SAN DIEGO — Roux-en-Y gastric bypass is an effective albeit technically challenging option for the common problem of intractable gastroesophageal reflux disease following failed fundoplication, Dr. Omar Awais said at the annual meeting of the Society of Thoracic Surgeons.
The procedure has an 80% success rate for control of GERD symptoms. That rate is as good as or better than the results usually reported for a first redo fundoplication. Second redo fundoplications have a success rate of about 60%, while third repeat fundoplications work less than 50% of the time, according to Dr. Awais of the University of Pittsburgh.
Another surgical option for patients with intractable GERD after failed antireflux surgery is esophagectomy. However, that operation has a mortality of 5% in expert hands, compared with the 0% mortality seen in this study, the cardiothoracic surgeon added.
Obesity is an important risk factor for GERD. With the worsening obesity epidemic, Dr. Awais and colleagues are seeing increasing referrals for failed antireflux operations. Indeed, they received 183 such referrals during 2000–2005. Most of these patients underwent redo partial or complete fundoplication. But 25, including 11 with two or more prior Nissen fundoplications, underwent Roux-en-Y gastric bypass (RNY).
Three-quarters of RNY recipients were obese or morbidly obese. All had severe GERD symptoms involving heartburn, regurgitation, dysphagia, and/or reflux-associated pulmonary symptoms.
The RNY operations began laparoscopically, although 40% were intraoperatively converted to open procedures. Surgery began by taking down the prior fundoscopies and reducing recurrent hiatal hernia. Surgeons then performed a standard RNY with one important modification: Instead of creating the 30-cc gastric pouch typical in bariatric surgery, they fashioned a much smaller pouch—just 5–10 cc—in order to divert acid.
The mean operative time was nearly 61/2 hours. One-quarter of patients experienced at least one major postoperative morbidity. These included two cases of anastomotic leak, three of pneumonia, a Roux-limb intussusception requiring reoperation, an MI, pulmonary embolism, and anoxic encephalopathy. There were no deaths.
Follow-up at a mean of more than 16 months showed 80% of patients were satisfied. The mean score on a 45-point GERD symptom scale on which 15 is considered clinically significant fell from 30 preoperatively to 7.
Moreover, patients lost a mean weight of 60 pounds, and more than two-thirds of comorbid conditions showed significant improvement. For example, 12 of 15 previously hypertensive patients required lower doses of antihypertensive drugs or no medication at all. Sleep apnea and hypercholesterolemia also showed marked improvement.
Dr. Awais' report had a decidedly mixed reception. Dr. Thomas J. Watson of the University of Rochester (N.Y.) declared RNY is an important operation for thoracic surgeons to master because they are the specialists best suited to perform it in the challenging group of patients with severe GERD after failed antireflux surgery.
He added that at the most recent meeting of the Society for Surgery of the Alimentary Tract he presented a case series of RNY patients; rates of symptomatic improvement and major complications were similar to those Dr. Awais described.
Not all patients with failed fundoplication who'll benefit from RNY present with intractable GERD symptoms, however. They may instead present with symptoms of poor esophageal emptying, with gastroparetic symptoms such as nausea and vomiting, or with pain, Dr. Watson said.
But Dr. Mark B. Orringer took a dim view of RNY for severe GERD after failed antireflux surgery.
“I hate to see the stomach being attacked when the culprit is the esophagus in these patients with reflux,” said Dr. Orringer, the John Alexander Distinguished Professor and head of thoracic surgery at the University of Michigan, Ann Arbor. “It just hurts me to the quick to see patients having the best organ with which to replace the organ that's causing their symptoms be injured or made unusable for esophageal replacement. You're explanting the wrong organ.”
He urged anyone considering doing such surgery to first perform upper GI endoscopy. “We're seeing patients referred to us who've had gastric bypass operations for obesity done in the presence of Barrett's mucosa and who now need esophagectomy for Barrett's adenocarcinoma because the Barrett's mucosa was overlooked.”
Dr. Daniel L. Miller concurred. “You had a dysmotility problem in two-thirds of your patients before surgery and dysphagia in more than 40%, and then you go on and do the surgery and leave the esophagus intact. I think you're going to have problems on down the road,” warned Dr. Miller of Emory University, Atlanta.
“Dysphagia is a very common problem in these patients, and I think this might not be the right operation for them. Esophagectomy would probably be better,” he said.