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ROUX-EN-Y GASTRIC BYPASS (RYGB) AFTER FAILED FUNDOPLICATION: OUTCOMES IN NON-OBESE PATIENTS
Michael Katzen*, Jana Sacco, Dau Ku, Gregory T. Scarola, Vedra Augenstein, Paul D. Colavita, Keith Gersin, B Todd Heniford
General Surgery, Atrium Health, Charlotte, NC

Introduction
RYGB has been successfully utilized for recurrent symptoms of gastroesophageal reflux disease(GERD) after failed fundoplication. RYBG is associated with weight loss due to reduced intake and absorption which could possibly lead to complications for non-obese patients. The aim was to determine the impact of RYGB on GERD, nutritional, and weight loss outcomes on patients with BMI under 30.
Methods
Single institution, restrospective data for patients with a failed fundoplication and BMI<30 who underwent RYGB for GERD between January 2007–May 2021 was analyzed. Multivariate analysis was performed evaluating risk for underweight post-op BMI (<18.5).
Results
40 patients were included with a mean age of 59.0±11.7years and preop BMI of 26.5±3.0kg/m2. Comorbidities included hypertension(47.5%), hyperlipidemia(17.5%), gastroparesis(15.0%), asthma/COPD(12.5%), obstructive sleep apnea(7.5%), and diabetes(5.0%). Thirteen patients(32.5%) had 2 prior fundoplications and 1 patient had 3. Preop symptoms included reflux(80.0%), dysphagia(50.0%), pain(35.0%), regurgitation(65.0%), and bloating(22.5%).
RYGB was performed laparoscopically(72.5%), robotic-assisted(22.5%), or open(5.0%). Three patients (7.9%) were converted from MIS to open. Mean operating time was 381±105minutes. Mean Roux length was 92cm (range:55-150). Mean biliopancreatic length was 45cm(range25-100). Operative findings include hiatal hernia(85.0%), slipped fundoplication(27.5%), and disrupted wrap(12.5%). Gastrostomy tubes were placed in 27.5%.
Median LOS was 3 days(range:1-48). Mean follow up was 3.6±3.2years. Reflux resolved in 90.0% of patients and 80.0% discontinued proton pump inhibitors. Eight patients developed post-op dysphagia and five underwent endoscopic dilation for stricture. Six patients underwent reoperation: gastrostomy(2), wound infection(1), intussusception(1), internal hernia(1), or incisional hernia(1). Iron infusion for anemia was performed in 16.2% of patients. Low B12 was identified in 17.5%.
Mean lowest post-op BMI was 20.6±2.8 at a median 1.0 year(range:0.14–10.3). Mean recent BMI was 22.2±3.2 at median 2.5 years(range:0.14-10.6). Nine patients' lowest BMI was <18.5 but 3 later normalized. The 6 patients with a recent underweight BMI were a mean of 1.6years post-op(range:0.5-3.8) and had a lower average pre-op BMI(22.7vs26.5;p=0.001). On multivariate analysis, pre-op BMI<25 increased risk for recent underweight BMI (3.0 odds ratio;p=0.004, while gastrostomy use and roux length did not (p=0.48 and 0.5).
Conclusion
With a mean follow-up of 3.6 years, 90% of non-obese patients who underwent RYGB after failed fundoplication have no GERD symptoms. Post-op complications included iron deficiency anemia, low B12, and 15% of patients were underweight during recent follow up. On multivariate analysis, pre-op BMI<25 was a risk factor for underweight BMI.


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