Laparoscopic revision of Nissen fundoplication to Roux-en-Y gastric bypass in morbidly obese patients

Efficacy and safety of laparoscopic Roux-en-Y gastric bypass in symptomatic patients following fundoplication failure: a meta-analysis

Revisional surgery may be required in a subset of patients who remain symptomatic despite undergoing laparoscopic fundoplication (LF) for gastroesophageal reflux disease (GERD). While revisional LF (RLF) is feasible in these patients, laparoscopic Roux-en-Y gastric bypass (LRYGB) may serve as an alternative, although its efficacy and safety remains unknown. This study aimed to determine the outcomes of LRYGB in symptomatic patients following failed LF for GERD. MEDLINE, EMBASE, and PubMed databases were systematically searched for studies reporting LRYGB outcomes in symptomatic adults despite undergoing LF for GERD. Postoperative symptom resolution, recurrence of heartburn and dysphagia, proton pump inhibitor (PPI) use, and body mass index (BMI) reduction were assessed to determine LRYGB efficacy. Postoperative morbidity and mortality were used to evaluate LRYGB safety. Twenty-two studies with 1523 patients were included. Pooled rates of symptom resolution, recurrence of heartburn and dysphagia, PPI use, morbidity, and mortality were 71.6% (95% CI 59.4-86.4), 15.6% (8.9-27.3), 20.7% (12.5-34.3), 29.6% (18.8-46.5), 39.5% (29.9-52.3), and 2.2% (1.2-4.0), respectively, following LRYGB. Similar rates were observed after RLF. However, BMI reduction was significantly greater after LRYGB compared with RLF (mean difference 6.1 kg/m², 4.8-7.4; p < 0.0001). LRYGB resulted in symptom relief in a majority of patients, and proved comparable to RLF regarding symptom recurrence and PPI use. Morbidity and mortality following LRYGB also did not differ from RLF. However, LRYGB was associated with considerably greater weight loss relative to RLF. Therefore, LRYGB is efficacious and an acceptable revisional procedure in symptomatic GERD patients who have previously undergone LF.

A Technique of Preserving Preexisting Fundoplication When Converting to Roux-en-Y Gastric Bypass

BACKGROUND

The standard surgical treatment of gastro-esophageal reflux disease (GERD) consists of either 360° (Nissen, NFP) or 270° (Toupet, TFP) fundoplication. On some occasions, such as recurrent GERD and/or severe overweight, patients may benefit from conversion to Roux-en-Y gastric bypass (RYGB), which is however technically difficult. Most techniques of conversion involve unwrapping of the fundoplication. We developed a laparoscopic technique that includes preservation of the wrap, while constructing a standard small-pouch RYGB. We describe the surgical technique and report the short-term outcomes of our technique.

METHODS

Consecutive patients underwent conversion of NFP to RYGB by our fundoplication preserving technique as described in surgical technique. Perioperative outcomes were assessed by analysis of the electronic patient records; progression of GERD symptoms and patient satisfaction were evaluated by an on-line questionnaire.

RESULTS

Fourteen patients underwent the conversion. There were no peroperative complications and no conversions. Short-term complications were registered in 4 patients (Clavien-Dindo grade 1, n = 2; grade 2, n = 1 and grade 3a, n = 1). No long-term complications were reported. None of the participants reported significant GERD symptoms Patient satisfaction was good.

CONCLUSION

We developed a laparoscopic technique of NFP to RYGB conversion, with preservation of fundoplication integrity, which appears to add to the safety and efficacy of the procedure.

LAPAROSCOPIC REDO FUNDOPLICATION ALONE, REDO NISSEN FUNDOPLICATION, OR TOUPET FUNDOPLICATION COMBINED WITH ROUX-EN-Y DISTAL GASTRECTOMY FOR TREATMENT OF FAILED NISSEN FUNDOPLICATION

BACKGROUND:

Laparoscopic Nissen fundoplication fails to control the gastroesophageal reflux in almost 15% of patients, and most of them must be reoperated due to postoperative symptoms. Different surgical options have been suggested.

AIMS:

This study aimed to present the postoperative outcomes of patients submitted to three different procedures: redo laparoscopic Nissen fundoplication alone (Group A), redo laparoscopic Nissen fundoplication combined with distal gastrectomy (Group B), or conversion to laparoscopic Toupet combined with distal gastrectomy with Roux-en-Y gastrojejunostomy (Group C).

METHODS:

This is a prospective study involving 77 patients who were submitted initially to laparoscopic Nissen fundoplication and presented recurrence of gastroesophageal reflux after the operation. They were evaluated before and after the reoperation with clinical questionnaire and objective functional studies. After reestablishing the anatomy of the esophagogastric junction, a surgery was performed. None of the patients were lost during follow-up.

RESULTS:

Persistent symptoms were observed more frequently in Group A or B patients, including wrap stricture, intrathoracic wrap, or twisted fundoplication. In Group C, recurrent symptoms associated with this anatomic alteration were infrequently observed. Incompetent lower esophageal sphincter was confirmed in 57.7% of patients included in Group A, compared to 17.2% after Nissen and distal gastrectomy and 26% after Toupet procedure plus distal gastrectomy. In Group C, despite the high percentage of patients with incompetent lower esophageal sphincter, 8.7% had abnormal acid reflux after surgery.

CONCLUSIONS:

Nissen and Toupet procedures combined with Roux-en-Y distal gastrectomy are safe and effective for the management of failed Nissen fundoplication. However, Toupet technique is preferable for patients suffering from mainly dysphagia and pain.

Does Sleeve Gastrectomy Worsen Gastroesophageal Reflux Disease in Obese Patients? A Prospective Study

BACKGROUND

To evaluate the impact of laparoscopic sleeve gastrectomy (LSG) and gastric bypass (LGB) on gastroesophageal reflux disease (GERD).

METHODS

GERD was evaluated by the Modified Italian Gastroesophageal reflux disease-Health-Related Quality of Life (MI-GERD-HRQL) questionnaire, pH-manometry, endoscopy, and Rx-esophagogram, before and 12 months after surgery. Based on these exams, patients without GERD underwent LSG, and patients with GERD underwent LGB.

RESULTS

Thirteen and six patients underwent LSG and LGB, respectively. After LSG, the only statistically significant difference observed at pH-manometry was the median DeMeester score, from 5.7 to 22.7 (P = .0026). De novo GERD occurred in 6 patients (46.2%), with erosive esophagitis in one. The median MI-GERD-HRQL score improved from 3 to 0. Overall, nine patients underwent LGB, but three were lost to follow-up. Preoperative pH-manometry changed the surgical indication from LSG to LGB in 7 out of 9 patients (77.8%). Six patients who underwent LGB completed the study, and at pH-manometry, statistically significant differences were observed in the percentage of total acid exposure time, with the number of reflux episodes lasting >5 minutes and DeMeester score (P = .009). The median MI-GERD-HRQL score improved from 6.5 to 0. Statistically significant differences were not observed at endoscopy and Rx-esophagogram findings in both groups.

CONCLUSIONS

LSG has a negative impact on GERD, even in patients without preoperative GERD. LGB confirmed to be the intervention of choice in patients with GERD. Preoperative pH-manometry may identify patients with silent GERD, to candidate them to LGB rather than LSG. pH-manometry should be used more liberally to establish the correct surgical indication on objective grounds.

Gastroesophageal reflux disease complicating laparoscopic sleeve gastrectomy: current knowledge and surgical therapies

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is currently the most commonly performed bariatric procedure worldwide. However, the incidence of gastroesophageal reflux disease (GERD) after LSG is high.

OBJECTIVES

The aim of this systematic review was to identify the optimal surgical strategy for treating GERD after LSG.

SETTING

West China Hospital, Sichuan University, Chengdu, China.

METHODS

A systematic literature search was performed to identify studies on surgical treatments for GERD after LSG. The effectiveness and safety profile of surgical management on GERD after LSG were analyzed.

RESULTS

A total of 40 articles enrolling 2049 patients were included in this review. Surgical strategies to prevent GERD after LSG were mainly of 2 types: concomitant LSG + antireflux procedures (hiatal hernia repair or fundoplication) and secondary procedures (conversion to Roux-en-Y gastric bypass [RYGB] or repeat sleeve gastrectomy). The short-term remission or improvement rate of GERD was 34.6%-100% after concomitant LSG + antireflux procedures. The postoperative complication rate was the same (3.0%) for both LSG + antireflux procedures and LSG alone. The remission or improvement rate of GERD was 57.1%-100% after conversion to RYGB and 100% after repeat sleeve gastrectomy.

CONCLUSIONS

The effectiveness and safety profile of concomitant LSG + antireflux procedures is uncertain. However, secondary operations after LSG, such as conversion to RYGB, appear to provide good results. The data overall are heterogeneous, with imprecise methods of documenting and defining GERD complicating LSG. More cohort studies or RCT studies of high quality with long-term follow-up are needed in the future.

Minimally Invasive Roux-en-Y Gastric Bypass for Fundoplication failure offers Excellent Gastroesophageal Reflux Control

Roux-en-Y gastric bypass (RYGB) may represent a superior alternative to reoperative fundoplication in patients with symptomatic failure. Our goal was to assess early outcomes of patients after RYGB for failed fundoplication. Records of patients who underwent fundoplication takedown and RYGB from March 2007 to June 2013 were reviewed for demographics, comorbidities, operative findings, and perioperative outcomes. Data are reported as medians (range). Forty-five patients who had undergone 64 prior antireflux procedures (range, one to three fundoplications) were identified. Median patient age was 56 years (range, 25 to 72 years) with a body mass index of 33 kg/m2 (range, 22 to 51 kg/m2). Most patients had comorbidities: hypertension (60%), anxiety/ depression (44.4%), dyslipidemia (33.3%), asthma (31%), obstructive sleep apnea (26.7%), arthritis (22.2%), and diabetes (11.1%). Median symptom-free interval was 3 years (range, 0 to 25 years). All patients had an anatomic reason for failure: 83 per cent had a hiatal hernia and 35 per cent had a slipped Nissen fundoplication. The procedures were accomplished laparoscopically in 28, robotically in 13, and open in four cases. Median operative time was 367 minutes (range, 190 to 600 minutes) and estimated blood loss averaged 100 mL (range, 25 to 500 mL). Five patients (11%) required reoperation: one for an anastomotic leak, one for anastomotic obstruction, and three for early obstruction resulting from adhesions. Two patients developed respiratory failure requiring prolonged mechanical ventilation. Length of stay averaged four days (range, 1 to 33 days) with two readmissions: one for melena and one for vomiting and dehydration; neither required intervention. There was no mortality. At 11 months of follow-up (range, 2.3 to 54 months), 93.3 per cent of patients were symptom-free. When primary fundoplication for gastroesophageal reflux disease fails, fundoplication takedown and RYGB can be accomplished safely with minimally invasive techniques. The conversion to a RYGB has an acceptable perioperative morbidity and excellent early symptom control, and, therefore, should be considered for reoperative patients gastroesophageal reflux disease.

Efficacy and Safety of Recurrent Paraesophageal Hernia Repair with Roux-en-Y Gastric Bypass

Roux-en-Y gastric bypass (RYGB) has been explored as a revisional option to failed paraesophageal hernia (PEH) repair with fundoplication, particularly in patients suffering from obesity. However, few studies have assessed long-term outcomes of RYGB with revisional PEH repairin regard to acid-suppressing medication use. We retrospectively identified 19 patients who underwent revisional PEH repair with RYGB between 2011 and 2018. The median operative time was 232 minutes with a median hospital length of stay of two days. The median length of follow-up was 24 months. Two patients (10.5%) had complications in the first 30 days, and five patients (26.3%) had complications within one year. Of the 12 patients on preoperative acid suppression, 6 (50%) were either off medication or on reduced dose at 12 months. The median BMI decrease was 14.4 kg/m2at 12 months and did not change significantly afterward. Although rates of acid-suppression medication use did not change overall after revisional PEH repair with RYGB, patients experienced successful long-term management of morbid obesity and sustained weight loss. Revisional PEH repair with RYGB is a safe and effective option, with a complication rate comparable with the reported rates after revisional foregut procedures such as revisional Nissen fundoplication.

Salvage Options for Fundoplication Failure

PURPOSE OF REVIEW

Gastroesophageal reflux disease (GERD) affects millions of people worldwide. Many patients with medically refractory symptoms ultimately undergo antireflux surgery, most often with a laparoscopic fundoplication. Symptoms related to GERD may persist or recur. Revisional surgery is necessary in some patients.

RECENT FINDINGS

A reoperative fundoplication is the most commonly performed salvage procedure for failed fundoplication. Although redo fundoplication has been reported to have increased risk of morbidity compared with primary cases, increasing experience with the minimally invasive approach to reoperative surgery has significantly improved patient outcome with acceptable resolution of reflux symptoms in the majority of patients. Recurrence of reflux symptoms after an initial fundoplication requires a thorough work-up and a thoughtful approach. While reoperative fundoplication is the most common procedure performed, there are other options and the treatment should be tailored to the patient, their history, and the mechanism of fundoplication failure.

FUNDOPLICATION CONVERSION IN ROUX-EN-Y GASTRIC BYPASS FOR CONTROL OF OBESITY AND GASTROESOPHAGEAL REFLUX: SYSTEMATIC REVIEW

Introduction:

Obesity is related with higher incidence of gastroesophageal reflux disease. Antireflux surgery has inadequate results when associated with obesity, due to migration and/or subsequent disruption of antireflux wrap. Gastric bypass, meanwhile, provides good control of gastroesophageal reflux.

Objective:

To evaluate the technical difficulty in performing gastric bypass in patients previously submitted to antireflux surgery, and its effectiveness in controlling gastroesophageal reflux.

Methods:

Literature review was conducted between July to October 2016 in Medline database, using the following search strategy: (“Gastric bypass” OR “Roux-en-Y”) AND (“Fundoplication” OR “Nissen ‘) AND (“Reoperation” OR “Reoperative” OR “Revisional” OR “Revision” OR “Complications”).

Results:

Were initially classified 102 articles; from them at the end only six were selected by exclusion criteria. A total of 121 patients were included, 68 women. The mean preoperative body mass index was 37.17 kg/m² and age of 52.60 years. Laparoscopic Nissen fundoplication was the main prior antireflux surgery (70.58%). The most common findings on esophagogastroduodenoscopy were esophagitis (n=7) and Barrett’s esophagus (n=6); the most common early complication was gastric perforation (n=7), and most common late complication was stricture of gastrojejunostomy (n=9). Laparoscopic gastric bypass was performed in 99 patients, with an average time of 331 min. Most patients had complete remission of symptoms and efficient excess weight loss.

Conclusion:

Although technically more difficult, with higher incidence of complications, gastric bypass is a safe and effective option for controlling gastroesophageal reflux in obese patients previously submitted to antireflux surgery, with the added benefit of excess weight loss.

Roux-en-Y gastric bypass as a salvage procedure in complicated patients with failed fundoplication(s)

BACKGROUND

In symptomatic patients after failed fundoplication, reoperation is considered. In complex or obese patients, Roux-en Y gastric bypass (RYGB) may be the best operation. We sought to characterize the outcomes of patients with failed fundoplication to undergo salvage RYGB, and to compare these outcomes to patients undergoing reoperative fundoplication.

METHODS

A prospectively maintained database was queried for procedures performed at a single institution from 2011 to 2017. GERD health-related quality of life (HRQL) surveys were administered at defined intervals.

RESULTS

Thirty-six patients underwent salvage RYGB and 84 patients underwent reoperative fundoplication. The RYGB cohort had a higher BMI (35.5 ± 6.8 vs. 28.7 ± 5.3, p < 0.01), more gastroparesis (52.8% vs. 9.5%, p < 0.01), more esophagitis (42.9% vs. 20.2%, p = 0.01), and more prior fundoplications (1.9 vs. 1.2, p < 0.01). The incidence of gastroparesis and esophagitis was directly related to the number of failed fundoplications (p < 0.05). Operative times were longer with RYGB (332.7 ± 131.5 vs. 200.0 ± 67.6 min, p < 0.01) as was length of stay (4.3 ± 3.4 vs. 2.8 ± 1.5 days, p = 0.02), incidence of Clavien-Dindo complications ≥ Grade 3 (19.4% vs. 4.8%, p = 0.01), 30-day reoperation (11.1% vs. 1.2%, p = 0.01), and 30-day readmission (32.4% vs. 11.9%, p < 0.01). In five patients with three or more prior fundoplication attempts, an esophagojejunostomy was necessary. If these patients are excluded, 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 follow-up.

CONCLUSIONS

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 three or more previous fundoplication attempts are more likely to require esophagojejunostomy. Complication rates in this subset of patients appear to be quite high.

Roux-en-Y Gastric Bypass Following Nissen Fundoplication: Higher Risk Same Reward

BACKGROUND

Roux-en-Y gastric bypass (RYGB) effectively treats obesity and gastroesophageal reflux disease (GERD). As more surgeons recommend RYGB to treat GERD in patients with obesity, there are concerns about this approach in patients with previous non-bariatric foregut surgery. This study aims to evaluate the effect of previous non-bariatric foregut surgery on subsequent RYGB.

METHODS

Retrospective review of 2089 patients undergoing RYGB between January 1985 and June 2015 was conducted to identify all patients with previous non-bariatric foregut surgery. Perioperative and postoperative data was collected by retrospective chart review.

RESULTS

A total of 11 patients with prior non-bariatric foregut surgery underwent RYGB with median time between operations of 95.6 months. Of note, 7/11 (63.6%) had previous Nissen fundoplication. Conversion to open operation was required in 3/7 (42.9%) with previous Nissen compared to 1/4 (25%) in those without previous Nissen. The average length of stay (LOS) was 3.9 ± 0.9 days, significantly longer than our institutional average for RYGB of 3.2 ± 3.2 days (p = 0.02). Mean percentage of excess body mass index loss (%EBMIL) was 64.7 ± 23.5 at 4-year median follow-up, comparable to our institution's previously reported data. No mortalities were attributed to RYGB and the overall complication rate was 18.2%, compared to our institutional complication rate for RYGB of 8.5% (p = 0.253).

CONCLUSION

Despite increased technical difficulty and increase perioperative morbidity, patients undergoing RYGB with previous non-bariatric foregut surgery had long-term symptom resolution and robust weight loss. This indicates that in the right hands, RYGB after non-bariatric foregut surgery may be performed safely and effectively.

Obesity-Related Digestive Diseases and Their Pathophysiology

Obesity is a growing medical and public health problem worldwide. Many digestive diseases are related to obesity. In this article, the current state of our knowledge of obesity-related digestive diseases, their pathogenesis, and the medical and metabolic consequences of weight reduction are discussed. Obesity-related digestive diseases include gastroesophageal reflux disease, Barrett’s esophagus, esophageal cancer, colon polyp and cancer, nonalcoholic fatty liver disease, hepatitis C-related disease, hepatocellular carcinoma, gallstone, cholangiocarcinoma, and pancreatic cancer. Although obesity-related esophageal diseases are associated with altered mechanical and humoral factors, other obesity-related digestive diseases seem to be associated with obesity-induced altered circulating levels of adipocytokines and insulin resistance. The relationship between functional gastrointestinal disease and obesity has been debated. This review provides a comprehensive evaluation of the obesity-related digestive diseases, including pathophysiology, obesity-related risk, and medical and metabolic effects of weight reduction in obese subjects.

Hiatoplasty with Crura Buttressing versus Hiatoplasty Alone during Laparoscopic Sleeve Gastrectomy

Introduction

In obese patients with hiatal hernia (HH), laparoscopic sleeve gastrectomy (LSG) with cruroplasty is an option but use of prosthetic mesh crura reinforcement is debated. The aim was to compare the results of hiatal closure with or without mesh buttressing during LSG.

Methods

Gastroesophageal reflux disease (GERD) was assessed by the Health-Related Quality of Life (GERD-HRQL) questionnaire before and after surgery in two consecutive series of patients with esophageal hiatus ≤ 4 cm². After LSG, patients in group A (12) underwent simple cruroplasty, whereas in group B patients (17), absorbable mesh crura buttressing was added.

Results

At mean follow-up of 33.2 and 18.1 months for groups A and B, respectively (p = 0.006), the mean preoperative GERD-HRQL scores of 16.5 and 17.7 (p = 0.837) postoperatively became 9.5 and 2.4 (p = 0.071). In group A, there was no difference between pre- and postoperative scores (p = 0.279), whereas in group B, a highly significant difference was observed (p = 0.002). The difference (Δ) comparing pre- and postoperative mean scores between the two groups was significantly in favor of mesh placement (p = 0.0058).

Conclusions

In obese patients with HH and mild-moderate GERD, reflux symptoms are significantly improved at medium term follow-up after cruroplasty with versus without crura buttressing during LSG.

Laparoscopic Sleeve Gastrectomy and Crural Repair as a Treatment of Morbid Obesity Associated with Gastroesophageal Reflux

Objective

The aim of this study was to evaluate the Laparoscopic Sleeve Gastrectomy (LSG) with simultaneous crural repair in treatment of morbid obesity associated with gastroesophageal reflux disease.

Methods

This prospective observational study was carried out from September 2012 to July 2016 in Al-Azhar University Hospital (Egypt). The study was conducted on 53 patients, 14 males (26.4%) and 39 females (73.6%) with the mean age 36.2 years (range 18–52 years), presenting with morbid obesity and reflux disease either symptomatic patients or asymptomatic (Endoscopic & Manometric), their mean Body Mass Index (BMI) was 50.1 kg/m² (range 40–62 kg/m²), who underwent LSG and antireflux procedure (crural repair).

Results

Excess weight Loss (EWL); the mean EWL at 6 months postoperatively was 46.3%, at 12 months was 54%, and at 18 months was 61%. Also, we found that, preoperative co-morbidities are resolved by 53% and improved by 23%. Reflux symptoms were absent in 30 patients (56 %), improved in 14 patients (26.4 %), but persistent in 7 patients (13.2 %).

Conclusion

Laparoscopic crural closure, during LSG, represents a valuable option for the treatment of morbid obesity and gastroesophageal reflux, and can result in favorable outcomes in terms of weight loss and gastroesophageal reflux disease (GERD) symptoms control.

Diagnosis and treatment of gastroesophageal reflux disease: recommendations of the Asociación Mexicana de Gastroenterología

Emerging concepts in the pathophysiology of gastroesophageal reflux disease (GERD) and the constant technologic advances in the diagnosis and treatment of this clinical condition make it necessary to frequently review and update the clinical guidelines, recommendations, and official statements from the leading academic groups worldwide. The Asociación Mexicana de Gastroenterología (AMG), aware of this responsibility, brought together national experts in this field to analyze the most recent scientific evidence and formulate a series of practical recommendations to guide and facilitate the diagnostic process and efficacious treatment of these patients. The document includes algorithms, figures, and tables for convenient consultation, along with opinions on GERD management in sensitive populations, such as pregnant women and older adults.

Laparoscopic Undo of Fundoplication with Roux-en-Y Gastric Bypass in a Morbidly Obese Patient with Prior Nissen's Fundoplication: A Video Report

BACKGROUND

Roux-en-Y gastric bypass (RYGB) may be a better option for morbidly obese patients with gastroesophageal reflux (GERD) for long-term reflux control. It is recommended after fundoplication if a patient is morbidly obese with GERD with failed fundoplication or if bariatric surgery is planned with a prior successful fundoplication (Kim et al., Am Surg 80(7):696-703, 2014; Kambiz Zainabadi, Surg Endosc. 22(12):2737-40, 2008). Complete takedown of the wrap to avoid stapling over the fundoplication creating an obstructed, septated pouch is needed (Kambiz Zainabadi, Surg Endosc. 22(12):2737-40, 2008). The aim of this video was to demonstrate the technical aspect of dissection and undo of Nissen's fundoplication followed by performance of a RYGB in a morbidly obese patient with GERD with prior successful Nissen's fundoplication opting for bariatric surgery after a year.

METHODS

We present a case of a 50-year-old woman with a BMI of 36.14 with previous laparoscopic Nissen's fundoplication for severe GERD (controlled after surgery) and a prior laparoscopic intraperitoneal onlay mesh repair who presented for bariatric surgery 1 year after fundoplication. She was successfully treated by laparoscopic undo of the fundoplication with RYGB.

RESULTS

In this multimedia high-definition video, we present step-by-step the laparoscopic undo of a Nissen's fundoplication followed by RYGB. The procedure included lysis of all adhesions between the liver and the stomach, dissection of the diaphragmatic crura, complete takedown of the wrap, repair of the hiatal hernia, creation of a gastric pouch, creation of an antecolic Roux limb, gastrojejunal anastomosis, and jejuno-jejunal anastomosis.

CONCLUSION

Laparoscopic RYGB after fundoplication in morbidly obese patients with GERD is a technically difficult but feasible option.

Gastroesophageal reflux disease in the obese: Pathophysiology and treatment

Obesity is a condition that has increased all over the world in the last 3 decades. Overweight and gastroesophageal reflux disease (GERD) are related. GERD may have different causative factors in the obese compared with lean individuals. This review focuses on the proper treatment for GERD in the obese based on its pathophysiology. Increased abdominal pressure may play a more significant role in obese subjects with GERD than the defective esophagogastric barrier usually found in nonobese individuals. A fundoplication may be used to treat GERD in these individuals; however, outcomes may be not as good as in nonobese patients and it does not act on the pathophysiology of the disease. All bariatric techniques may ameliorate GERD symptoms owing to a decrease in abdominal pressure secondary to weight loss. However, some operations may lead to a disruption of natural anatomic antireflux mechanisms or even lead to slow gastric emptying and/or esophageal clearance and thus be a refluxogenic procedure. Roux-en-Y gastric bypass decreases both acid and bile reflux from the stomach into the esophagus. On the other hand, gastric banding is a refluxogenic operation, and sleeve gastrectomy may show different outcomes based on the anatomy of the gastric tube.

Reoperative antireflux surgery

Patient satisfaction with primary antireflux surgery is high, but a small percentage of patients experience recurrent reflux and dysphagia, requiring reoperation. The major anatomic causes of failed fundoplication are slipped fundoplication, failure to identify a short esophagus, and problems with the wrap. Minimally invasive surgery has become more common for these procedures. Options for surgery include redo fundoplication with hiatal hernia repair if needed, conversion to Roux-en-Y anatomy, or, as a last resort, esophagectomy. Conversion to Roux-en-Y anatomy has a high rate of success, making this approach an important option in the properly selected patient.

Treatment of giant hiatal hernia by laparoscopic Roux-en-Y gastric bypass

•

LRYGB plus HHR is safe and feasible.

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LRYGB plus HHR results in additional weight loss and improvement of co-morbidity.

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LRYGB plus HHR is a good alternative for antireflux surgery in obese HH-patients.

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HH-patients meeting bariatric surgery criteria should be informed about LRYGB plus HHR.

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Randomized trials comparing fundoplication with LRYGB plus HHR are needed.

Introduction

Obesity is a risk factor for hiatal hernia. In addition, much higher recurrence rates are reported after standard surgical treatment of hiatal hernia in morbidly obese patients. Laparoscopic Roux-en-Y gastric bypass (LRYGB) is an effective surgical treatment for morbid obesity and is known to effectively control symptoms of gastroesophageal reflux (GERD).

Case presentation

Two patients suffering from giant hiatal hernias where a combined LRYGB and hiatal hernia repair (HHR) with mesh was performed are presented in this paper. There were no postoperative complications and at 1 year follow-up, there was no sign of recurrence of the hernia.

Discussion

The gold standard for all symptomatic reflux patients is still surgical correction of the paraesophageal hernia, including complete reduction of the hernia sac, resection of the sac, hiatal closure and fundoplication. However, HHR outcome is adversely affected by higher BMI levels, leading to increased HH recurrence rates in the obese.

Conclusion

Concomitant giant hiatal hernia repair with LRYGB appears to be safe and feasible. Moreover, LRYGB plus HHR appears to be a good alternative for HH patients suffering from morbid obesity as well than antireflux surgery alone because of the additional benefit of significant weight loss and improvement of obesity related co-morbidity.

Does BMI predict recurrence or complications after reoperative reflux surgery? Review of a single center's experience and a comparison of outcomes

INTRODUCTION

Obese patients who fail primary surgical management of gastroesophageal reflux present a significant challenge. We reviewed our outcomes with reoperative reflux surgery in obese (body mass index (BMI) >30) and nonobese patients to identify predictors of failure and complications and evaluate whether reoperative fundoplication is the ideal solution for obese patients.

METHODS

We conducted a retrospective review of consecutive patients undergoing reoperation for failed anti-reflux surgery between 1994 and 2013. Medical record review identified preoperative, intraoperative, and postoperative characteristics. Short- and long-term outcomes for obese and nonobese patients were compared using descriptive statistics and logistic regression.

RESULTS

One hundred and nine interventions were identified in 95 patients. Clinical characteristics were similar between obese and nonobese patients. Eighty-eight (83.8%) patients underwent laparoscopic repair, 87 (79.8%) of whom had a Nissen fundoplication. Obese patients were more likely to fail via a slipped wrap (64.7 vs. 40.0%; p = 0.02). No differences were seen in short- or long-term symptomatic relief or major complications. In bivariate analysis, short-term outcomes were predicted by preoperative albumin <3.5 mg/dL (odds ratio (OR), 0.27 (confidence interval (CI), 0.08-0.96); p = 0.04) and laparoscopic conversion (OR, 0.19 (CI, 0.04-1.03); p = 0.05). Laparoscopic conversion was associated with major complications (OR, 7.33 (CI, 1.33-40.55); p = 0.02). BMI was a significant predictor for long-term outcome (p = 0.03) as a continuous variable in sensitivity analyses.

CONCLUSIONS

Obese patients with recurrence after failed anti-reflux operation may be safely treated with a repeat operation. Our data indicate no difference in outcomes for patients with BMI >30, underscoring the importance of preoperative discussion as to the best approach: reoperative fundoplication or a gastric bypass.

The effect of bariatric surgery on gastroesophageal reflux disease

Obesity is an epidemic that is known to play a role in the development of gastroesophageal reflux disease (GERD). Studies have shown that increasing body mass index plays a role in the incompetence of the gastroesophageal junction and that weight loss and lifestyle modifications reduce the symptoms of GERD. As a method of producing effective and sustainable weight loss, bariatric surgery plays a major role in the treatment of obesity. We reviewed the literature on the effects of different types of bariatric surgery on the symptomatic relief of GERD and its complications. Roux-en- Y gastric bypass was considered an effective method to alleviate symptoms of GERD, whereas laparoscopic sleeve gastrectomy appeared to increase the incidence of the disease. Adjustable gastric banding was seen to initially improve the symptoms of GERD; however, a subset of patients experienced a new onset of GERD symptoms during long-term follow-up. The literature suggests that different surgeries have different impacts on the symptomatology of GERD and that careful assessment may be needed before performing bariatric surgery in patients with GERD.

EAES recommendations for the management of gastroesophageal reflux disease

BACKGROUND

Gastroesophageal reflux disease (GERD) is one of the most frequent benign disorders of the upper gastrointestinal tract. Management of GERD has always been controversial since modern medical therapy is very effective, but laparoscopic fundoplication is one of the few procedures that were quickly adapted to the minimal access technique. The purpose of this project was to analyze the current knowledge on GERD in regard to its pathophysiology, diagnostic assessment, medical therapy, and surgical therapy, and special circumstances such as GERD in children, Barrett's esophagus, and enteroesophageal and duodenogastroesophageal reflux.

METHODS

The European Association of Endoscopic Surgery (EAES) has tasked a group of experts, based on their clinical and scientific expertise in the field of GERD, to establish current guidelines in a consensus development conference. The expert panel was constituted in May 2012 and met in September 2012 and January 2013, followed by a Delphi process. Critical appraisal of the literature was accomplished. All articles were reviewed and classified according to the hierarchy of level of evidence and summarized in statements and recommendations, which were presented to the scientific community during the EAES yearly conference in a plenary session in Vienna 2013. A second Delphi process followed discussion in the plenary session.

RESULTS

Recommendations for pathophysiologic and epidemiologic considerations, symptom evaluation, diagnostic workup, medical therapy, and surgical therapy are presented. Diagnostic evaluation and adequate selection of patients are the most important features for success of the current management of GERD. Laparoscopic fundoplication is the most important therapeutic technique for the success of surgical therapy of GERD.

CONCLUSIONS

Since the background of GERD is multifactorial, the management of this disease requires a complex approach in diagnostic workup as well as for medical and surgical treatment. Laparoscopic fundoplication in well-selected patients is a successful therapeutic option.

Long-term outcomes of reintervention for failed fundoplication: redo fundoplication versus Roux-en-Y reconstruction

BACKGROUND

Redo fundoplication (RF) is the mainstay of treatment for failed fundoplication. A subset of patients with failed fundoplication requires Roux-en-Y reconstruction (RNY) for symptom relief. The aim of this study was to compare the long-term subjective outcomes between RF and RNY in patients with failed fundoplication.

METHODS

After Institutional Board Review approval, retrospective review of a prospective database identified 119 RF (mean = 54.1 years, 78 women) and 64 RNY (mean = 54.8 years, 35 women) patients who underwent reoperative surgery between December 2003 and September 2009. Data variables analyzed included demographics, esophageal manometry, 24-h pH study, type of procedure, perioperative findings, complications, pre- and postoperative symptom (heartburn, regurgitation, dysphagia, and chest pain) scores (scale 0-3), and patient satisfaction score (scale 1-10). Patients with grade 2 and 3 scores were considered to have significant symptoms.

RESULTS

Patients who underwent RNY had a significantly higher body mass index, higher mean number of risk factors, and higher preoperative severity of heartburn and regurgitation compared to the RF group. Of the 183 patients, long-term (>3 years) follow-up was available for 132 (89 RF and 43 RNY) patients. Symptom severity significantly improved after both procedures, with the exception of dysphagia in the RNY group. Overall, there was no significant difference in patients' satisfaction between the RF and RNY groups. In subset analysis, patients with morbid obesity, esophageal dysmotility, or ≥4 risk factors have better satisfaction with RNY compared to RF (p = 0.027, 0.031, and 0.045, respectively).

CONCLUSIONS

RF and RNY have equally good patient satisfaction at 3 years follow-up. RNY may have improved outcomes in patients who are morbid obese, have esophageal dysmotility, or have four or more risk factors.

Laparoscopic treatment of obese patients with gastroesophageal reflux disease and Barrett's esophagus: a prospective study

BACKGROUND

Short-segment Barrett's esophagus (SSBE) or long-segment Barrett's esophagus (LSBE) is the consequence of chronic gastroesophageal reflux disease (GERD), which is frequently associated with obesity. Obesity is a significant risk factor for the development of GERD symptoms, erosive esophagitis, Barrett's esophagus, and esophageal adenocarcinoma. Morbidly obese patients who submitted to gastric bypass have an incidence of GERD as high as 50% to 100% and Barrett's esophagus reaches up to 9% of patients.

METHODS

In this prospective study, we evaluate the postoperative results after three different procedures--calibrated fundoplication + posterior gastropexy (CFPG), fundoplication + vagotomy + distal gastrectomy + Roux-en-Y gastrojejunostomy (FVDGRYGJ), and laparoscopic resectional Roux-en-Y gastric bypass (LRRYGBP)--among obese patients.

RESULTS

In patients with SSBE who submitted to CFPG, the persistence of reflux symptoms and endoscopic erosive esophagitis was observed in 15% and 20.2% of them, respectively. Patients with LSBE were submitted to FVDGRYGJ or LRRYGBP which significantly improved their symptoms and erosive esophagitis. No modifications of LESP were observed in patients who submitted to LRRYGBP before or after the operation. Acid reflux diminished after the three types of surgery were employed. Patients who submitted to LRRYGBP presented a significant reduction of BMI from 41.5 ± 4.3 to 25.7 ± 1.3 kg/m(2) after 12 months.

CONCLUSIONS

Among patients with LSBE, FVDGRYGJ presents very good results in terms of improving GERD and Barrett's esophagus, but the reduction of weight is limited. LRRYGBP improves GERD disease and Barrett's esophagus with proven reduction in body weight and BMI, thus becoming the procedure of choice for obese patients.

Sleeve gastrectomy and crural repair in obese patients with gastroesophageal reflux disease and/or hiatal hernia

BACKGROUND

Gastroesophageal reflux disease (GERD) with or without hiatal hernia (HH) is now recognized as an obesity-related co-morbidity. Roux-en-Y gastric bypass has been proved to be the most effective bariatric procedure for the treatment of morbidly obese patients with GERD and/or HH. In contrast, the indication for laparoscopic sleeve gastrectomy (SG) in these patients is still debated. Our objective was to report our experience with 97 patients who underwent SG and HH repair (HHR). The setting was a university hospital in Italy.

METHODS

From July 2009 to December 2011, 378 patients underwent a preoperative workup for SG. In 97 patients, SG was performed with HHR. The clinical outcome was evaluated considering GERD symptom resolution or improvement, interruption of antireflux medications, and radiographic evidence of HH recurrence.

RESULTS

Before surgery, symptomatic GERD was present in 60 patients (15.8%), and HH was diagnosed in 42 patients (11.1%). In 55 patients (14.5%), HH was diagnosed intraoperatively. The mean follow-up was 18 months. GERD remission occurred in 44 patients (73.3%). In the remaining 16 patients, antireflux medications were diminished, with complete control of symptoms in 5 patients. No HH recurrences developed. "De novo" GERD symptoms developed in 22.9% of the patients undergoing SG alone compared with 0% of patients undergoing SG plus HHR.

CONCLUSION

SG with HHR is feasible and safe, providing good management of GERD in obese patients with reflux symptoms. Small hiatal defects could be underdiagnosed at preoperative endoscopy and/or upper gastrointestinal contrast study. Thus, a careful examination of the crura is always recommended intraoperatively.

Surgical treatment of gastroesophageal reflux disease

BACKGROUND

Gastroesophageal reflux disease is by far the most prevalent disorder of the foregut. For a long time during the twentieth century, surgical therapy was the mainstay of treatment and the only chance for cure for patients with severe symptoms. Later, after introduction of proton pump inhibitor therapy in the early 1990 s, surgical therapy was considered widely a second choice option due to its potential morbidity and side effects. More recently, however, there is growing evidence that long-term antisecretory therapy might be associated to a number of adverse effects such as osteoporosis and increased risk of cardiovascular events. This is the rationale why interventional and surgical options are coming back into focus.

PURPOSE

The purpose of this review is to analyze and to discuss the current spectrum of surgical therapy of gastroesophageal reflux disease.

The impact of previous fundoplication on laparoscopic gastric bypass outcomes: a case-control evaluation

BACKGROUND

Gastroesophageal reflux disease (GERD) is a common comorbid condition in morbidly obese gastric bypass candidates. Unfortunately, some patients who ultimately present for bariatric surgery have previously undergone Nissen fundoplication for GERD. Many surgeons consider previous fundoplication to be a relative contraindication to subsequent laparoscopic Roux-en-Y gastric bypass (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 (revision) to matched control patients.

METHODS

Data were obtained from our prospectively maintained bariatric surgery database. Patients who underwent laparoscopic takedown of a previous fundoplication and conversion to LRYGB were compared to control patients who underwent primary LRYGB. For every revision patient, two control subjects were randomly selected from the database after matching for preoperative body mass index and year of surgery.

RESULTS

From July 2002 to April 2011, 14 patients underwent laparoscopic takedown of a previous Nissen fundoplication and then underwent LRYGB. During the same interval, 673 patients underwent LRYGB as a primary procedure for obesity from which 28 were selected as controls. There were no conversions to open laparotomy in any patient. Subjects were similar demographically. Operating time and duration of hospital stay were significantly longer in revision patients. Complications were more frequent in revisions (36% revisions vs. 7% controls, P = 0.03). Excess weight loss 1-year after surgery was excellent in both groups and did not differ (69% revision vs. 69.6% controls, P = 0.93).

CONCLUSIONS

Although associated with longer operating times, longer duration of hospital stay, and complications, LRYGB after fundoplication is feasible and safe. Long-term weight loss outcomes are similar to those seen following primary LRYGB. Previous fundoplication is not a contraindication to LRYGB.

Giant hiatal hernia

A giant hiatal hernia (HH) is a hernia that includes at least 30% of the stomach in the chest, although a uniform definition does not exist; most commonly, a giant HH is a type III hernia with a sliding and paraesophageal component. The etiology of giant HH is not entirely clear, and two potential mechanisms exist: (1) gastroesophageal reflux disease (GERD) leads to esophageal scarring and shortening with resulting traction on the gastroesophageal junction and gastric herniation; and (2) chronic positive pressure on the diaphragmatic hiatus combined with a propensity to herniation leads to gastric displacement into the chest, resulting in GERD. The short esophagus and GERD are key concepts to understanding the pathophysiology of giant HH, and these concepts are critical to address this problem appropriately. A successful repair of giant HH requires adherence to basic hernia repair principles (ie, hernia sac excision, tension-free repair), recognition and correction of a short esophagus, and a well-performed antireflux procedure. Recurrence rates for open giant HH repairs in expert hands range between 2% and 12%; large series have demonstrated that meticulous laparoscopic surgical technique can emulate the results of open giant HH repair.

Initial experience with laparoscopic crural closure in the management of hiatal hernia in obese patients undergoing sleeve gastrectomy

BACKGROUND

The prevalence of gastroesophageal reflux disease (GERD) and/or hiatal hernia (HH) is significantly increased in morbidly obese patients. Laparoscopic bariatric procedures such as gastric banding (LGB) and Roux-en-Y gastric bypass have been shown to improve both obesity and reflux symptoms. The aim of this paper is to evaluate the effectiveness of laparoscopic sleeve gastrectomy (LSG) and hiatal hernia repair (HHR) for the treatment of obesity complicated by HH.

METHODS

From October 2008, six patients underwent HHR in addition to LSG. Clinical outcomes have been evaluated in terms of GERD symptoms improvement or resolution, interruption of antireflux medication, and X-ray evidence of HH recurrence.

RESULTS

Symptomatic HH was diagnosed preoperatively in four patients. In two additional patients, HH was asymptomatic and it was diagnosed intraoperatively. Prosthetic reinforcement of crural closure was performed in two symptomatic cases with a HH >5 cm. Mortality was nil and no complications occurred. After a mean follow-up of 4 months, GERD symptoms resolution occurred in three patients, while the other patient reported an improvement of reflux. Body mass index had fallen from 43.4 to 36.2 kg/m(2). A small recurrence in the patient with persistence of reflux symptoms has been radiologically reported.

CONCLUSIONS

Laparoscopic crural closure in addition to LSG could represent a valuable option for the synchronous management of morbid obesity and HH, providing good outcomes in terms of weight loss and GERD symptoms control.

Comparison between Laparoscopic Paraesophageal Hernia Repair with Sleeve Gastrectomy and Paraesophageal Hernia Repair Alone in Morbidly Obese Patients

Treatment options for morbidly obese patients with complications from large paraesophageal hernias (PEH) are limited. Simple repair of the PEH has a high recurrence rate and may be associated with poor gastric function. We compared a series of patients who underwent repair of large PEH plus gastrostomy tube gastropexy (PEH-GT) with PEH plus sleeve gastrectomy (PEHSG). Retrospective review of patients undergoing PEH-SG and patients with PEH-GT was performed. We assessed symptoms of delayed gastric emptying and reflux postoperatively. In selected patients, gastric-emptying studies and upper gastrointestinal contrast studies were also obtained. All patients with large PEH were repaired laparoscopically with sac resection, primary crural closure using pledgeted sutures, and biologic patch onlay. SG for patients undergoing concomitant weight loss surgery (PEH-SG) was performed with linear endoscopic staplers and staple line reinforcement. Patients undergoing PEH repair alone had a gastrostomy tube gastropexy (PEH-GT). Patients had intraoperative endoscopic evaluation and postoperative contrast swallow studies. In a 12-month period, five patients underwent laparoscopic PEH-SG; two of five had previous antireflux surgery and one of five with a previous diagnosis of delayed gastric emptying. Postoperatively, two patients undergoing PEH-SG had readmission for dehydration and odynophagia. Six-month follow-up body mass index was 32 kg/m2 for the PEH-SG group with no hernia recurrence and complete resolution of gastroesophageal reflux disorder symptoms. Six patients underwent PEH-GT, one for acute incarceration and anemia and four with previous antireflux surgery. Follow up at 8 months demonstrated one recurrence, four of six had severe delayed gastric emptying and reflux, three of six had additional hospitalization for poor oral intake, and three of six underwent reoperation for delayed gastric emptying. There were no perforations, leaks, or deaths in either group. Combined laparoscopic PEH-SG is a clinically reasonable option for patients with morbid obesity with minimal additional risks and decreased incidence of delayed gastric emptying, reflux, and reoperation.