Cynthia E Weber, MD, Melissa C Helm, BS, Zia Kanani, BS, Max Schumm, MD, John C Gould, MD. Medical College of Wisconsin
INTRODUCTION: In patients with recurrent GERD or dysphagia secondary to failed fundoplication, reoperative fundoplication is the most commonly performed procedure. In complex patients with 2 or more failed fundoplication attempts or in patients with morbid obesity (risk factor for repeat fundoplication failure), Roux-en Y gastric bypass (RYGB) may be the best operation. We sought to characterize the outcomes in a complex cohort of patients with failed fundoplication to undergo salvage RYGB, and to compare these outcomes to patients undergoing reoperative fundoplication.
METHODS AND PROCEDURES: A prospectively maintained database was queried for procedures performed at a single institution by a single surgeon from 2011-17. GERD Health Related Quality of Life (HRQL) surveys were administered at defined intervals.
RESULTS: There were 36 patients to undergo salvage RYGB and 84 patients to undergo reoperative fundoplication. All cases were completed laparoscopically. Mean BMI was higher in the RYGB group (35.5±6.8 vs. 28.7±5.3, p<0.01). The RYGB cohort was more likely to have gastroparesis (52.8% vs. 9.5%, p<0.01) and esophagitis (42.9% vs. 20.2%, p=0.01). The mean number of prior fundoplications was significantly higher in the RYGB group (1.9 vs. 1.1, p<0.01). The incidence of gastroparesis and esophagitis was directly related to the number of failed fundoplication attempts (p<0.05).
Operative times were longer in RYGB patients (333±132 vs. 200± 68 minutes, p<0.01) as was length of stay (4.3±3.4 vs. 2.8±5.3 days, p=0.02). Clavien-Dindo complications ≥ Grade 3 occurred more frequently following RYGB (19.4% vs. 4.8%, p=0.01). 30-day reoperation (11.1% vs. 1.2%, p=0.01) and readmission rates (32.4% vs. 11.9%, p<0.01) were higher in RYGB patients. In 4 of the 11 patients with 3 or more prior fundoplication attempts, an esophagojejunostomy was necessary. If these 4 patients are eliminated from the RYGB cohort, there was no difference for RYGB with gastrojejunostomy compared to reoperative fundoplication for complications, reoperations, or readmissions. GERD-HRQL scores were similar prior to surgery in both cohorts and improved significantly and to a similar degree on long-term (2 year or more) follow-up (table).
CONCLUSIONS: An increasing number of failed fundoplication attempts results in a higher likelihood of gastroparesis and esophagitis. In a complex cohort of patients with high rates of obesity and numerous failed previous fundoplication attempts, conversion to RYGB results in good symptomatic outcomes. Patients with 3 or more previous fundoplication attempts are more likely to require esophagojejunostomy in our experience. Complication rates in this subset of patients appear to be quite high.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 87017
Program Number: S045
Presentation Session: Foregut Session
Presentation Type: Podium