Surgery for Obesity and Related Diseases 11 (2015) 973–974
Video case report
Conversion of Nissen fundoplication to laparoscopic gastric bypass: video case report and literature review Jérémie Thereaux, M.D.a,b,*, Charles Roche, M.D.a, Jean-Pierre Bail, M.D.a,b a
Keywords:
Department of General, Digestive and Metabolic Surgery, La Cavale Blanche University Hospital, Brest, France b University of Bretagne Occidentale (UBO), Brest, France Received January 14, 2015; accepted January 15, 2015
Gastric bypass; Nissen fundoplication; Revisional procedure
Gastroesophageal reflux disease (GERD) is a common disease, especially in developed countries, with a prevalence of 415% in the United States [1]. Its risk increases progressively with increasing weight [2]. Hence, GERD can develop as an obesity-related co-morbidity and is one of the main factors leading to bariatric surgery in obese patients, with a preoperative rate of around 30% [3,4]. However, before the routine use of bariatric surgery, fundoplication was considered the treatment of choice for GERD showing dependence on or resistance to proton pump inhibitors. Laparoscopic Roux-en-Y gastric bypass (LRYGB) has become the procedure of choice because of its high success rate for the treatment of GERD [5]. Furthermore, sleeve gastrectomy may actually worsen the symptoms of GERD and is not recommended for some patients [6]. However, LRYGB for morbidly obese patients is a technically challenging procedure, especially in those who have undergone hiatal surgery [6,7–12]. Here, we report the case of a woman who underwent laparoscopy to convert a Nissen fundoplication to LRYGB. Case presentation and management We present the case of a 56-year-old woman (127 kg, 1.67 m) with a body mass index (BMI) of 45.5 kg/m2. She was referred to our tertiary care center for morbid obesity. She had undergone both a cholecystectomy for acute * Correspondence: Dr. Jérémie Thereaux, Department of General, Digestive and Metabolic Surgery, La Cavale Blanche University Hospital, Boulevard Tanguy-Prigent, 29200 Brest, France. Tel: +332 98 22 33 33. E-mail: [email protected]
cholecystitis and a Nissen fundoplication for GERD 20 years ago. Both procedures were performed under open approach (right subcostal and midline laparotomy). She also had a history of type 2 diabetes and obstructive sleep apnea requiring nocturnal continuous positive airway pressure. Clinical GERD was not diagnosed from a dedicated questionnaire. Upper GI endoscopy indicated an intact wrap without hiatal hernia and no esophagitis. Manometry revealed no insufficiency of the lower esophageal sphincter and 24-hour pH metry confirmed the diagnosis of GERD. No operative report of the previous fundoplication was available; therefore, we performed an abdominal computed tomography (CT) scan with oral contrast agent. This exam confirmed that fundoplication was circumferential (Nissen procedure) and was not associated with hiatal hernia. The use of bariatric surgery was approved by a multidisciplinary team. LRYGB was chosen because of the patient’s history of hiatal surgery and the presence of GERD. The procedure was performed under laparoscopy. The first step of this procedure was to reverse totally fundoplication surgery. A harmonic Ultracision Scalpel device (Ethicon Endosurgery, Cincinnati, OH, USA) was used for this step. Dissection of the fundoplication was facilitated by dividing short vessels of the greater curvature toward the retro gastric path of the fundus. The hiatal region was totally exposed during the procedure. Attention was made to preserve the right blood supply to the gastric pouch by minimizing dissection along the lesser curvature. The gastric pouch was initially divided beneath the second vessel of the lesser curvature. A circular stapler anvil was
http://dx.doi.org/10.1016/j.soard.2015.01.022 1550-7289/r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
974
J. Thereaux et al. / Surgery for Obesity and Related Diseases 11 (2015) 973–974
inserted with a small gastrotomy. The fundus was removed because it appeared ischemic. An omega loop was created in a precolic pregastric manner. Termino-lateral gastrojejunal anastomosis was performed with a 25-mm circular stapler, 40 cm after the angle of Treitz. The jejunostomy was resected and a jejuno-jejunostomy was created by sideto-side mechanical anastomosis. All mesenteric defects (Petersen’s space, and transmesenteric) were closed with a nonabsorbable running suture. No adverse outcomes occurred during the postoperative period.
Disclosures The authors have no conflicts of interest or financial ties to disclose. Appendix Supplementary data Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1016/j. soard.2015.01.022. References
Discussion and literature review Here, we provide the first didactic high-quality video of the conversion of a previous fundoplication to LRYGB in a morbidly obese patient. We think that this video will help surgeons who may be confronted with such a situation. Few studies have assessed the feasibility of converting a previous fundoplication to LRYGB [7–12] and only 1 was a controlled study [7]. The number of patients with a low BMI in these studies was small. This procedure is deemed both challenging and difficult and should be performed by experienced surgeons [9]. Indeed, in the first report of successful conversion of fundoplication to LRYGB, Raftopoulos et al. report a mean operative time of 46 hours [11]. These difficulties may be explained by hiatal region adhesions, association with hiatal hernia, previous open approach, and the presence of the wrap. We think that the entire wrap should be removed and eventual hiatal hernia should be treated, as suggested previously [11]. Furthermore, this is important to avoid injuring the lesser curvature vessels and the small gastric pouch. Worse injuries may be caused by stapling the fundus twice, which can create a blind pouch, or by devascularizing the future small gastric pouch. The prevalence of postoperative morbidity is around 40% [7,9,11,12] with between 11% [8] and 20% of patients undergoing reoperation [9]. Houghton et al. found the prevalence of postoperative morbidity is 21% in patients undergoing an open approach [10]. Furthermore, Ibele et al. found that LRYGB after fundoplication is associated with a higher rate of postoperative morbidity than primary procedures [7]. Regarding expected weight loss and the outcome of GERD [13], LRYGB seems to be the procedure of choice for patients who have previously undergone fundoplication. The percentage of excess weight loss at 1 year varies between 60% and 79.5% [7,9,11,12]. Furthermore, LRYGB provides an excellent success rate for treating GERD [5,8,10]. Despite its association with postoperative complications, LRYGB is the procedure of choice for the conversion of a previous fundoplication in patients needing bariatric surgery. Special attention must be paid when removing the wrap to limit per and postoperative complications.
[1] Dent J, El-Serag HB, Wallander MA, Johansson S. Epidemiology of gastro-oesophageal reflux disease: a systematic review. Gut 2005;54 (5):710–7. [2] Hampel H, Abraham NS, El-Serag HB. Meta-analysis: obesity and the risk for gastroesophageal reflux disease and its complications. Ann Intern Med 2005;143(3):199–211. [3] Mechanick JI, Youdim A, Jones DB, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient—2013 update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery. Surg Obes Relat Dis 2013;9(2):159–91. [4] Thereaux J, Veyrie N, Barsamian C, et al. Similar postoperative safety between primary and revisional gastric bypass for failed gastric banding. JAMA Surg 2014;149(8):780–6. [5] DuPree CE, Blair K, Steele SR, Martin MJ. Laparoscopic sleeve gastrectomy in patients with preexisting gastroesophageal reflux disease: a national analysis. JAMA Surg 2014;149(4):328–34. [6] Rosenthal RJ, Diaz AA, Arvidsson D, et al. International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of 412,000 cases. Surg Obes Relat Dis 2012;8(1):8–19. [7] Ibele A, Garren M, Gould J. The impact of previous fundoplication on laparoscopic gastric bypass outcomes: a case-control evaluation. Surg Endosc 2012;26(1):177–81. [8] Kim M, Navarro F, Eruchalu CN, Augenstein VA, Heniford BT, Stefanidis D. Minimally invasive Roux-en-Y gastric bypass for fundoplication failure offers excellent gastroesophageal reflux control. Am Surg 2014;80(7):696–703. [9] Stefanidis D, Navarro F, Augenstein VA, Gersin KS, Heniford BT. Laparoscopic fundoplication takedown with conversion to Roux-en-Y gastric bypass leads to excellent reflux control and quality of life after fundoplication failure. Surg Endosc 2012;26(12):3521–7. [10] Houghton SG, Nelson LG, Swain JM, et al. Is Roux-en-Y gastric bypass safe after previous antireflux surgery? Technical feasibility and postoperative symptom assessment. Surg Obes Relat Dis 2005;1 (5):475–80. [11] Raftopoulos I, Awais O, Courcoulas AP, Luketich JD. Laparoscopic gastric bypass after antireflux surgery for the treatment of gastroesophageal reflux in morbidly obese patients: initial experience. Obes Surg 2004;14(10):1373–80. [12] Zainabadi K, Courcoulas AP, Awais O, Raftopoulos I. Laparoscopic revision of Nissen fundoplication to Roux-en-Y gastric bypass in morbidly obese patients. Surg Endosc 2008;22(12):2737–40. [13] Thereaux J, Corigliano N, Poitou C, Oppert JM, Czernichow S, Bouillot JL. Five-year weight loss in primary gastric bypass and revisional gastric bypass for failed adjustable gastric banding: results of a case-matched study. Surg Obes Relat Dis. 2015;11(1): 19–25. Epub 2014 Jun 5.
Video case report
Conversion of Nissen fundoplication to laparoscopic gastric bypass: video case report and literature review Jérémie Thereaux, M.D.a,b,*, Charles Roche, M.D.a, Jean-Pierre Bail, M.D.a,b a
Keywords:
Department of General, Digestive and Metabolic Surgery, La Cavale Blanche University Hospital, Brest, France b University of Bretagne Occidentale (UBO), Brest, France Received January 14, 2015; accepted January 15, 2015
Gastric bypass; Nissen fundoplication; Revisional procedure
Gastroesophageal reflux disease (GERD) is a common disease, especially in developed countries, with a prevalence of 415% in the United States [1]. Its risk increases progressively with increasing weight [2]. Hence, GERD can develop as an obesity-related co-morbidity and is one of the main factors leading to bariatric surgery in obese patients, with a preoperative rate of around 30% [3,4]. However, before the routine use of bariatric surgery, fundoplication was considered the treatment of choice for GERD showing dependence on or resistance to proton pump inhibitors. Laparoscopic Roux-en-Y gastric bypass (LRYGB) has become the procedure of choice because of its high success rate for the treatment of GERD [5]. Furthermore, sleeve gastrectomy may actually worsen the symptoms of GERD and is not recommended for some patients [6]. However, LRYGB for morbidly obese patients is a technically challenging procedure, especially in those who have undergone hiatal surgery [6,7–12]. Here, we report the case of a woman who underwent laparoscopy to convert a Nissen fundoplication to LRYGB. Case presentation and management We present the case of a 56-year-old woman (127 kg, 1.67 m) with a body mass index (BMI) of 45.5 kg/m2. She was referred to our tertiary care center for morbid obesity. She had undergone both a cholecystectomy for acute * Correspondence: Dr. Jérémie Thereaux, Department of General, Digestive and Metabolic Surgery, La Cavale Blanche University Hospital, Boulevard Tanguy-Prigent, 29200 Brest, France. Tel: +332 98 22 33 33. E-mail: [email protected]
cholecystitis and a Nissen fundoplication for GERD 20 years ago. Both procedures were performed under open approach (right subcostal and midline laparotomy). She also had a history of type 2 diabetes and obstructive sleep apnea requiring nocturnal continuous positive airway pressure. Clinical GERD was not diagnosed from a dedicated questionnaire. Upper GI endoscopy indicated an intact wrap without hiatal hernia and no esophagitis. Manometry revealed no insufficiency of the lower esophageal sphincter and 24-hour pH metry confirmed the diagnosis of GERD. No operative report of the previous fundoplication was available; therefore, we performed an abdominal computed tomography (CT) scan with oral contrast agent. This exam confirmed that fundoplication was circumferential (Nissen procedure) and was not associated with hiatal hernia. The use of bariatric surgery was approved by a multidisciplinary team. LRYGB was chosen because of the patient’s history of hiatal surgery and the presence of GERD. The procedure was performed under laparoscopy. The first step of this procedure was to reverse totally fundoplication surgery. A harmonic Ultracision Scalpel device (Ethicon Endosurgery, Cincinnati, OH, USA) was used for this step. Dissection of the fundoplication was facilitated by dividing short vessels of the greater curvature toward the retro gastric path of the fundus. The hiatal region was totally exposed during the procedure. Attention was made to preserve the right blood supply to the gastric pouch by minimizing dissection along the lesser curvature. The gastric pouch was initially divided beneath the second vessel of the lesser curvature. A circular stapler anvil was
http://dx.doi.org/10.1016/j.soard.2015.01.022 1550-7289/r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
974
J. Thereaux et al. / Surgery for Obesity and Related Diseases 11 (2015) 973–974
inserted with a small gastrotomy. The fundus was removed because it appeared ischemic. An omega loop was created in a precolic pregastric manner. Termino-lateral gastrojejunal anastomosis was performed with a 25-mm circular stapler, 40 cm after the angle of Treitz. The jejunostomy was resected and a jejuno-jejunostomy was created by sideto-side mechanical anastomosis. All mesenteric defects (Petersen’s space, and transmesenteric) were closed with a nonabsorbable running suture. No adverse outcomes occurred during the postoperative period.
Disclosures The authors have no conflicts of interest or financial ties to disclose. Appendix Supplementary data Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1016/j. soard.2015.01.022. References
Discussion and literature review Here, we provide the first didactic high-quality video of the conversion of a previous fundoplication to LRYGB in a morbidly obese patient. We think that this video will help surgeons who may be confronted with such a situation. Few studies have assessed the feasibility of converting a previous fundoplication to LRYGB [7–12] and only 1 was a controlled study [7]. The number of patients with a low BMI in these studies was small. This procedure is deemed both challenging and difficult and should be performed by experienced surgeons [9]. Indeed, in the first report of successful conversion of fundoplication to LRYGB, Raftopoulos et al. report a mean operative time of 46 hours [11]. These difficulties may be explained by hiatal region adhesions, association with hiatal hernia, previous open approach, and the presence of the wrap. We think that the entire wrap should be removed and eventual hiatal hernia should be treated, as suggested previously [11]. Furthermore, this is important to avoid injuring the lesser curvature vessels and the small gastric pouch. Worse injuries may be caused by stapling the fundus twice, which can create a blind pouch, or by devascularizing the future small gastric pouch. The prevalence of postoperative morbidity is around 40% [7,9,11,12] with between 11% [8] and 20% of patients undergoing reoperation [9]. Houghton et al. found the prevalence of postoperative morbidity is 21% in patients undergoing an open approach [10]. Furthermore, Ibele et al. found that LRYGB after fundoplication is associated with a higher rate of postoperative morbidity than primary procedures [7]. Regarding expected weight loss and the outcome of GERD [13], LRYGB seems to be the procedure of choice for patients who have previously undergone fundoplication. The percentage of excess weight loss at 1 year varies between 60% and 79.5% [7,9,11,12]. Furthermore, LRYGB provides an excellent success rate for treating GERD [5,8,10]. Despite its association with postoperative complications, LRYGB is the procedure of choice for the conversion of a previous fundoplication in patients needing bariatric surgery. Special attention must be paid when removing the wrap to limit per and postoperative complications.
[1] Dent J, El-Serag HB, Wallander MA, Johansson S. Epidemiology of gastro-oesophageal reflux disease: a systematic review. Gut 2005;54 (5):710–7. [2] Hampel H, Abraham NS, El-Serag HB. Meta-analysis: obesity and the risk for gastroesophageal reflux disease and its complications. Ann Intern Med 2005;143(3):199–211. [3] Mechanick JI, Youdim A, Jones DB, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient—2013 update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery. Surg Obes Relat Dis 2013;9(2):159–91. [4] Thereaux J, Veyrie N, Barsamian C, et al. Similar postoperative safety between primary and revisional gastric bypass for failed gastric banding. JAMA Surg 2014;149(8):780–6. [5] DuPree CE, Blair K, Steele SR, Martin MJ. Laparoscopic sleeve gastrectomy in patients with preexisting gastroesophageal reflux disease: a national analysis. JAMA Surg 2014;149(4):328–34. [6] Rosenthal RJ, Diaz AA, Arvidsson D, et al. International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of 412,000 cases. Surg Obes Relat Dis 2012;8(1):8–19. [7] Ibele A, Garren M, Gould J. The impact of previous fundoplication on laparoscopic gastric bypass outcomes: a case-control evaluation. Surg Endosc 2012;26(1):177–81. [8] Kim M, Navarro F, Eruchalu CN, Augenstein VA, Heniford BT, Stefanidis D. Minimally invasive Roux-en-Y gastric bypass for fundoplication failure offers excellent gastroesophageal reflux control. Am Surg 2014;80(7):696–703. [9] Stefanidis D, Navarro F, Augenstein VA, Gersin KS, Heniford BT. Laparoscopic fundoplication takedown with conversion to Roux-en-Y gastric bypass leads to excellent reflux control and quality of life after fundoplication failure. Surg Endosc 2012;26(12):3521–7. [10] Houghton SG, Nelson LG, Swain JM, et al. Is Roux-en-Y gastric bypass safe after previous antireflux surgery? Technical feasibility and postoperative symptom assessment. Surg Obes Relat Dis 2005;1 (5):475–80. [11] Raftopoulos I, Awais O, Courcoulas AP, Luketich JD. Laparoscopic gastric bypass after antireflux surgery for the treatment of gastroesophageal reflux in morbidly obese patients: initial experience. Obes Surg 2004;14(10):1373–80. [12] Zainabadi K, Courcoulas AP, Awais O, Raftopoulos I. Laparoscopic revision of Nissen fundoplication to Roux-en-Y gastric bypass in morbidly obese patients. Surg Endosc 2008;22(12):2737–40. [13] Thereaux J, Corigliano N, Poitou C, Oppert JM, Czernichow S, Bouillot JL. Five-year weight loss in primary gastric bypass and revisional gastric bypass for failed adjustable gastric banding: results of a case-matched study. Surg Obes Relat Dis. 2015;11(1): 19–25. Epub 2014 Jun 5.
