OUTCOMES OF GASTRIC DIVERSION IN PATIENTS WITH INTRACTABLE GERD, A COMPARISON BETWEEN PATIENTS WITH PRIOR NISSEN FUNDOPLICATION AND THOSE WITH NO PRIOR FUNDOPLICATION
Suhail Zeineddin*, Danuel Laan, Travis J. McKenzie, Michael L. Kendrick, Todd A. Kellogg
Surgery, Mayo clinic, Rochester, MN
Objective:
Roux-en-Y gastric bypass as a means of gastric diversion (GD) is an antireflux procedure that is increasingly performed in obese patients with hiatal hernia and refractory reflux given poor outcomes and high recurrence with Nissen fundoplication (NF). Additionally, GD is an option for patients who have failed previous fundoplication regardless of BMI. The outcomes for patients undergoing GD are poorly described in the literature. To help determine the benefit of GD in patients with intractable GERD, we compared GD outcomes between patients with and without a previous failed NF.
Methods:
A retrospective review was performed over a 5-year period on patients who had GD performed for intractable reflux and/or symptomatic hiatal hernia. A total of 37 patients were included. Of these, 12 had at least one previous NF while 25 had no history of hiatal or gastric surgery. We compared the two groups by examining postoperative outcomes, need for additional procedures, and symptom improvement as defined by the Gastroesophageal Reflux Disease-Health Related Quality of Life questionnaire (GERD-HRQL). Resolution of symptoms was defined as discontinuation of anti-reflux medications.
Results:
Patient demographics and pre/post-operative characteristics are displayed in Table 1. Median follow-up was 12 months (7-24) for the entire cohort. Per GERD-HRQL 25% of patients with previous fundoplication and 82% of those without had no symptoms, the remainder had only mild symptoms. Of the patients with a previous fundoplication, 50% were able to discontinue all acid reducing medications compared with 68% of patient with no previous fundoplication (p=0.3). Also, BMI decreased by 24% in patients with a previous fundoplication and 19% in patients without.
Major (grade III-V) or minor (Grade I-II) morbidity as defined by the Clavien-Dindo grading system were similar between groups. Throughout the entire follow-up period, need for reoperation occurred in 12% (n=3) of patients without previous fundoplication (one for early bleeding and two for internal hernias occurring late), and 42% (n=5) of patients with previous fundoplication for early anastomotic leak (n=1), and delayed presentation of recurrent hiatal hernia (n=2), internal hernia (n=1), and ventral hernia (n=1), (p=0.04).
Conclusion:
When used as an antireflux operation in patients with intractable GERD, GD improves symptoms and decreases the need for antireflux medications. In those without previous fundoplication, GD appears to have low morbidity and has the added benefit of weight loss. Those who have had a previous failed fundoplication have a higher rate of re-operation and a lower rate of complete resolution of symptoms. GD should be considered a potentially valuable antireflux operation in carefully selected patients with intractable GERD.
Table 1: Patient Demographics and Preoperative Characteristics
No previous fundoplication n=25 | Previous fundoplication n=12 | p Value | |
| Age, median (range) | 60 (40-74) | 52 (30-70) | 0.2 |
| Men | 4 (16%) | 1 (8%) | |
| Preoperative BMI, mean (SD) | 36.68 (8.0) | 34.09 (7.97) | 0.2 |
| Number of Prior Hiatal Surgeries, # | |||
| 0 | 25 (100%) | 0 | |
| 1 | 0 | 7 (58%) | |
| >1 | 0 | 5 (42%) | |
| Preoperative hiatal hernia | 22 (88%) | 12 (100%) | <0.01 |
| Preoperative EGD, yes | 23 (92%) | 11 (92%) | 1 |
| Esophagitis | 7 (30%) | 6 (55%) | |
| Barrett's esophagus | 2 (8%) | 2 (17%) | 0.43 |
| Cameron erosions | 6 (24%) | 0 | 0.26 |
| Preoperative reflux medication, # | 21 (84%) | 12 (100%) | 0.14 |
| 0 | 4 (16%) | 0 | |
| 1 | 0 | 1 (8%) | |
| 2 | 15 (60%) | 8 (67%) | |
| 3 | 6 (24%) | 3 (25%) | |
Abbreviations: EGD: Esophagogastroduodenoscopy, BMI: Body Mass Index, SD: Standard deviation.
Table 2: Postoperative Outcomes
| No previous fundoplication n=25 | Previous fundoplication n=12 | p Value | |
| Postoperative reflux medication, # | 8 (32%) | 6 (50%) | 0.29 |
| 0 | 17 (68%) | 6 (50%) | |
| 1 | 2 (8%) | 1 (8%) | |
| 2 | 6 (24%) | 5 (42%) | |
| 3 | 0 | 0 | |
| Postoperative complications | 6 (24%) | 4 (33%) | 0.55 |
| Minor | 5 (83%) | 2 (50%) | 0.8 |
| Major | 1 (17%) | 2 (50%) | 0.19 |
| Operative time, median (IQR) | 220 (180-284) | 340.5 (279.75-526) | <0.01 |
| EBL, median (IQR) | 75 (50-100) | 87.5 (75-150) | 0.07 |
| Reoperation, # | 3 (12%) | 5 (42%) | 0.04 |
| Early < 90 days | 1 (33%) | 1 (20%) | |
| Late > 90 days | 2 (67%) | 4 (80%) | |
| Other symptom relieving procedures, # | 3 (12%) | 1 (8%) | 0.74 |
Abbreviations: EBL: Estimated Blood Loss, IQR: InterQuartile Range
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