Laparoscopic Roux-en-Y Gastric Bypass for Intractable GERD Following a Failed Nissen

Karan Bath, MD, Rena Moon, MD, Samuel Szomstein, MD FACS FASMBS, Raul Rosenthal, MD FACS FASMBS. Cleveland Clinic Florida

 Introduction: GERD is a highly prevalent disease process and, with the advent of PPI, it has been successfully treated with medical management. In those patients that fail maximal medical management, Nissen fundoplication is the procedure of choice. Following a failed fundoplication, an acid-diverting procedure like RYGB is highly successful.

Materials and Methods: A 60-year-old male with a past medical history of fibromyalgia, arthritis, anxiety, depression, aspiration pneumonia, presented with a history of severe, longstanding GERD with aspiration and dysphagia; he had failed maximal medical therapy and a Nissen fundoplication.
The patient underwent a laparoscopic Roux –en –Y gastric bypass as an acid-diverting procedure. Intraoperative findings were large amounts of adhesions between the colon, small bowel, omentum, stomach, liver, and abdominal wall. An intraoperative EGD was performed in order to identify the GE junction. The hiatus was closed. An antecolic side-to-side gastrojejunostomy between the pouch and alimentary limbs was performed on the posterior wall with a linear stapler, on the anterior wall with double layer of interrupted sutures, and checked for leakage with air. A side-to-side jejunojejunostomy between the biliopancreatic and alimentary limbs was performed 100 cm from the gastrojejunostomy. The patient tolerated the procedure well.

Result: The recovery of the patient was uneventful, with a normal UGI on POD2 without leak or obstruction. The patient noted that his symptoms of reflux and aspiration improved dramatically.

Conclusion: Roux-en-Y gastric bypass has been shown to be the most effective bariatric procedure that consistently leads to weight reduction and improvement of GERD symptoms. RYGB is the procedure of choice for patients with intractable GERD, following failed standard fundoplication procedures.