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.
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Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 87017
Program Number: S045
Presentation Session: Foregut Session
Presentation Type: Podium