2 posts in this topic

I had a consult with my surgeon who performed my Nissen Fundoplication and he told me I wasn't a candidate for the band or sleeve because of it. He said my only option was bypass. Has this been your experience also? Can you tell me what I will do about throwing up post surgery since my Nissen is unable to be untied. I appreciate your input. 

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Dear Connie77,

I can't give personal medical advice, because I don't know all the details of your situation. Here are some general points. 

Lap gastric bypass after Nissen fundoplication is feasible, but is one of the most technically advanced bariatric procedures. The Nissen wrap is taken down (unwrapped. If there is a recurrent hiatus hernia, it is repaired. Then the gastric bypass is performed. There is usually a lot of scar tissue, and it very tricky to unwrap the stomach safely. The biggest risk is damage to the esophagus causing a leak followed by a stomach staple line leak. The complication rates reported in the medical reports have been high.  I have a lot of respect for the difficulties that can be encountered with this procedure. As a general rule, I don't think a sleeve is a good choice in this situation for a number of reasons.

I haven't seen any reports of leaving the Nissen intact and doing a bypass under it.

I've included a couple of abstracts from the surgical literature regarding GBP after Nissen fundoplication. 

Some surgeons are performing combination anterior fundoplication/sleeve procedures for patients with reflux. I included one summary below. I haven't seen any reports of doing a fundoplication/sleeve after takedown of a Nissen. 

I hope this information helps.

Dr. Callery
 

2015 Jul-Aug;115(4):268-72.

The Efficacy of Laparoscopic Roux-En-Y Gastric Bypass after Previous Anti-Reflux Surgery: A Single Surgeon Experience.

BACKGROUND:

In this study we assessed feasibility, weight loss results and recurrence of Gastro-Oesophageal Reflux Disease (GORD) in patients undergoing laparoscopic Roux-en-Y Gastric Bypass (RYGB) after previous anti-reflux surgery.

METHODS:

Retrospective analysis of prospectively collected data was performed for patients undergoing laparoscopic RYGB after previous anti-refux surgery between 1/1/2000 and 1/1/2015. Weight loss was assessed using %Excess Weight Loss (%EWL) and every patient was compared with two matched control subjects. Telephone interviews were conducted to assure maximum follow-up data. Quality Of Life (QOL) was assessed using the Gastro-Intestinal Quality of Life Index (GIQLI), Gastro-intestinal Symptom Rating Scale (GSRS) and Bariatric Analysis and Reporting Outcome System (BAROS).

RESULTS:

A total of 18 patients (11 female, 7 male) were identified (17 Nissen and 1 former Belsey-Mark IV fundoplication). Mean time between surgical interventions was 9.4 years. Laparoscopic RYGB was feasible without intra-operative complications. One patient needed relaparoscopy for falsely suspected leakage and another suffered from postoperative pneumonia. Symptomatic GORD after RYGB was reported by 3 patients (16.7%). QOL was rated good with a GIQLI-score of 118 (range 97-140), GSRS score of 33 (range 15-59) and BAROS-score of 4,6 (range 1.2-6.8). EWL 3 years after surgery was comparable with matched control subjects (80.1% vs. 79.2% in controls, P=0.70).

CONCLUSIONS:

Laparoscopic conversion of anti-reflux surgery to RYGB with breakdown of the fundoplication is feasible and safe. Weight loss results are equal to control subjects and treatment of GORD is good. No significant decrease in QOL was reported.

_____________________________________________________________________

 

Surg Endosc. 2012 Dec;26(12):3521-7. doi: 10.1007/s00464-012-2380-7. Epub 2012 Jun 13.

Laparoscopic fundoplication takedown with conversion to Roux-en-Y gastric bypass leads to excellent reflux control and quality of life after fundoplication failure.

Stefanidis D1, Navarro F, Augenstein VA, Gersin KS, Heniford BT.

BACKGROUND:

Recent data suggest that reoperative fundoplication is associated with poor long-term control of reflux. For long-term reflux control, laparoscopic Roux-en-Y gastric bypass (LRYGB) may be a better option. This study assessed outcomes and quality-of-life data after fundoplication takedown and conversion to LRYGB for patients with failed fundoplications.

METHODS:

After institutional review board approval, the medical records of 25 patients who underwent fundoplication takedown and LRYGB conversion between March 2007 and July 2011 were reviewed. The data recorded included patient demographics, body mass index (BMI), preoperative symptoms, operative duration and findings, hospital length of stay (LOS), estimated blood loss (EBL), length of the follow-up period, and postoperative outcomes. The gastrointestinal quality of life index (GIQLI) and the gastrointestinal symptoms rating scale (GSRS) were used at the most recent follow-up visit to assess symptom severity and quality of life.

RESULTS:

The patients in this study had undergone 40 total prior antireflux surgeries. They had a median age of 55 years (range 36-72 years), a BMI of 34.4 kg/m(2) (range 22-50 kg/m(2)), an operative duration of 345 min (range 180-600 min), an EBL of 181 ml (range 50-500 ml), and an LOS of 7 days (range 2-30 days). Five patients had concomitant incisional hernia repair. There was no mortality. Of the 10 patients (40%) who had had complications, 5 required reoperation. During a 14-month follow-up period (range 1-48 months), 96% of the patients were reflux-free with a GIQLI score of 114 (range 80-135) and a GSRS score of 25 (range 17-45). Excess weight loss was 60%, and comorbidity resolution was 70%. Most of the patients (96%) were satisfied with their outcome and would undergo the surgery again, and 62% reported that their personal relationships and sexual life had improved.

CONCLUSIONS:

Patients who undergo LRYGB after failed fundoplications have excellent symptomatic control of reflux, excellent quality of life, and high rates of satisfaction with their outcome. Nevertheless, because the procedure is challenging and associated with considerable morbidity, it should be performed by surgeons experienced in antireflux and bariatric surgery.

________________________________________________________________________________

2016 Oct 17. pii: S1550-7289(16)30747-X. doi: 10.1016/j.soard.2016.10.008. [Epub ahead of print]

Safety and effectiveness of anterior fundoplication sleeve gastrectomy in patients with severe reflux.

BACKGROUND:

Laparoscopic sleeve gastrectomy has become a popular bariatric surgery in recent years. However, it has been linked to worsening or newly developed gastroesophageal reflux disease (GERD) in the postoperative period.

OBJECTIVES:

The purpose of this study is to determine the safety and effectiveness of anterior fundoplication sleeve gastrectomy in patients with reflux.

SETTING:

Academic hospital, United States.

METHODS:

We prospectively collected data on 31 sleeve gastrectomy patients who concurrently underwent anterior fundoplication between July 2014 and March 2016. Patients were selected when they reported severe reflux before the procedure. Each patient was interviewed using the GERD score questionnaire (scaled severity and frequency of heartburn, regurgitation, epigastric pain, epigastric fullness, dysphagia, and cough) before and 4 months after the procedure.

RESULTS:

Our patients comprised 27 females and 4 males with a mean age of 49.9±9.6 years (range, 29-63 yr). They had a mean preoperative body mass index of 42.8±5.6 kg/m2 (range, 33.3-58.4 kg/m2), and 67.7% (n = 21) of these patients underwent hiatal hernia repair as well. Preoperatively, patients had a mean heartburn score of 7.4±3.6 (range, 1-12), regurgitation score of 5.4±4.1 (range, 0-12), epigastric pain score of 2.1±3.2 (range, 0-12), epigastric fullness score of 2.7±3.9 (range, 0-12), dysphagia score of 1.3±2.2 (range, 0-9), and cough score of .9±1.8 (range, 0-6). Mean preoperative GERD score was 18.9±9.8 (range, 6-36) in these patients. Patients were interviewed with the same questionnaire approximately 4 months postoperative. Patients had a mean heartburn score of 1.5±3.2 (range, 0-12), regurgitation score of .9±1.7 (range, 0-8), epigastric pain score of .4±1.1 (range, 0-4), epigastric fullness score of 1.1±2.4 (range, 0-8), dysphagia score of .3±1.1 (range, 0-6), and cough score of 0. Mean postoperative GERD score dropped down to 4.1±5.8 (range, 0-28), and the difference was statistically significant (P<.01). One patient was readmitted 28 days later for a staple line leakage, and was treated conservatively. No patient required a reoperation due to the procedure within 30 days.

CONCLUSION:

Anterior fundoplication sleeve gastrectomy may be a safe and effective alternative in obese patients with severe reflux who want to undergo sleeve gastrectomy.

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