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Acta Chirurgica Belgica

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Surgical treatment of therapy-resistant refluxafter Roux-en-Y gastric bypass. A case series of themodified Nissen fundoplication

Jan Colpaert, Julie Horevoets, Leander Maes, Gilles Uijtterhaegen & BrunoDillemans

To cite this article: Jan Colpaert, Julie Horevoets, Leander Maes, Gilles Uijtterhaegen &Bruno Dillemans (2019): Surgical treatment of therapy-resistant reflux after Roux-en-Y gastricbypass. A case series of the modified Nissen fundoplication, Acta Chirurgica Belgica, DOI:10.1080/00015458.2019.1696028

To link to this article: https://doi.org/10.1080/00015458.2019.1696028

Accepted author version posted online: 20Nov 2019.Published online: 29 Nov 2019.

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SURGICAL TECHNIQUE

Surgical treatment of therapy-resistant reflux after Roux-en-Y gastricbypass. A case series of the modified Nissen fundoplication

Jan Colpaert, Julie Horevoets, Leander Maes, Gilles Uijtterhaegen and Bruno Dillemans

Department of Surgery, AZ Sint-Jan Brugge, Bruges, Belgium

ABSTRACTIntroduction: Patients with intractable reflux after RYGB have limited treatment options. Herea modified Nissen fundoplication (MNF) as described by N. Kawahara might be the answer.Methods: In this retrospective case study we identified six patients with therapy-resistantGERD after RYGB. All six were treated with a MNF, using the remnant stomach to constructthe fundoplication. Short term follow-up 1 month and 6–12 months postoperatively wasconducted to inquire about GERD symptoms.Results: Six patients underwent a MNF. Three out of six patients had had a gastric band intheir medical history. Upper GI barium swallow test revealed herniation of the gastric pouchin 4/6 patients. After surgery all patients were symptom free and 4/6 completely stoppedPPI treatment.Discussion: Mechanisms of new onset or deteriorating GERD after RYGB are herniation ofgastric pouch and destruction of the lower esophageal sphincter after banding. Both prob-lems are tackled when constructing a MNF.Conclusion: Complete symptom relief was seen 1 month after MNF. The procedure seemssafe, feasible and effective. The study is limited by small sample size and short follow-up yetshows clear improvement of symptoms. Larger trials are needed to establish validity ofthe MNF.

ARTICLE HISTORYReceived 12 November 2018Accepted 18 November 2019

KEYWORDSGastro-esophageal reflux;Roux-en-Y gastric bypass;Nissen fundoplication;modified Nissenfundoplication;GERD; obesity

Introduction

Gastro-esophageal reflux disease (GERD) affects alarge portion of morbidly obese patients. An inci-dence of up to 61% has been cited in the obesepopulation [1]. Large numbers of studies havereported a clear improvement in GERD symptomsafter Roux-en-Y gastric bypass (RYGB), making itthe gold standard surgical treatment in the mor-bidly obese patient with GERD [2–4]. The mainmechanisms of the antireflux effect of a RYGB arefourfold: a derivation of bile, weight loss whichresults in decreased abdominal pressures over thelower esophageal sphincter (LES), a lowered acidproduction in the gastric pouch and rapid pouchemptying. In a review of the Bariatric OutcomesLongitudinal Database, it was clearly demonstratedthat GERD score improvement was the highest inthe RYGB group, with 56.5% of patients showingamelioration of symptoms [5].

Although RYGB is widely accepted as the stand-alone procedure of choice for GERD treatment inthe morbidly obese, it is not a conclusive treat-ment for all patients [6,7]. Up to 22% of patientswho underwent a successful RYGB operation still

complain about postoperative GERD symptoms [6].The initial treatment for GERD in the post-bariatricpatient remains conservative and is similar to thatof the general population. Optimal medical ther-apy combined with lifestyle changes such asweight loss and dietary optimization form thebasis for treatment and prevention of this acidreflux. In case of continuing or worsening symp-toms despite pharmacotherapy further evaluationis warranted [8]. Useful diagnostic tests such as 24-hour pH study, an upper gastro-intestinal endos-copy, esophageal manometry and Barium swallowX-rays can help further differentiate the problem.

For these patients with persisting GERD afterbariatric surgery and despite optimal medical ther-apy there is no clear consensus on further treat-ment options. To the best of our knowledge onlytwo surgical case reports have been published onsurgical intervention with either a conversion to aBelsey Mark IV fundoplication [9] or a fundoplica-tion using the remnant stomach [10]. Both techni-ques had excellent short postoperative outcomes.Other techniques using the MUSE systemTM,Stretta ProcedureTM and EsophyxTM are all

CONTACT Jan Colpaert jcolpaert@gmail.com Department of Surgery, AZ Sint-Jan Brugge, Ruddershove 10, Bruges 8000, Belgium� 2019 The Royal Belgian Society for Surgery

ACTA CHIRURGICA BELGICAhttps://doi.org/10.1080/00015458.2019.1696028

proposed emerging endoluminal therapies or themagnetic Linx deviceTM have no clear availabledata on their outcomes [8].

Building on these earlier reported cases, wewanted to further evaluate the feasibility and useof a modified Nissen fundoplication (MNF) in gas-tric bypass patients with therapy resistant gastro-esophageal reflux disease.

Methods

Study design and setting

We wanted to evaluate the safety and feasibility aswell as the impact on GERD of the MNF procedureas described by Kawahara et al. [10]

This retrospective case study was conducted ata secondary referral hospital for bariatric surgery inBruges, Belgium. From 1 April 2017 over the dur-ation of 1 year, we identified six patients with ther-apy-resistant gastro-esophageal reflux afterbariatric surgery. Inclusion criteria were symptomsof reflux disease despite optimal medical therapywith high-dose proton-pump inhibitors (PPI’s) andlifestyle changes in patients who already under-went a gastric bypass.

All six were treated with a MNF, using the rem-nant stomach to construct the fundoplication. Thedetails of the surgery and the specificities of ourapproach are mentioned lower in the article. Oneperson underwent a concomitant gastrojejunalsleeve because of weight regain and the finding ofa large pouch during surgery. The procedure wasperformed by an experienced surgeon and histeam with a long-standing experience in bariatricand bariatric revisional surgery. Data were col-lected from patient files. Any incomplete datawere retrospectively added through thoroughanamnesis on consultation. A short term clinicalfollow-up 1 month after surgery, either on consult-ation or telephonically was conducted to inquireabout persisting or improving GERD symptoms, aswell as a follow-up 6–12 months postoperatively.

Rationale of the procedure

The original Nissen fundoplication was first per-formed by Dr. Rudolph Nissen in 1955. He pub-lished the results of two cases in an edition of the1956 Swiss Medical Weekly [11]. In 1961, he pub-lished a more detailed overview of the procedure[12]. The main mechanism of the fundoplication isbased on reinforcing the closing function of thelower esophageal sphincter (LES). The esophageal

hiatus is also narrowed down by sutures to pre-vent or treat concurrent hiatal hernia.

The rationale behind the MNF after RYGB lies inthe fact that -by wrapping the remnant stomacharound the gastro-esophageal junction – the LES issufficiently reinforced. Secondly, by reducing anyintrathoracic herniation when necessary and byclosing of the pillars any further herniation is pre-vented. Thus both main mechanisms of gastro-esophageal reflux are tackled in one surgery. Athird possible explanation for the improvement ofGERD after hiatoplasty and Nissen fundoplicationmay be found in the maintenance of a segment ofintra-abdominal esophagus.

Procedure

In essence, a laparoscopic 360� fundoplication wasperformed to reinforce the LES by wrapping theexcluded stomach around the distal esophagus.The patient was put in beach chair position and apneumoperitoneum of 15mmHg was established.One scope trocar and four utility trocars wereplaced, using the same position as the initial gas-tric bypass surgery (Figure 1) [13]. After initialadhesiolysis from the previous surgery theexcluded stomach is carefully isolated by dividingthe short gastric vessels with harmonic scissors.Subsequently the lesser omentum (or hepatogas-tric ligament) is opened at the pars flaccida anddissection continues toward the diaphragm toexpose the right crus. Further blunt dissection isused to separate the right crus from the esopha-gus. The dissection is then continued to free theesophagus circumferentially.

Once the hiatus is meticulously dissected thecrurae are approximated with interrupted stitchesinferior to the esopaghus. The crucial part here is toprevent a kinking of the esophagus which mighthappen when the crurae are approximated tootightly. Consecutively a loose wrap of approximately3 cm is constructed around the esophagus usingthe remnant stomach with an intra-esophageal 32-Fr bougie for guidance. The mobilized remnantstomach is pulled behind the gastric pouch and theanterior and posterior lips are sutured togetherusing three interrupted stitches. The middle stitch isalso used to fix the wrap to the esophagus anteri-orly. (Figures 2–4) All stitches were placed using theEndoStitch device with Ethibond 2/0 sutures.Finally, the smooth passage is checked by slidingthe 32-Fr bougie back and forth through the wrap.After careful hemostasis and methylene blue leak

2 J. COLPAERT ET AL.

test the surgery is completed. In one case, becauseof associated weight regain, the dilated gastricpouch was resized before performing the modifiedNissen fundoplication.

Results

Over the course of 1 year, six patients received thisspecific surgical treatment. Of these six patients,

two were male and four female. Age of thepatients at the time of their MNF ranged from 20to 60 years old with a mean age of 42.

Each patient had already undergone a laparo-scopic RYGB. Five of these were performed in ourcenter, one RYGB was performed elsewhere. Allpatients had severe to morbid obesity before theirinitial RYGB. Body Mass Index (BMI) before the RYGBranged from 35.1 to 58.9 with a mean BMI of 42.5.All patients had known a satisfactory initial weightloss with BMI’s between 19 and 31 (mean 24.2).

Two patients had already undergone adjustablegastric banding before RYGB. In both cases, the bandhad been removed due to associated problems (slip-ping, reflux and dysphagia). One patient had his bandremoved before the RYGB, the other patient hadthe band removed simultaneously with the RYGBsurgery. A third patient underwent gastric bandingfor weight regain after his initial RYGB surgery.

Timing between RYGB and MNF varied from 3to 11 years. During this interval, two patients

Figure 1. Position of the trocars as described by Dillemans et al. [15].

Figure 2. Cruraplasty using EndoStitch. The crucial part ofthis step is to prevent kinking of the esophagus.

Figure 3. Creating a loose wrap with the remnant stomacharound the distal esophagus.

Figure 4. Completing the loose 3 cm wrap with three inter-rupted stitches.

ACTA CHIRURGICA BELGICA 3

underwent surgery for an internal herniation andone patient had a revisional bariatric procedure forweight regain with adjustable banding of thepouch. This band was later removed during theMNF. At the time of the MNF, mean BMI was 31.3(range 24.7–40.5). This is in line with the increasein weight as often seen over the years after bariat-ric surgery.

Before the initial RYGB, four out of six patientsalready had GERD symptoms and acid reflux. Thiscorresponds with the 61% incidence of reflux inthe obese population as found in the literature [1].After RYGB, all patients were asymptomatic for atleast 1 year. We found a gradual increase in GERD-related complaints and symptoms starting as soonas 1 year after RYGB.

Main complaints before the MNF were GERD-related. Heartburn and regurgitation were found in6 out of 6 patients. Four out of six patients alsomanifested a gradual weight regain. One patientexperienced intermittent episodes of postprandialvomiting. Associated comorbidities were mainlyobesity-related with dyspnea on exertion, ortho-paedic and psychological discomfort. Prior to sur-gery all patients were put on high dose PPI’s1 yetremained symptomatic. Upper GI series with bar-ium swallow revealed herniation of the pouch anda delayed passage of contrast in 4 out of 6patients. Further investigation with gastroscopyshowed a grade A esophagitis in 2 out of 6patients. One patient had esophagitis grade C andtwo others had a sliding hernia on gastroscopy.One patient with a normal gastroscopy underwentfurther investigations with pH-manometry whichshowed some regurgitation but no significant acidexposition of the lower esophagus (pH > 4). Eventhough not all patients had objectified esophagitis,they demonstrated clear symptoms of GERD,impacting their quality of life. The absence of anyesophagitis on gastroscopy – despite obvioussymptoms – might be attributed to the long-termPPI use masking clear signs of GERD.

One month after surgery, 4 out of 6 patientscould already permanently stop their PPI’s andwere completely symptom free. One patient wasstill on low dose PPI’s because of esophagitisgrade A on control gastroscopy. Before his MNF,however, the gastroscopy had shown a grade Creflux esophagitis. Subjectively he no longer expe-rienced any GERD-related symptoms and was verysatisfied with the surgery. Another patient was stillusing PPI’s 1 month after surgery but stated to becompletely symptom free and very content. Seeing

the good symptomatic results of this surgery nofollow-up gastroscopy was performed inthis group.

In further follow-up 6 months to 1 year postop-eratively, we find that 3 out of 6 patients (50%) stillhad adequate symptom relief with no need forPPI’s. The remaining three however had startedtaking low-dose PPI’s2 again due to recurrence ofthe reflux symptoms (heartburn, dyspepsia and/orregurgitation) although they all stated to be muchmore comfortable now than before their surgery.

As an additional benefit, we found a markedweight loss postoperatively. Both with or withoutgastrojejunal sleeve for dilated pouch the generaltendency was that of a loss of around 1.8 points ofBMI. One patient however had weight regain afterthe MNF due to an orthopedic trauma and long-term immobilization which severely reduced hisphysical activity level.

After 6- to 12-month follow-up, we did see asignificant increase in weight regain. Two out ofsix patients had returned to their initial weightfrom before the RYGB. Four out of six patients stillremained stable with a weight similar to that1 month after the MNF.

Both in the 1 month and in the 6- to 12-monthpostoperative follow-up no complications wereidentified.

Discussion

Six patients with a RYGB and intractable acid refluxdespite optimal medical therapy underwent a lap-aroscopic MNF in our center. The first two caseswere performed in April of 2017. Strengthened bythe positive results of these first cases four morepatients were operated for the same problemusing the same technique. To the best of ourknowledge the only time this surgery has previ-ously been described was in a case report byN. Kawahara [10].

Although the RYGB remains the gold standardtreatment for GERD in the obese, it does notalways offer a permanent solution [6,7]. Up to 22%of patients who underwent a successful RYGBoperation still complain about postoperativeGERD-related symptoms [6]. In our series we findthat a large portion of the reflux symptoms afterRYGB are associated with earlier or concomitantgastric banding or supradiaphragmatic herniationof the gastric pouch. Gastric banding either beforeor after the bypass-operation has a detrimentaleffect on the LES which can contribute to

4 J. COLPAERT ET AL.

worsening of GERD [14]. In four out of six patientsthere was a herniation of the pouch on upper GIseries. The altered pressure systems when the gas-tric pouch herniates into the thoracic cavity alsocontributes to a reduced functioning of the LESand more gastro-esophageal reflux.

The initial resolution of symptoms 1month aftersurgery is a strong indicator of good results butcan be biased by the fact that all patients also lostweight, which in turn has an impact on symptomreduction. One patient also underwent a gastroje-junal sleeve together with the MNF, this resultedin a more pronounced weight loss and also lowersacid production which might further positivelyaffect symptoms of GERD. Six months to 1 yearafter surgery however we see an increase in overallweight in three out of six patients with still suffi-cient symptom control. This finding suggests thatthe initial weight loss is not the main reason forsymptom relief. Other confounding factors such asa short term placebo effect postoperatively andthe removal of the band in one case might alsohave impact symptom relief.

Some might argue that the mechanism of aMNF loses part of its function as the remnantstomach does not fill with food or gas, thus givingless pressure around the esophagus. We howeverhypothesized that the wrapping of the stomacharound the pouch gives enough a mechanical bar-rier to strengthen the LES and prevent reflux. Thismechanism of a mechanical barrier was also usedin the Angelchik prosthesis from the late 1970sand early 80s [15]. The C-shaped ring with Dacronfitted tape created a mechanical barrier with goodinitial results on GERD symptoms but was aban-doned after long-term complications such as slip-ping and erosion became obvious [16].

Despite some promising results in our first sixpatients this study has some severe limitations.The biggest limitation of this study is its relativelysmall sample size and the lack of strong objectivedata to evaluate the efficacy. In order to establisha more definitive answer to whether or not thissurgery benefits patients a larger study populationis needed. Furthermore, routine barium swallowand pH manometry could be useful to objectivelyevaluate the functionality of the MNF. Finally, aretrospective case series scores relatively low inthe hierarchy of evidence, although being themost prevalent type of clinical research.Nevertheless it can be useful to use a case seriesto generate hypothesis that are to be tested inlarger, randomized trials. Another limitation is the

short follow-up period, however even in this shorttime period we find a manifest improvementof symptoms.

Conclusion

This study was mainly used to evaluate the feasi-bility of a MNF after RYGB. Overall the MNF fortherapy-resistant reflux after RYGB seems to have,to some extent, a positive effect up to 1 year post-operatively. Both a complete remission of GERDsymptoms in all patients and – as an additionalbenefit – a marked overall weight loss are seenalready 1 month after the revisional surgery. In the6- to 12-month follow-up, we find a recurrence ofsymptoms in 50% of patients. These symptoms arecurrently treated with low-dose PPI’s again.Despite this recurrence all six patients attest to asubjective decrease of symptoms and concomitantincrease in their quality of life after the MNF.

No postoperative complications were seen. Inthe hands of a skilled surgeon with experience inrevisional bariatric surgery this procedure seems tobe safe and feasible. At this point no firm conclu-sion can be drawn however about the impact onGERD, although we do see a positive tendency insymptom relief.

Further investigation with objective data collec-tion both pre- and postoperatively is needed tocorroborate our thesis that the MNF does in factalleviates intractable acid reflux after RYGB.

Notes

1. At least one PPI 2 times 40mg daily, whether or notassociated with antacids.

2. Low-dose PPI’s ¼ 20 to 40mg omeprazole orpantoprazole daily

Disclosure statement

None of the authors have any conflict of interestto declare.

ORCID

Bruno Dillemans http://orcid.org/0000-0001-8135-4844

References

[1] Iovino P, Angrisani L, Galloro G, et al. Proximal stom-ach function in obesity with normal or abnormaloesophageal acid exposure. NeurogastroenterolMotil. 2006;18(6):425–432.

[2] Nelson LG, Gonzalez R, Haines K, et al. Ameliorationof gastroesophageal reflux symptoms following

ACTA CHIRURGICA BELGICA 5

Roux-en-Y gastric bypass for clinically significant obes-ity. Am Surg. 2005;71(11):950–953. discussion 3–4.

[3] Mejia-Rivas MA, Herrera-Lopez A, Hernandez-CallerosJ, et al. Gastroesophageal reflux disease in morbidobesity: the effect of Roux-en-Y gastric bypass. ObesSurg. 2008;18(10):1217–1224.

[4] Merrouche M, Sabate JM, Jouet P, et al. Gastro-esophageal reflux and esophageal motility disordersin morbidly obese patients before and after bariatricsurgery. Obes Surg. 2007;17(7):894–900.

[5] Pallati PK, Shaligram A, Shostrom VK, et al.Improvement in gastroesophageal reflux diseasesymptoms after various bariatric procedures: reviewof the Bariatric Outcomes Longitudinal Database.Surg Obes Relat Dis. 2014;10(3):502–507.

[6] Frezza EE, Ikramuddin S, Gourash W, et al.Symptomatic improvement in gastroesophageal refluxdisease (GERD) following laparoscopic Roux-en-Y gas-tric bypass. Surg Endosc. 2002;16(7):1027–1031.

[7] Varban OA, Hawasli AA, Carlin AM, et al. Variation inutilization of acid-reducing medication at 1 year fol-lowing bariatric surgery: results from the MichiganBariatric Surgery Collaborative. Surg Obes Relat Dis.2015;11(1):222–228.

[8] Altieri MS, Pryor AD. Gastroesophageal reflux diseaseafter bariatric procedures. Surg Clin North Am. 2015;95(3):579–591.

[9] Chen RH, Lautz D, Gilbert RJ, et al. Antireflux oper-ation for gastroesophageal reflux after Roux-en-y

gastric bypass for obesity. Ann Thorac Surg. 2005;80(5):1938–1940.

[10] Kawahara NT, Alster C, Maluf-Filho F, et al. ModifiedNissen fundoplication: laparoscopic antireflux sur-gery after Roux-en-Y gastric bypass for obesity.Clinics (Sao Paulo). 2012;67(5):531–533.

[11] Nissen R. [A simple operation for control of refluxesophagitis]. Schweiz Med Wochenschr. 1956;86(Suppl 20):590–592.

[12] Nissen R. Gastropexy and “fundoplication” in surgicaltreatment of hiatal hernia. Digest Dis Sci. 1961;6(10):954–961.

[13] Dillemans B, Sakran N, Van Cauwenberge S, et al.Standardization of the fully stapled laparoscopicRoux-en-Y gastric bypass for obesity reduces earlyimmediate postoperative morbidity and mortality: asingle center study on 2606 patients. Obes Surg.2009;19(10):1355–1364.

[14] Khan A, Kim A, Sanossian C, et al. Impact of obesitytreatment on gastroesophageal reflux disease. WorldJ Gastroenterol. 2016;22(4):1627–1638.

[15] Angelchik JP, Cohen R. A new surgical procedurefor the treatment of gastroesophageal reflux andhiatal hernia. Surg Gynecol Obstet. 1979;148(2):246–248.

[16] Crookes PF, DeMeester TR. The Angelchik prosthesis:what have we learned in fifteen years? Ann ThoracSurg. 1994;57(6):1385–1386.

6 J. COLPAERT ET AL.