Is Roux-en-Y gastric bypass safe after previous antireflux surgery? Technical feasibility and postoperative symptom assessment

Background: Clinically significant morbid obesity is associated with an increased risk of gastroesophageal reflux disease. Vertical Roux-en-Y gastric bypass (RYGBP) is known to eliminate acid (and bile) in the pouch of cardia, which would provide control of reflux symptoms. The aim of our study was to assess the technical considerations, morbidity, and safety of RYGBP after previous antireflux surgery and evaluate postoperative reflux symptoms. Methods: Retrospective review of all patients undergoing RYGBP after previous antireflux surgery from three institutions. Follow-up (mean 18 months) data were obtained from medical records and by questionnaire. Results: A total of 19 patients (18 women and 1 man) underwent standard (n = 18) or distal (n = 1) RYGBP 8 ± 1 years after Nissen (n = 18) or Toupet (n = 1) fundoplication. Open RYGBP was undertaken in 17 of 19 patients. No postoperative deaths occurred. Substantive complications occurred in 4 patients (21%) and included hemorrhage requiring transfusion, concomitant splenectomy, and reoperation for suspected leak in 2. Of the 19 patients, 16 returned the questionnaire, 15 of whom reported subjective improvement in reflux symptoms after RYGBP compared with after antireflux surgery. No patient in this series required medical therapy for reflux symptoms at the last follow-up visit. The body mass index decreased from 42 ± 2 kg/m² to 32 ± 2 kg/m² (mean ± SEM); all patients with ≥1 year of follow-up had a body mass index of ≤32 kg/m². At last follow-up, 88% of patients were very satisfied subjectively with their outcome. Conclusions: RYGBP after previous antireflux surgery is technically feasible and safe, but it is associated with greater complication rates than those seen with other forms of reoperative bariatric procedures. RYGBP results in effective weight loss, controls reflux symptoms, and may be the procedure of choice in morbidly obese patients with previous antireflux surgery, and obese patients requiring surgical treatment for gastroesophageal reflux disease.