Laparoscopic Modified Nissen Fundoplication over Roux-En-Y Gastric Bypass and Hiatal hernia repair for Intractable Gastroesophageal Reflux
Roux-en-Y gastric bypass (RYGB) is an effective treatment for morbid obesity and gastroesophageal reflux disease (GERD) 1. Despite majority of patients with resolution of GERD after RYGB, some patients will continue to complain of significant, persistent reflux symptomatology or develop de novo symptoms despite aggressive medical management. It ’s true incidence is unknown and one study showed an improvement in GERD but not resolution in 22% of patients after RYGB with GERD2. Possible mechanisms may include primary lower esophageal sphincter incompetence, disruption of the angle of His or development of hiatal hernia with intrathoracic m igration of the gastric pouch.
Gastroesophageal reflux disease (GERD) has a reported incidence of between 10% and 20% in Western populations with an even higher incidence in populations with obesity . The vast majority of patients are managed medically with surgical intervention undertaken in those with recalcitrant GERD. Populations with obesity and recalcitrant GERD who are interested in weight loss surgery have historically undergone laparoscopic Roux-en-Y gastric bypass (LRYGB). De Goot et al. , in their 2009 meta-analysis, demonstrated improvement in GERD in people with obesity after LRYGB.
Gastroesophageal reflux disease (GERD) has a reported incidence of between 10 to 20% in western populations with an even higher incidence in populations with obesity (1). The vast majority of patients are managed medically with surgical intervention undertaken in those with recalcitrant GERD. Populations with obesity and recalcitrant GERD who are interested in weight loss surgery have historically undergone Laparoscopic Roux En Y Gastric Bypass (LRYGB). De Goot et al in their 2009 meta-analysis demonstrated improvement in GERD in people with obesity following LRYGB(2).
This study aimed to assess practice patterns regarding concomitant HH repair (HHR) during laparoscopic sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). The incidence of concomitant HHR with LSG or LRYGB was analyzed using the 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. One hundred thirty thousand, seven hundred seventy-two patients underwent RYGB (30.5%) and LSG (69.5%). Concomitant HHR was more common, despite less GERD, in SG patients compared to RYGB (21.0% vs 10.8%,p
Laparoscopic sleeve gastrectomy (LSG) is shown to be effective in achieving weight loss and improving related co-morbidities in patients who suffer from morbid obesity. Despite this, there is ongoing controversy regarding the potential of worsening and de novo gastrointestinal reflux disease (GERD) postoperatively. Current standard of care for worsening or new onset GERD status-post LSG indicates revision to laparoscopic roux-en-y gastric bypass (RYGB) in those patients not responsive to medical therapy.
This study aims to assess differences in practice patterns regarding concomitant HH repair during laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (LRYGB).
DiscussionRefractory GERD can be surgically managed with various techniques. In obese individuals, laparoscopic Roux-en-Y gastric bypass should be considered due to significant symptom improvement and lower incidence of recurrent symptoms with weight loss. Otherwise, laparoscopic Nissen fundoplication is the preferred surgical technique for treatment of this disease with concomitant hiatal hernia repair when present for either procedure. The short-term risks associated with these procedures include esophageal or gastric injury, pneumothorax, wound infection, and dysphagia. Emerging techniques for treatment of this disease ...
In conclusion, the recent publication of pH monitoring data and the new insights in the association between sleeve morphology and GERD control have led to a wider acceptance of LSG as bariatric procedure also in obese patients with GERD, as recently stated in the 5(th) International Consensus Conference on sleeve gastrectomy. PMID: 28428706 [PubMed - in process]
CONCLUSIONS: Combined laparoscopic paraesophageal hernia repair with longitudinal partial gastrectomy offers a safe, feasible approach to the management of large or recurrent paraesophageal hernia in well-selected obese and morbidly obese patients. Short-term results were promising; however, intermediate results showed increasing rates of reflux symptoms that required medical therapy or conversion to gastric bypass. PMID: 26508825 [PubMed - in process]
As the number of patients increase who have previously undergone a laparoscopic Roux-en-Y Gastric Bypass (LRYGB) for morbid obesity, so does the amount of late complications associated with this procedure. The presence of GERD after bypass surgery is a very challenging disease process for the bariatric surgeon. Although the LRYGB is the procedure of choice for obese patients with severe reflux, where do we go if the patient develops reflux after the LRYGB. Some have advocated performing a Toupet or a Dor-like wrap using the remnant stomach with little evidence that it works.
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 GERD 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.