Aaron R Bolduc, MD, Matthew D Spann, MD, D Brandon Williams, MD, Wayne J English, MD, Chetan V Aher, MD. Vanderbilt University Medical Center
Introduction: Gastroesophageal Reflux Disease (GERD) is a known risk following laparoscopic sleeve gastrectomy (LSG), with up to 50% of patients affected by the disease postoperatively. Of these patients, an unknown number progress to medically refractory GERD. Due to their postsurgical anatomy, these patients have limited options for intervention. While endoluminal therapies are available, surgical revision to Roux-en-Y gastric bypass (LRYGB) has become an accepted revisional treatment. Despite this therapeutic option, many payors deny coverage for this treatment. In this study, we report outcomes of revision of LSG to LRYGB and difficulties in obtaining insurance approval for the operation.
Methods: We conducted a retrospective review of all patients who underwent a revisional bariatric operation at a single institution between January 2015 and August 2017. We analyzed all patients who underwent conversion of LSG to LRYGB. We collected data on 30-day mortality and morbidities, pre- and postoperative antacid use, and the insurance approval process.
Results: Within the study period, we identified 164 patients undergoing revisional bariatric surgery. Seventeen patients had undergone conversion of LSG to LRYGB. All of these patients underwent revision due GERD refractory to maximal medical therapy. The average body mass index was 37 kg/m2, and our average operative time was 184 minutes. One patient required laparoscopic cholecystectomy within 30 days due to acute cholecystitis, and another patient required reoperation for control of staple line bleeding. There were otherwise no 30-day morbidities or readmissions.
Fifty nine percent stopped all antacid medication by six months, and 65% stopped by 24 months. Of the 35% percent of patient still on proton pump inhibitor therapy, none of those patients complained of reflux symptoms.
Of non-Medicare patients, 69% were initially denied insurance coverage for revision. Only one plan accounted for all initial approvals. Twenty five percent of denied patients eventually paid out of pocket, and the remaining 75% ultimately secured coverage after an appeal process.
Conclusion: Our results indicate that conversion of LSB to LRYGB for intractable GERD is a safe and effective surgical intervention. Despite promising results, insurance coverage for this treatment remains a challenge.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 87380
Program Number: P601
Presentation Session: iPoster Session (Non CME)
Presentation Type: Poster