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Laparoscopic Roux-en-Y Reconstruction as a Salvage Operation after Failed Nissen Fundoplication

Joshua P Landreneau, MD, MSc1, Andrew T Strong, MD1, Matthew Kroh, MD2, John Rodriguez, MD1, Kevin El-Hayek, MD1. 1Cleveland Clinic, 2Cleveland Clinic Abu Dhabi

Introduction: Conversion of Nissen fundoplication to Roux-en-Y (RnY) anatomy may be indicated in patients with post-surgical complications or who fail to achieve durable control of their disease. Herein we describe the largest series of patients at a single institution who underwent laparoscopic conversion of Nissen fundoplication to RnY anatomy.

Methods: All patients with prior Nissen fundoplication which were converted to roux-en-y anatomy at our institution from March 2009 through November 2017 were retrospectively reviewed and analyzed. Patients were identified based on CPT codes and the description of the operation performed. All cases with attempted minimally-invasive approach were included for analysis

Results: Fifty patients underwent conversion from prior Nissen fundoplication to RnY anatomy during the study period. The cohort was 84.0% female with a mean age of 53.5 years and a median body mass index of 36.7 kg/m2. Thirteen patients (26.0%) had multiple prior foregut operations. Complications from fundoplication that warranted revision included recurrent hiatal hernia (n=16), medically-refractory post-surgical gastroparesis (n=10), and mechanical complications from the wrap (n=8).  An additional fourteen patients underwent conversion to RnY for the purpose of weight loss. The mean operative time and estimated blood loss were 266 min. and 132 mL, respectively, with all but one (98.0%) completed with a minimally-invasive approach. The median length of stay was 5 days. Four patients (8.0%) underwent reoperation, which included negative diagnostic laparoscopy (n=2), small bowel resection for early post-operative small bowel obstruction (n=1), and laparoscopic removal of gastrostomy tube (n=1). Other complications included marginal ulcer (n=2), superficial surgical site infection (n=2), anastomotic leak (n=2), and one case each of pulmonary embolism and gastrointestinal bleeding. There were no mortalities at a mean follow up of 12.4 months.

Conclusions: Conversion of prior Nissen fundoplication to Roux-en-y anatomy is technically challenging, although it is safe and feasible even in the setting of multiple prior foregut operations. A minimally invasive approach should be offered to patients by surgeons with experience in revisional foregut and bariatric surgery.


Presented at the SAGES 2017 Annual Meeting in Houston, TX.

Abstract ID: 93517

Program Number: S081

Presentation Session: Foregut III

Presentation Type: Podium

71

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