LONG-TERM OUTCOMES OF ROUX-EN-Y GASTRIC DIVERSION AFTER FAILED SURGICAL FUNDOPLICATION IN A LARGE COHORT
Veeravich Jaruvongvanich*, Reem Matar, Blake Movitz, Daniel B. Maselli, Travis J. McKenzie, Todd A. Kellogg, Michael L. Kendrick, Barham K. Abu Dayyeh
Gastroenterology, Mayo Clinic - Rochester, Rochester, MN
Background: Persistent or recurrent gastroesophageal reflux disease (GERD) is observed up to 30% after surgical fundoplication. Reoperation may be necessary in patients with intractable symptoms. Roux-en-Y gastric diversion (RNYG) is an alternative surgical approach especially for those with esophageal dysmotility or morbid obesity, as redo fundoplication offers unfavorable outcomes. Based on our literature review, there is a paucity of data regarding long-term outcomes of GERD and dysphagia after this surgery. Our study, the largest series to date, aimed to evaluate the long-term outcomes of this procedure and impact on esophageal function.
Methods: Patients who underwent RNYG after failed fundoplication between 1995 and 2019 at our tertiary care center were identified. Demographics, operative details, and clinical outcomes were analyzed. All esophageal manometries (EM) were reviewed by a single investigator. Clavien-Dindo classification was used for grading of surgical complications, in which severe complications were defined as grade III-V. Resolution of GERD was defined as discontinuation of acid blockers.
Results: A total of 101 patients with a mean age of 52.1years, 86.1% female, and a mean body mass index (BMI) of 35.8±7.8 kg/m2were included. The median follow-up was 56.2 (18.5 – 104.7) months. Overall complication rate within 30 days was 36.3%, with 22.8% being grade III-IV. Overall complication rate after 30 days was 53.5%, with 39.6% being grade III-IV and no surgical-related mortality. For clinical outcomes, the mean total body weight loss was 19.4±15.3% at follow-up. GERD symptoms were present in 97 patients pre-operatively; 68 patients (70.1%) had symptom resolution after surgery; 27 patients (39.1%) had symptom recurrence during follow-up, and 53 patients (52.4%) used acid blockers at follow-up. In patients with no baseline dysphagia (n=36), 16 (44%) developed dysphagia after surgery. In those with severe dysphagia (n=9), 5 patients (56%) continued to have severe dysphagia. Esophageal diameter did not significantly change after RNYG. Forty patients (39.6%) had pre/post operative endoscopy. Ten patients had baseline esophagitis, 9 patients (90%) had improvement of esophagitis at follow-up. Eight patients had baseline Barrett’s esophagus, 3 remained unchanged, 3 regressed, and 2 progressed. There was no evidence of acid reflux (Lyon criteria) on pH test off acid blocker in 7 patients after surgery. Nine patients had EM after surgery, in which 2 had absent contractility, 2 had ineffective esophageal motility, and 1 had Jackhammer.
Conclusions: RNYG is an effective alternative surgery in a subset of patients with intractable symptoms who failed fundoplication. However, patients should be informed of the risks of postoperative GERD symptoms and dysphagia. Referral for a careful evaluation by a multidisciplinary foregut team is warranted.
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