ENDOSCOPIC AND PHYSIOLOGIC OUTCOMES OF LAPAROSCOPIC CONVERSION OF SLEEVE GASTRECTOMY TO GASTRIC BYPASS DUE TO GASTROESOPHAGEAL REFLUX DISEASE
Guilherme M. Campos*, Edward Gray, Jennifer Salluzzo, Roel M. Bolckmans, Guilherme D. Mazzini, Renato Roriz-Silva, Luke Wolfe
Virginia Commonwealth University Medical Center, Richmond, VA
Introduction: An estimated 30% of patients may develop de-novo or worsen pre-existing gastroesophageal reflux disease (GERD) after Sleeve Gastrectomy (LSG). For those with medically refractory GERD after LSG, laparoscopic conversion of LSG to Gastric Bypass (RYGB) has been offered and a few single center cases series (with 10 to 25 patients) and a multi-center study with 80 patients have been published. However, all studies present mostly symptoms resolution as the outcome measure and surgical technique varied. We evaluated perioperative, physiologic, endoscopic, and symptomatic outcomes of laparoscopic conversion of LSG to RYGB due to GERD following a standardized technique.
Methods: All consecutive patients converted from LSG to RYGB due to GERD at a quaternary medical center were studied. Laparoscopic technique for conversion included routine esophageal hiatus dissection and repair, creation of a small 3 to 4-cm-long gastric pouch while removing any excess fundus with the division of the lateral aspect of the pouch at 2 cm lateral from the Angle of His, circular stapled gastrojejunostomy, and closure of both mesenteric defects. Primary outcomes were changes in distal esophageal acid exposure measured by 48h wireless pH-monitoring, esophagitis, and GERD symptoms. Secondary outcomes were perioperative outcomes.
Results: 35 patients were studied, 100% female, median age 41 years (range 30-69), median BMI 38.3 kg/m2 at conversion (range 27.3-52.5). Hiatal hernia was present in 29 patients (83%, 2-10cm), esophagitis was found in 21 patients (60%, LA Grades C or D in 7 patients), and Barrett's Esophagus (BE) in 3 (9%). Median follow-up was 22 months (range 3 to 58). All parameters of distal esophageal acid exposure decreased significantly and normalized in all patients after conversion (Table). Esophagitis healed in all patients. Complete symptom resolution occurred in 30/35 (86%), and five had residual GI symptoms. Median BMI at latest follow-up decreased by 6.5 kg/m2 (range 0.4-23.3). Perioperative complications occurred in 6 patients (17%); three were GJ strictures treated with endoscopic dilation, two post-operative bleeding that required transfusion, one readmission for dehydration. Length of stay was 2.4 days (range 2-5). There were no reoperations or deaths.
Conclusion: These results provide objective evidence to support that conversion from LSG to RYGB due to GERD, when following certain technical aspects, is an effective treatment. Laparoscopic LSG conversion to RYGB should be considered the preferred method to treat medically refractory GERD after LSG.
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