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

Introduction

Gastroesophageal reflux disease (GERD) has a prevalence of 20%–40% in the United States and Europe, and ∼12% in Brazil. ¹ It has been directly linked with high BMI.^2,3 It is estimated that 55% of morbidly obese patients have symptoms of chronic GERD. ⁴ Although laparoscopic antireflux surgical procedures have been generally accepted as the treatment of choice for the general population, results have been disappointing in morbidly obese patients.^5,6 The reasons for that are still debatable, whether it is the result of increase in intra-abdominal pressure or intrinsic factors.^7–10 Most of the obese undergoing an antireflux operation, and still complaining of weight issues continue to experience reflux symptoms.

As a result of the success of bariatric surgery, it has been suggested that laparoscopic Roux-en-Y gastric bypass (LRNYGB) can provide an alternative option for both weight gain and GERD symptoms.^1,6,11,12 However, some surgeons consider converting antireflux surgery to LRNYGB as contraindication because of complexity of surgical technique, obscure anatomy, and possible dense adhesions to adjacent organs, especially the liver. Nevertheless, GERD control would be achieved in most patients but not all of them.

Although the procedure is considered difficult to perform, it is feasible for experienced surgeons. The objective of this retrospective study was to present and discuss a series of 85 patients who underwent a previous antireflux surgery, and later sought a bariatric revision surgery because of weight gain and persistence of GERD symptoms. We reviewed patients' data regarding weight, BMI, duration of surgery, complications, and endoscopic comparison before and after surgery.

Methods

A retrospective study was performed in a series of patients operated by a bariatric team in one medical center located in Curitiba (capital of Paraná State), Brazil. Following 85 morbidly obese patients with mean BMI of 37.71 kg/m² who had previously undergone a Nissen or a Nissen Rosseti fundoplication, were converted to LRNYGB. Baseline characteristics are given in Table 1.

Preoperative endoscopy was carried out in all patients before conversion to LRNYGB. Forty-nine patients (57.64%) had findings of fundoplication failure or signs of persistent GERD: 20 of 49 (40.81%) patients had loose wrap, and 9 (45%) of them had loose wrap and esophagitis, whereas 11 (55%) had no esophagitis associated with loose wrap. In addition, 7 of 49 (14.28%) patients had hiatal hernia, 5 of them (71.42%) had esophagitis, and 2 (28.5%) had no other endoscopic findings.

Twenty of 49 (40.81%) patients had esophagitis: 13 (15.29%) Grade A, 7 (8.23%) Grade B, 2 (2.35%) Grade C, and 2 of 49 (4.08%) patients had Barrett's esophagus (Table 2).

All of them underwent conversion to LRNYGB between the years 2010 and 2018. Average time between fundoplication and LRNYGB was 6.23 years.

Results

Follow-up of 85 patients was collected from 2011 to 2019. Complication occurred in 12 patients (14.11%) and they were as follows: 2 (2.35%) conversion 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.

Mean duration of surgery was 61.21 minutes (range 50–120 minutes). Mean weight before surgery was 98.35 kg, and after LRNYGB was 71.27 kg (P < .0001). Mean BMI before surgery was 37.71 kg/m², and after surgery it was 27.07 kg/m² (P = .001). No mortality was reported postoperatively (Table 3).

A follow-up endoscopy of 79 of 85 (92.9%) patients was carried out after 6 months of LRNYGB surgery and the results showed that 8 of 79 (10.12%) patients had persistent signs of GERD, 5 of them (62.5%) had esophagitis grade A, 3 of 8 (37.5%) patients had esophagitis grade B, and 1 of 8 patients (12.5%) presented with gastrogastric fistulae from previous postoperative complication (Table 4).

In the subgroup that had persistent esophagitis after LRNYGB, all of them were men with ages ranging between 35 and 54 years, weight before LRNYGB between 98 and 125 kg, and BMI between 32 and 45 kg/m².

Discussion

Obesity has become an epidemic disease worldwide; it reached 30% of the world's population in the last century.^13,14 The majority of the obese patients in the western population have symptoms of GERD. ¹⁵ Many of them undergo antireflux surgery. Nevertheless, 31.3% of those patients used to show symptoms of recurrence after primary fundoplication. ¹⁶ This raises concern to perform an antireflux surgery on obese patients. ³ Reasons for failure are still debatable; however, several hypothesis have been proposed, from higher intra-abdominal pressure in obese patients causing wrap disruption or recurrent hiatal hernia, to difficult anatomy/dissection during primary surgery. ¹⁵

In our study a preoperative endoscopy before the bariatric surgery showed that 8.23% of patients recurred from their hiatal hernia, and 23.5% of patients had disrupted fundoplication. This is quite normal after years of fundoplication in the obese population, but still disruption of the fundoplication is considered to be the most common pattern of failure in morbidly obese patients. Kellogg et al. described intraoperative findings of 11 morbidly obese patients who underwent reoperative intervention for recurrent GERD symptoms; 46% of those patients had disrupted fundoplication, which was probably the reason for failure.^3,5,17 Therefore, as morbidly obese patients are at high risk of failure with fundoplication than the rest of the general population, other options have to be considered as an alternative treatment for GERD among them. ¹⁸

Recent studies have shown that in obese patients^17,18 LRNYGB is as effective as antireflux surgery. It has been suggested that it has good control over GERD symptoms, with additional weight loss benefits and improvement in comorbidities.^17,18 In addition, a good long-term effect has been observed in comparison with fundoplication in obese patients.^19,20

Although it seems to be a very complex and technically demanding procedure, LRNYGB after fundoplication can be performed by experienced surgeons, with an acceptable possibility of complications. A collection of retrospective articles was reviewed, discussing the outcome in smaller groups of patients, 11 and 14, respectively. Authors described the outcome of converting laparoscopic gastric fundoplication to LRNYGB. Both studies showed comparisons made among patients who underwent previous primary LRNYGB at the same institution. They have concluded that although difficulties were encountered during surgery, all patients had minimal complication rate, with a robust weight and BMI reduction on follow-up, compared with patients with primary LRNYGB.^21,22 This has been shown in our study with a much larger number of patients going from fundoplication to LRNYGB. Twelve of 85 (14.2%) patients had minor to moderate complications. This concludes that such procedure can be feasible under experienced surgeons.

On the contrary, doubts regarding full GERD resolution have been raised in the literature. ¹ Studies have described persistent symptoms in some patients after LRNYGB.^1,23,24 In our study, 8 of 79 (10.12%) patients still had evidence of GERD on postoperative endoscopy findings after 6 months, but no GERD symptoms were noted. This was also shown in a systemic review conducted by Mendes-Filho et al. between 2004 and 2014, reviewing articles related to conversion of gastric fundoplication to LRNYGB. A selection of 121 patients from 102 articles was reviewed in terms of outcome postconversion from fundoplication to LRNYGB. A total number of 118 patients were followed up after LRNYGB; from those patients 106 showed remission of GERD (89.8%), whereas the remaining 12 patients showed partial improvement (10.2%), so they were kept on antireflux medication. ¹

In our group of patients, it has been noticed that of 49 positive endoscopic findings, 20 (40.81%) patients had preoperative (before bariatric) esophagitis (Table 2), and among them 8 patients continued to have persistent endoscopic esophagitis. These data showed that even with no symptoms noted, 40% (8 of 20) of the patients who had esophagitis before LRNYGB, remained with esophagitis after the bypass (Table 4). Therefore, full resolution of GERD is not only still debatable after LRNYGB, but it seems that it is not achievable for an important part of the patients.

Reasons for that still require further research. Thus, it is our responsibility to conduct such information on our patients as we see them in an appointment before they undergo LRNYGB. Nevertheless, this technique is still considered the gold standard for GERD associated with bariatric patients. Yet, there are other techniques to be considered, which are still under investigation, like the Nissen sleeve, which could be an alternative solution. ²⁵

Conclusion

LRNYGB after laparoscopic fundoplication is a feasible procedure with an excepted higher rate of complications because of the complexity of the procedure. On the contrary, not all cases of esophagitis were resolved completely after the bypass procedure.