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

Does routine upper gastrointestinal swallow study after metabolic and bariatric surgery lead to earlier diagnosis of leak?

BACKGROUND

It is unclear whether routine upper gastrointestinal swallow study (SS) in the immediate postoperative period is associated with earlier diagnosis of gastrointestinal leak after bariatric surgery.

OBJECTIVE

To investigate the relationship between routine SS and time to diagnosis of postoperative gastrointestinal leak.

SETTING

MBSAQIP-accredited hospitals in the United States and Canada.

METHODS

We conducted an observational cohort study of adults who underwent laparoscopic primary Roux-en-Y gastric bypass (RYGB) (n = 82,510) and sleeve gastrectomy (SG) (n = 283,520) using the MBSAQIP 2015-2019 database. Propensity scores were used to match patient cohorts who underwent routine versus no routine SS. Primary outcome was time to diagnosis of leak. Median days to diagnosis of leak were compared. The Nelson-Aalen estimator was used to determine the cumulative hazards of leak.

RESULTS

In our study, 36,280 (23%) RYGB and 135,335 (33%) SG patients received routine SS. Routine SS was not associated with earlier diagnosis of leak (RYGB routine SS median 7 [IQR 3-12] days v. no routine SS 6 [2-11] days, P = .9; SG routine SS 15 [9-22] days v. no routine SS 14 [8-21] days, P = .06) or lower risk of developing leak (RYGB HR 1.0, 95%-CI .8-1.2; SG HR 1.1, 95%-CI 1.0-1.4). More routine SS patients had a length of stay 2 days or greater (RYGB 78.3% v. 61.1%; SG 48.6% v. 40.3%).

CONCLUSIONS

Routine SS was not associated with earlier diagnosis of leaks compared to the absence of routine SS. Surgeons should consider abandoning the practice of routine SS for the purpose of obtaining earlier diagnosis of postoperative leaks.

Safety and efficacy of Roux-en-Y gastric bypass as revisional bariatric surgery after failed anti-reflux surgery: a systematic review

This systematic review evaluates the safety and efficacy of Roux-en-Y gastric bypass (RYGB) on weight loss and anti-reflux outcomes when used as a revisional bariatric surgical procedure after failed anti-reflux surgery. A systematic literature search next to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed for articles published by 30 Mar 2022. After examining 416 papers, 23 studies were included (n = 874 patients). Primary anti-reflux surgery included mainly Nissen fundoplication (16 studies). Reasons for revisional surgery included predominantly gastroesophageal reflux disease (GERD) (reported by 18 studies), obesity (reported by 6 studies), and hiatal hernia (reported by 6 studies). Interval to surgical revision was 5.58 ± 2.46 years (range, 1.5-9.4 yr). Upper endoscopy at revision was performed for all patients; esophageal manometry and pH monitoring were reported in 6 and 4 studies, respectively. Mean body mass index (BMI) at revision was 37.56 ± 5.02 kg/m2 (range, 31.4-44 kg/m2). Mean excess weight loss was 69.74% reported by 12 studies. Delta BMI reported by 7 studies was 10.41 kg/m2. The rate of perioperative complications was 16.7%, including mostly stenosis, leakage, ventral hernia, and small bowel obstruction. Mean improvement rate of GERD was 92.62% with a mean follow-up of 25.64 ± 16.59 months reported in 20 studies. RYGB seems to be an efficient surgical treatment option in failed anti-reflux procedures, but should be performed in experienced centers for selected patients, since the rate of perioperative and long-term complications must be minimized. Cooperation between bariatric and reflux surgeons is essential to offer patients with obesity and GERD the best long-term outcome.

Revisional One-Anastomosis Gastric Bypass (OAGB) After Intrathoracic Migration of Nissen Fundoplication

According to the latest IFSO recommendations, bariatric and metabolic surgery is the recommended treatment for patients with a BMI above 35 kg/m² (with or without associated pathology), achieving good results in terms of weight loss in the medium to long term, as well as improving a significant percentage of comorbidities in this type of patient (diabetes mellitus, arterial hypertension, dyslipidaemia, gastro-esophageal reflux disease (GERD)...). The incidence of GERD is higher in patients with obesity, with more severe symptoms. Over the years, Nissen fundoplication has been the gold standard treatment for patients with GERD who do not respond to medical treatment. However, in patients with obesity, gastric bypass is a valid option to consider. We present the case of a patient who had previously undergone anti-reflux surgery (laparoscopic Nissen) for GERD, with favorable evolution, who presented intrathoracic migration of the same after 8 years, with new onset of symptoms, and who was offered revision bariatric surgery. The video presents on the performance of OAGB in a patient who had previously undergone antireflux surgery, with intrathoracic Nissen. Performing this technique after a previous Nissen fundoplication (as well as migration of the Nissen) is a somewhat more complex procedure than primary surgery but can be performed safely with careful technique (there are often previous adhesions that hinder mobility and separation of the fundoplication) and provides good symptom control.

Robotic revision surgery after failed Nissen anti-reflux surgery: a single center experience and a literature review

BACKGROUND

The gastroesophageal reflux disease (GERD) worldwide prevalence is increasing maybe due to population aging and the obesity epidemic. Nissen fundoplication is the most common surgical procedure for GERD with a failure rate of approximately 20% which might require a redo surgery. The aim of this study was to evaluate the short- and long-term outcomes of robotic redo procedures after anti-reflux surgery failure including a narrative review.

METHODS

We reviewed our 15-year experience from 2005 to 2020 including 317 procedures, 306 for primary, and 11 for revisional surgery.

RESULTS

Patients included in the redo series underwent primary Nissen fundoplication with a mean age of 57.6 years (range, 43-71). All procedures were minimally invasive and no conversion to open surgery was registered. The meshes were used in five (45.45%) patients. The mean operative time was 147 min (range, 110-225) and the mean hospital stay was 3.2 days (range, 2-7). At a mean follow-up of 78 months (range, 18-192), one patient suffered for persistent dysphagia and one for delayed gastric emptying. We had two (18.19%) Clavien-Dindo grade IIIa complications, consisting of postoperative pneumothoraxes treated with chest drainage.

CONCLUSION

Redo anti-reflux surgery is indicated in selected patients and the robotic approach is safe when it is performed in specialized centers, considering its surgical technical difficulty.

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.

Combined Partial Toupet Fundoplication With Laparoscopic Sleeve Gastrectomy for Patients With Morbid Obesity and Symptomatic GERD: Preliminary Results of the T-sleeve Technique

AIM

The aim of this study to reveal preliminary results of our Toupet-sleeve technique in morbid obese patients with symptomatic gastroesophageal reflux disease (GERD) and compare their outcomes with laparoscopic sleeve gastrectomy (LSG) patients' outcomes.

METHODS

The study included 103 patients who underwent primary LSG between March 2018 and October 2020 and 18 patients who underwent partial T-sleeve. Patients were stratified into 2 groups according to the surgical technique. All of the patients had preoperative symptomatic GERD. Patients were reevaluated with regard to GERD symptoms and weight loss in the postoperative period. Two groups' data were compared.

RESULTS

The mean age of the patients was 39.2±10.2 years (63% female), and the mean body mass index was 43.2±6.4 kg/m2. The median operative time was 93 minutes (75 to 110 min) in group A (primary LSG) and 110 minutes (90 to 120 min) in group B (partial T-sleeve). The mean body mass index decreased to 28±4.5 kg/m2 in group A and 25.8±3.5 kg/m2 in group B at 12 months after the surgery. At the 12th month, the patients were reevaluated for GERD symptoms. Reflux symptoms were found to be resolved in 62% of the patients (n=64) in group A, while 32% of the patients (n=39) had persistent GERD symptoms. In group B, all of the patients had discontinued proton pump inhibitors postoperatively, and GERD symptoms were completely resolved in 94% of these patients (n=17).

CONCLUSIONS

The present study showed that T-sleeve provides a very good weight loss and reflux control in patients with symptomatic GERD with morbid obesity in the short-term period. This technique can be proposed in some cases as a primary treatment modality. High numbers of patients and longer follow-up are needed.

Endoscopic Management of Bariatric Surgery Complications According to a Standardized Algorithm

BACKGROUND AND AIMS

Endoscopy is effective in management of bariatric surgery (BS) adverse events (AEs) but a comprehensive evaluation of long-term results is lacking. Our aim is to assess the effectiveness of a standardized algorithm for the treatment of BS-AE.

PATIENTS AND METHODS

We retrospectively analyzed 1020 consecutive patients treated in our center from 2012 to 2020, collecting data on demographics, type of BS, complications, and endoscopic treatment. Clinical success (CS) was evaluated considering referral delay, healing time, surgery, and complications type. Logistic regression was performed to identify variables of CS.

RESULTS

In the study period, we treated 339 fistulae (33.2%), 324 leaks (31.8%), 198 post-sleeve gastrectomy twist/stenosis (19.4%), 95 post-RYGB stenosis (9.3 %), 37 collections (3.6%), 15 LAGB migrations (1.5%), 7 weight regains (0.7%), and 2 hemorrhages (0.2%). Main endoscopic treatments were as follows: pigtail-stent positioning under endoscopic view for both leaks (CS 86.1%) and fistulas (CS 77.2%), or under EUS-guidance for collections (CS 88.2%); dilations and/or stent positioning for sleeve twist/stenosis (CS 80.6%) and bypass stenosis (CS 81.5%). After a median (IQR) follow-up of 18.5 months (4.29-38.68), complications rate was 1.9%. We found a 1% increased risk of redo-surgery every 10 days of delay to the first endoscopic treatment. Endoscopically treated patients had a more frequent regular diet compared to re-operated patients.

CONCLUSIONS

Endoscopic treatment of BS-AEs following a standardized algorithm is safe and effective. Early endoscopic treatment is associated with an increased CS rate.

Impact of bariatric surgery on gastroesophageal reflux disease and esophageal motility

PURPOSE OF REVIEW

Obesity is rapidly increasing in prevalence, and bariatric surgery has become a popular treatment option that can improve all-cause mortality in obese individuals. Gastroesophageal reflux disease (GERD) and esophageal motility disorders are common in the obese population, and the effects of bariatric surgery on these conditions differ depending on the type of bariatric surgery performed.

RECENT FINDINGS

Laparoscopic adjustable gastric banding has declined in popularity due to its contributions to worsening GERD symptoms and the development of esophageal dysmotility. Although laparoscopic sleeve gastrectomy (LSG) is the most popular type of bariatric surgery, a comprehensive assessment for acid reflux should be performed as LSG has been linked with worsening GERD. Novel methods to address GERD due to LSG include magnetic sphincter augmentation and concomitant fundoplication. Due to the decreased incidence of postoperative GERD and dysmotility compared to other types of bariatric surgeries, Roux-en-Y gastric bypass should be considered for obese patients with GERD and esophageal dysmotility.

SUMMARY

Bariatric surgery can affect esophageal motility and contribute to worsening or development of GERD. A thorough workup of gastrointestinal symptoms before bariatric surgery should be performed with consideration for formal testing with high-resolution manometry and pH testing. Based on these results, the choice of bariatric surgery technique should be tailored accordingly to improve clinical outcomes.

Development of the "OS-SEV90 Score" to Predict Severe Postoperative Complications at 90 Days Following Bariatric Surgery

BACKGROUND

Bariatric surgery may be associated with severe postoperative complications (SPC). Factors associated with the risk of SPC have not been fully investigated.

OBJECTIVES

This study aimed to identify preoperative risk factors of SPC within 90 days and to develop a risk prediction model based on these factors.

METHODS

We conducted a retrospective single-center cohort study based on a prospectively maintained database of obese patients undergoing laparoscopic bariatric surgery from October 2005 to May 2019. All SPC occurring up to the 90th postoperative day were recorded according to the Dindo-Clavien classification. Associations between potential risk factors and SPC were analyzed using a logistic regression model, and the risk prediction ("OS-SEV90 score") was computed. Based on the OS-SEV90 score, the patients were grouped into 3 categories of risk: low, intermediate, and high.

RESULTS

Among 1963 consecutive patients, no patient died and 82 (4.2%) experienced SPC within 90 days. History of gastric or esophageal surgery (adjusted odds ratio (aOR) 3.040, 95% confidence interval; CI 1.78-5.20, p< 0.0001), past of thromboembolic event aOR 2.26, 95%; CI 1.12-4.55, p = 0.0225), and surgery performed by a junior surgeon (aOR 1.99, 95%; CI 1.26-3.13, p = 0.003) were all independently associated with risk for SPC, adjusting for ASA physical status system (ASA) score ≥ 3, severe OSA, psychiatric disease, asthma, a history of abdominal surgery, alcohol, cardiac disease, and dyslipidemia. "the OS-SEV90 score" based on these factors was constructed to classify patients into 3 risk groups: low (≤2), intermediate (3-4), and high (≥5). According to "the OS-SEV90 score," SPC increased significantly from 2.9% in the low-risk group, 7.7% in the intermediate-risk group, and 23.3% in the high-risk group.

CONCLUSIONS

A predictive model of SPC within 90 days "the OS-SEV90 score" has been developed using 9 baseline risk factors. The use of the OS-SEV90 score may help the multidisciplinary team to identify the specific risk of each patient and inform them about and optimize the comorbidities before the surgery. Further studies are warranted to validate this score in a new independent cohort before using it in clinical practice.

Combined partial posterior fundoplication with laparoscopic sleeve gastrectomy for morbid obese patients with symptomatic GERD. Video case report

•

Gastro esophageal reflux disease (GERD) remains to be an important complication after sleeve gastrectomy.

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The general trend for patients who are planning to have bariatric surgery and have symptomatic GERD, Roux-en-Y gastric bypass is the most common choice.

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Combined partial posterior fundoplication with laparoscopic sleeve gastrectomy for morbid obese patients with symptomatic GERD is a feasible and effective method.

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This technique can be proposed in some case of obese patients with GERD as primery treatment modality.

İntroduction

Gastroesophageal reflux disease (GERD), which can be seen in up to 30% in postoperative series, is perhaps the most important complication of sleeve gastrectomy(SG). The general trend for patients who are planning to have bariatric surgery and have symptomatic GERD, Roux-en-Y gastric bypass is the most common choice.

Case Presentation and Management

A 42-year-old female patient with a body mass index of 36 kg/m² presented to our clinic with obesity and symptomatic GERD. She had been using proton pump inhibitör (PPI) regularly for 1 year. Preoperative endoscopy showed hiatal hernia but no esophagitis. The patient underwent ambulatory pH study and GERD was confirmed. The patient was scheduled to have laparoscopic hiatal hernia repair plus combined partial posterior fundoplication and sleeve gastrectomy. Hiatal hernia was repaired, gastric fundus was passed behind the esophagus and partial posterior fundoplication was performed, and than SG was completed.

She stopped using PPI in the early postoperative period and her reflux symptoms disappeared completely. The patient lost 20 kg in the 3rd month (%40 ewl) and underwent controlled ambulatory pH moniterization and no reflux was detected.

Conclusion

İn some cases this technique can be proposed to obese patients with GERD as a primary treatment modality. High numbers of patients and longer follow up care are needed to assess the long term efficacy and safety of this technique.

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.

Laparoscopic Roux-en-Y Gastric Bypass After Gastroesophageal Reflux Disease Surgical Procedure: Analysis of 85 Consecutive Patients with Pre- and Post-Operative Endoscopy Control

Background: Most of the obese patients undergoing an anti-reflux operation experience recurrence of gastroesophageal reflux disease (GERD). Laparoscopic Roux-en-Y gastric bypass (LRNYGB) has been accepted as the bariatric surgery of choice for a previous GERD-operated obese patients. Methods: We present 85 consecutive patients from a single institution, previously submitted to antireflux surgery and then to LRNYGB. Preoperative endoscopy was carried out in all patients; 49 (57.64%) patients had findings of fundoplication failure or signs of persistent GERD, of those 20 (40.81%) with esophagitis. Results: From the bypass, per or postoperative minor to moderate complications occurred in 12 patients (14.11%): 2 (2.35%) conversions to laparotomy, 1 (1.17%) melena, 8 (9.41%) stenosis of gastrojejunostomy, treated by a simple endoscopic dilatation with a balloon, and 1 (1.17%) gastrogastric fistula. A follow-up endoscopy of 79 of 85 (92.9%) patients was carried out after 6 months of LRNYGB. Eight of 79 (10.12%) patients had persistent esophagitis that represented 40% (8 of 20 patients) of persistent reflux esophagitis even after LRNYGB. All of them were men. Conclusion: LRNYGB after laparoscopic fundoplication is a feasible procedure with an excepted higher rate of complications because of the complexity of the procedure. Nevertheless esophagitis still persisted in many of those patients.

Nissen Fundoplication–Preserving Laparoscopic Sleeve Gastrectomy

Gastroesophageal reflux disease (GERD) is significantly more prevalent in obese patients. Nissen fundoplication alleviates symptoms in those refractory to dietary changes and optimal medical management. The need for concomitant treatment of GERD and obesity is becoming more prevalent. The objective of this study was to determine whether Nissen-preserving laparoscopic sleeve gastrectomy (SG) is a safe and effective weight loss option for patients with pre-existing Nissen fundoplication. The study was conducted at the Hospital Corporation of America, Memorial Health, Savannah, Georgia, academic institution. We retrospectively reviewed five patients who underwent laparoscopic Nissen-preserving SG between 2011 and 2017. We compared pre- and postoperative subjective GERD symptoms, occurrence of any immediate postoperative complications, change in BMI, and excess weight loss. Of the five patients, four were female and one was male. The mean age was 50.6 years. The mean preoperative BMI was 44.8 ± 5.4, one-month postoperative BMI was 41.2 ± 6.1 (P < 0.001), and six-month postoperative BMI was 37.5 ± 8.1 (P < 0.009), with mean excess weight loss at six months of 33.9 ± 23 per cent. There were no immediate postoperative complications. Subjective GERD symptoms were unchanged in two patients and improved in the other three. We demonstrate the early feasibility of Nissen-preserving SG for surgical weight loss in patients with existing Nissen fundoplication. Although our results are early, we feel encouraged by mean excess weight loss to date and control of GERD symptoms.

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.