Laparoscopic gastric exclusion with small bowel diversion as primary treatment for complicated GERD

Cory Richardson, MD, Shawn Roberts, MD, FACS, Timothy LeMieur, MD, FACS, Howard McCollister, MD, FACS, Paul Severson, MD, FACS. Minnesota Institute for Minimally Invasive Surgery

Intro

Roux-en Y gastric bypass (RYGB) was performed for complicated gastro-esophageal reflux disease (GERD) long before it was considered a weight loss operation.  Studies have confirmed resolution of esophageal ulcerations and strictures after RYGB.  Early publications, however, lacked a common term for this procedure, often referred to as gastric diversion, duodenal diversion, or partial gastrectomy with roux en Y diversion.  RYGB became known solely as a weight loss procedure as improved medical therapy for GERD diminished the necessity of RYGB for reflux.  The current preferred anti-reflux procedure, laparoscopic gastric fundoplication, has reported failure rates of up to 22%.  Additionally, co-morbidities such as esophageal motility disorders, dysphagia, diabetes, gastroparesis, and obesity make fundoplication less effective or even contraindicated.  In some centers RYGB continues to be recognized as an excellent and permanent treatment for GERD.  However, as RYGB is acknowledged only as an obesity operation by coding language and payers, many non-obese patients are left without any options after failed fundoplication.

Materials and Methods

PubMed search performed using terms: “gastric diversion”, “esophagitis”, “gastric bypass for GERD”, “gastric resection for esophagitis”, and “roux-en Y duodenal diversion”.

Twenty-two studies were reviewed for: type of study, time period of study, operation performed, number of patients, length of roux limb, length of follow up, prior anti-reflux procedures, and improvement of symptoms.  Additionally, we are currently analyzing the same variables in 50 non-morbidly obese patients who have undergone this procedure (termed “Laparoscopic gastric exclusion with small bowel diversion”), at the Minnesota Institute for Minimally Invasive Surgery. 

Results

A review of these studies, in addition to our own experience shows that:

1. RYGB for complicated reflux has been shown to be safe with 5-17 years of follow up.

2. RYGB is effective for both the symptoms and complications of GERD regardless of BMI.

3. RYGB in the non-morbidly obese does not cause weight loss below normal BMI.

 

Conclusion

The literature supports the argument for RYGB to be the indicated operation for complicated GERD in the morbidly obese, for the less than morbidly obese, and for patients with failed fundoplication regardless of weight.  A definitive procedure exists to eliminate or drastically reduce symptoms and complications of GERD, and it should not be withheld from patients simply because it is also a highly visible procedure performed on the morbidly obese for weight loss.

« Return to SAGES 2016 abstract archive