Laparoscopic Fundoplication Takedown With Roux-en-Y Gastric Bypass Leads to Excellent Reflux Control and Quality of Life in Patients After One Or More Failed Fundoplications

Fernando A Navarro, MD, Brant T Heniford, Keith Gersin, Dimitrios Stefanidis. Carolinas Medical Center, Division of Gastrointestinal and Minimally Invasive Surgery, Charlotte, NC

Introduction: Recent data suggest that redo fundoplication after prior failed fundoplication (FP) is associated with a high failure rate to control reflux in the long term. In this patient population, a laparoscopic Roux-en-Y gastric bypass (LRYGB) may be a better option for long term reflux control, especially in the obese, but outcome and quality of life data are sparse. Our aim was to assess outcomes and quality of life data after fundoplication takedown and LRYGB for patients with failed fundoplications.

Methods: The records of 25 patients who underwent fundoplication takedown and LRYGB between March 2007 and July 2011 were reviewed. Patient demographics, body mass index (BMI), preoperative symptoms, operative duration and findings, length of stay (LOS), Estimated Blood loss (EBL), length of follow up (FU) and postoperative outcomes were recorded. The Gastrointestinal Quality of Life Index (GIQLI) and the Gastrointestinal Symptoms Rating Scale (GSRS) were used at the latest follow up to assess symptom severity and quality of life.

Results: Patient age was 55 (36-72) years, BMI 34.4 (22-50) kg/m², and 22 were women (88%). Heartburn (100%), dysphagia (40 %), regurgitation (32 %), and chest pain (15 %) were the most common preoperative symptoms. Comorbidities included; Diabetes, hypertension, sleep apnea, osteoarthritis, coronary artery disease, arthritis. Symptom free interval since last surgery was 5.2 (1-25) years. Patients had undergone a total of 40 prior antireflux surgeries, 41 % via an open approach. Operative duration was 345 (180-600) minutes, LOS 7 (2-30) days, and EBL 181 (50-500) ml. A slipped FP was found in 10 patients (40%), wrap disruption in 9 patients (36%), 3 patients had a combination of these, and one had a herniation of an intact wrap. Twenty three (92%) patients had an associated hiatal hernia. There was no mortality but 11 patients (44%) had complications and five required a reoperation. At 14 (1-48) months FU excess weight loss was 60% and comorbidity resolution 68 %. 24 (96%) patients were free of reflux with a mean postoperative GIQLI score of 114 (80-135) and a GSRS score of 25 (17-45). Twenty four patients (96%) reported being much happier with their physical appearance, more energetic and more able to take part in recreational and leisure activities. Fifteen patients (62%) believed that their personal relations and sexual life were better than before their LRYGBP. Twenty four patients (96%) were satisfied with their outcome and would undergo the surgery again. There were no quality of life differences between obese and non-obese patients.

Conclusions: Patients who undergo LRYGBP after failed fundoplication(s) have excellent control of their reflux and excellent quality of life and high satisfaction rates with their outcome. Nevertheless, the procedure is challenging and associated with considerable morbidity and should be undertaken by surgeons experienced in antireflux and bariatric surgery. Longer term outcomes of this procedure and comparison to outcomes of redo fundoplication are needed to better document its value for this challenging and high risk patient population.