Roux-en-Y with Distal Gastrectomy for Gastroesophageal Reflux After Sleeve Gastrectomy

Abstract

Sleeve gastrectomy (SG) is currently the most commonly performed bariatric procedure, but it has been associated with postoperative gastroesophageal reflux disease (GERD) and Barrett’s esophagus (BE). 2 We present a single-surgeon (SKM) experience with distal gastrectomy (DG) and Rouxen-Y (RNY) reconstruction as a remedial measure for severe reflux after previous SG. After IRB approval, we queried our prospectively maintained database of benign foregut surgeries to identify patients who underwent re-operative intervention after previous SG from August 2016 to February 2020. Symptom severity was scored from 0 to 75 on the GERD-Health Related Quality of Life (GERD-HRQL) questionnaire. The study cohort included 12 patients. Patient demographics, symptom scores, and workup results are shown in Table 1. The interval from SG to re-operation was 4.0±1.9 years (5.8±1.9 years in the 3 patients with BE). All patients underwent laparoscopic hiatal hernia repair (if present) and DG with RNY gastrojejunostomy (GJ). The mean operative time was 155±27 min, and the median postoperative hospital stay was 2 days. There were no perioperative complications. At follow-up of 2±1.4 years, mean GERD-HRQL scores declined significantly (53±18 vs 2±5, p<0.001). BMI declined from 33±5 to 29±5 kg/m (p=0.055). Our series has 2 distinct features: (1) only patients with severe GERD symptoms uncontrolled on maximal medical therapy and diet adjustments were included, and (2) DG and RNY reconstruction with 60 cm (short limb) alimentary limb was the remedial procedure. The prevalence of erosive esophagitis and BE in our cohort (all with uncontrolled symptomatic GERD) is nearly identical to those reported in larger systematic follow-up studies including all post-SG patients (erosive esophagitis (15.5–73.6%) and BE (15–18.8%) irrespective of symptoms. This finding argues that instead of symptom-guided esophagogastroduodenoscopy, a routine surveillance program irrespective of symptomsmay be warranted in post-SG patients. Progression of post-SG BE to adenocarcinoma has been reported, highlighting the need for vigilance in follow-up. Although the cause, prevalence, and sequelae in patients with post-SG GERD are a subject of debate, the successful treatment of GERD is not. The most definitive intervention for remission of post-SG reflux is hiatal hernia repair (if present) and RNY reconstruction. Others have reported excellent resolution of post-SG GERD after conversion to RNY gastric bypass (GBP). 6 The question arises whether the distal stomach should be left in situ (GBP) or resected (DG). RNYGBP is probably safer in the hands of surgeons with limited experience in laparoscopic gastrectomy. However, leaving a redundant hollow viscus in the abdomen—which can potentially lead to retained-antrum syndrome—defies basic surgical principles. Hence, our practice is to proceed with laparoscopic DG with RNY GJ. We leave a generous proximal stomach pouch (5–7 cm) along the lesser curvature and create 20-cm biliary and 60to 70-cm alimentary limbs. This potentially avoids nutritional deficiencies, as evidenced by normal micronutrient and protein levels at 3 and 12 months after surgery in our cohort (data available but not reported). An excellent midterm outcome with definitive control of reflux and improved quality of life in our series renders RNY with DG a safe and effective procedure for patients with esophageal issues after SG. Our study has the limitation of * Sumeet K. Mittal [email protected]