Introduction: Gastroesophageal reflux disease (GERD) is a common comorbid condition in morbidly obese gastric bypass candidates. The ideal operation for medically refractory GERD in a patient who is also morbidly obese is a laparoscopic Roux-en-Y gastric bypass (LRYGB). Unfortunately, some patients who ultimately present for bariatric surgery have previously undergone Nissen fundoplication for their GERD. Many surgeons consider previous fundoplication to be a relative contraindication to subsequent LRYGB due to increased technical complexity and risk. We sought to compare the perioperative and long term outcomes of a cohort of patients who had first undergone fundoplication and ultimately chose to later pursue LRYGB for morbid obesity to matched control LRYGB patients who had not previously had a fundoplication.
Methods and Procedures: Upon IRB approval, data was attained via retrospective review of a prospectively maintained bariatric surgery database. Patients with fundoplications converted to LRYGB (reoperative group) were each matched by BMI to 3 randomly selected controls (control group). Statistical analysis was performed using Wilcoxon rank sum tests and Fisher’s exact tests, depending on whether data was continuous or categorical.
Results: There were 9 patients in the study group matched to 27 controls. Mean BMI was similar between both groups (44.5 vs. 45.0, p =0.97). Mean follow-up was 8 months for reoperative patients (range 1.5 to 25) vs. 25.4 months (range 3-72 months) for controls (p = 0.004). Major complications in the reoperative group included one non-operative leak and one intra-abdominal bleed necessitating transfusion. There were no complications in the control group (22% reoperative vs. 0% control, p= 0.06). There was one readmission for dehydration in each group (11.1% reoperative vs. 3.7% control, p=0.4).
|Length of Stay (Days)||Complications||% EWL at 1 Year|
|Reoperative||3||2||78.6 +/-8.3 (n=3)|
|Control||2||0||69.2 +/- 13.6 (n=20)|
% EWL = percent excess weight loss
Conclusions: Although associated with longer operative times and hospital stay, LRYGB after fundoplication is feasible and safe. Long term weight loss outcomes are similar. Our experience is small, but there may be a higher perioperative complication rate in reoperative cases. Previous fundoplication should not be considered a contraindication to LRYGB. Optimally, morbidly obese patients with medically refractory GERD would be advised to undergo primary LRYGB without an attempt at a fundoplication.
Program Number: P077