomy stricture. Length of stay was between 1-4 days. Preoperatively, all patients had severe continuous heartburn and reflux episodes throughout the day and night on symptom assessment form. One patient complained of occasional (1-2 times/week) chest pain and dysphagia to solid foods. Postoperatively at 1 month, there was complete symptom resolution reported in all patients. There were no 30-day complications.
Conclusion: The Hill repair is a safe and effective treatment for refractory GERD in post bypass patients who have documented disease.
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