Kathleen Coakley, DO, Steven A Groene, MD, Paul D Colavita, MD, Tanushree Prasad, MA, Dimitrios Stefanidis, MD, Amy E Lincourt, PhD, MBA, Keith S Gersin, MD, B. Todd Heniford, MD. Carolinas HealthCare System
Introduction: RYGB is an alternative to reoperative fundoplication in patients with technical or symptomatic failure after fundoplication. The aim of this study was to expand long-term outcomes of patients undergoing RYGB after failed fundoplication and assess symptom resolution.
Methods: A single institution review of patients undergoing fundoplication takedown and RYGB between March 2007 and May 2016 was performed. Patient demographics, body mass index (BMI), preoperative symptoms, operative duration and findings, and postoperative outcomes were recorded. Data were assessed using standard statistical methods.
Results: 85 patients with failed anti-reflux surgery underwent RYGB. Average age was 56.9±10.2 years and preoperative BMI 33.8±6.7 kg/m2. Comorbidities included hypertension (49.4%), diabetes (9.4%), and sleep apnea (13.0%). Nissen Fundoplication was the most common prior anti-reflux procedure, of which 11.8% had been previously performed open. 67 patients had undergone 1 prior fundoplication, 15 had 2 previous fundoplications, and 3 had 3 prior fundoplications. The most common recurrent symptoms were reflux (71.8%), dysphagia (30.6 %), regurgitation (22.4%), and abdominal pain (30.6%). Symptom free interval from last anti-reflux surgery was 5.1±5.1 years. RYGB was performed laparoscopically in 47.1% of cases, robotically in 47.1% of cases, and laparoscopic converted to open in 5.9%. Operative duration was similar regardless of technique, with a median time of 338 minutes. During RYGB, 73 (85.9%) patients were found to have an associated hiatal hernia, 28 patients (32.9%) had intrathoracic migration of the fundoplication, 28 patients (32.9%) a slipped fundoplication onto proximal stomach, and 13 patients (15.3%) had wrap disruption. The average length of stay was 5.2 ±5.5 days. With an average follow up of 23.9±20.8 months, 11 patients (10.0%) had recurrent symptoms after RYGB. The average BMI decrease was 6.5±3.8kg/m2 with average excess body weight loss (EWL) of 63.9%±38.7%; patients with BMI<30 had average decrease of BMI from 26.4 to 21.9. There was no mortality but 7 patients required re-operation: due to anastomotic obstruction (1), adhesions (2), internal hernia (3), and incisional hernia (1). There were no differences between those with and without recurrence for preoperative symptoms, surgical technique (6 robotic, 4 laparoscopic, 1 conversion to open), or BMI.
Conclusions: Fundoplication takedown with RYGB was successful for long-term reflux resolution in 90% of patients. When primary, or redo fundoplication fails, RYGB is a viable option to provide long-term treatment of recurrent GERD. Most can be performed via a minimally invasive approach with acceptable perioperative morbidity, symptom resolution, and the additional benefit of EWL.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 78958
Program Number: S123
Presentation Session: Bariatric surgery – Sleeves, Conversions and More
Presentation Type: Podium