Minimally Invasive Management of Multiple Failed Nissen Fundoplications in the Obese Patient

Jeffrey Mino, MD, MPH, Mihir Shah, MD, Rosebel Monteiro, MD, Kevin El-Hayek, MD. Cleveland Clinic Foundation.

Introduction: Refractory gastroesophageal reflux can be a debilitating and even deadly condition if left unresolved for a prolonged period of time. Traditional surgical management after failure of acid reduction medications is a Nissen fundoplication. However, in some patients, especially those who suffer from morbid obesity, this procedure can result in inadequate control and ultimately wrap disruption.

Case Presentation: We present a 40 year old female with a history significant for severe gastric reflux who had initially undergone a Nissen procedure in 2008 complicated by a wrap disruption requiring revision, a second disruption requiring a second revision, and worsening reflux symptoms requiring a third revision, all of which failed to relieve her symptoms. At that point her surgical team offered her a total esophagectomy with colonic interposition. She presented to our institution for a second opinion. Given her BMI of 33 and surgical history, it was felt that further revision would be futile. Therefore, she was offered a laparoscopic takedown of Nissen fundoplication, distal esophagectomy and proximal gastrectomy with roux-en-y esophagojejunostomy. Work up included an EGD and upper GI series, both of which showed intact wrap with evidence of recurrent paraesophageal hernia.  This video demonstrates the procedure.

Follow-up: Post-operatively the patient recovered well and was discharged on a liquid oral diet with enteral feedings as supplementation. At two month follow-up she declared resolution of her reflux symptoms and is off all anti-reflux medications. Her remnant gastrostomy was removed at that time as she was tolerating a regular diet.
 

Conclusion: This case highlights the failure of Nissen fundoplication in the obese population. Following failure, takedown of the fundoplication with Roux-en-Y reconstruction offers excellent symptom relief and a decreased risk of recurrence in this challenging patient population. Further studies should be aimed at extending bariatric coverage to obese patients with severe GERD, who may not otherwise qualify for these procedures.