Laparoscopic revision of Nissen fundoplication to Roux-en-Y gastric bypass in morbidly obese patients.

BACKGROUND: We present a case of a morbidly obese patient with previous laparoscopic Nissen fundoplication (LNF) who was successfully treated by revision to a laparoscopic Roux-en-Y gastric bypass (RYGB) and discuss our collective experience.

METHODS: Between June 2000 and April 2006 seven morbidly obese patients with mean body mass index (BMI) of 39.4 kg/m(2) underwent laparoscopic revision of LNF to RYGB by our group. Important steps of the revision include lysis of all adhesions between the liver and the stomach, dissection of the diaphragmatic crura and gastroesophageal fat pad, reduction and repair of hiatal hernia and complete take-down of the wrap to avoid stapling over the fundoplication which can create an obstructed, septated pouch.

RESULTS: There was one (14.3%) conversion. Mean operative time (OT) was 324 (206-419) minutes and length of stay was 4.9 (3-8) days. Early complications occurred in 3/7 (42.9%) patients including a staple line hemorrhage without a need for re-exploration, a small pulmonary embolism without hemodynamic instability and a small-bowel obstruction due to a pre-existing incisional ventral hernia that was not repaired on original operation. There were no anastomotic leaks or deaths. At a mean follow-up of 32.9 (12-39) months, mean percentage excess weight loss was 79.5% and 18/28 (64.3%) comorbid conditions were improved or resolved. Gastroesophageal reflux disease (GERD) evaluation with the GERD health-related quality of life (GERD-HRQL) scale showed a significant reduction of GERD scores postoperatively (16.7 versus 4.4).

CONCLUSIONS: Although laparoscopic RYGB after antireflux surgery is technically difficult and carries higher morbidity, it is feasible and effective in the treatment of recurrent GERD in morbidly obese patients.