Roux-en-y Gastric Bypass (RYGB) for Failed Laparoscopic Fundoplication

Mena Boules, MD, Julie Chang, MD, Ricard Corcelles, MD, PhD, Christopher Daigle, MD, Kevin El-Hayek, MD, Stacy Brethauer, MD, Matthew Kroh, MD. Cleveland Clinic

Introduction

Gastro esophageal reflux disease (GERD) is estimated to affect 40% of the population in the United States. In appropriate patients, laparoscopic fundoplication is currently considered to be the anti-reflux procedure of choice, with successful re-establishment of G-E junction physiology. Failure rates are reportedly between2% and 30%. Obesity, technical approach of repair, and anatomical variation of each patient are associated with operative failure and recurrent GERD. Recent reports suggest re-operative fundoplication is associated with poorer results than primary operations. Laparoscopic Roux-en-Y gastric bypass (LRYGB) is an option for selected patients who have failed initial fundoplication. This study aims to evaluate the outcomes of patients who have undergone LRYGB after prior fundoplication failure.

Methods

Records of 23 patients who underwent laparoscopic takedown of failed fundoplication with conversion to LRYGB from March 2007 to October 2013 were analyzed retrospectively. Data collected included baseline patient demographics, peri-operative parameters, intra and post-operative complications, follow-up time, symptom control, and recurrence. The primary endpoint studied was symptom relief, whereas recurrence and technical success were analyzed as secondary endpoints.

Results

Twenty-three patients who had undergone 33 prior anti-reflux procedures (range: 1 to 4) underwent LRYGB for failed fundoplication during the 6-year study period. The cohort had a male-to-female ratio of 6:17, mean age of 53.3±9.6 years; mean body mass index (BMI) of 35.7±7.1 kg/m2 (range: 25.1 to 54.1 kg/m2), and mean number of comorbidities of 4.9±2.3. Major comorbidities were: hiatal hernia (73.9%), hypertension (56.5%), dyslipidemia (52.1%), obstructive sleep apnea (26%), diabetes (17.3%), chronic obstructive pulmonary disease (8.6%), and chronic peptic ulcer disease (8.6%). Prior to LRYGB 20 patients were on anti-secretory agents specifically proton pump inhibitors (PPI) (n=16, 69.5%) and histamine blockers (n=4, 17.3%). Evidence of anatomic failure as defined by recurrent hiatal hernia was seen in 74% of patients. The operations were performed laparoscopically in 18 (78.2%) cases and open in 5 (21.8%). Mean operative time and estimated blood loss was 272.7±112.3 minutes and 346.7±639.8 mL, respectively. Early postoperative complications (30 days) occurred in 3 patients and included anastomotic leakage (n=2, 8%), and wound infection (n=1, 4%). The reoperation rate was 4.3%, and there were no mortalities. After a mean follow-up of 20.9±20.8 months (range 0-73 months), 3 (13.0%) patients complained of persistent dysphagia, and 1 (4.3%) reported regurgitation. No GERD-related symptoms were reported; however, 10 patients continued with anti-secretory medication (PPI n=7, H2 blockers n=3) for early continuation of GERD symptoms post-operatively which resolved within 7-10 days post-operatively. Upper gastro-intestinal series (UGI) and/or esophagogastroduodenoscopy (EGD) were performed in 9 patients (39%), for surveillance of anastomotic integrity (n=2), nausea (n=1), dysphagia (n=4), and abdominal pain (n=3). No hernia recurrence was demonstrated at an average of 15.5±19.1 months (rang e 0-47 months).

Conclusion

Conversion of failed fundoplication to RYGB can be performed with acceptable peri-operative morbidity and reasonable long-term control of GERD symptoms. Overall operative and peri-operative morbidity is higher in this population when compared to patients undergoing primary RYGB.

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