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Ann Thorac Surg 2005;80:1938-1940
© 2005 The Society of Thoracic Surgeons

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Case report

Antireflux Operation for Gastroesophageal Reflux After Roux-en-Y Gastric Bypass for Obesity

^a Division of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
^b Division of General Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
^c Division of Gastroenterology, St. Elizabeth's Medical Center, Boston, Massachusetts, USA

Accepted for publication June 4, 2004.

^_* Address correspondence to Dr Bueno, Thoracic Surgery, 75 Francis St, Brigham and Women's Hospital, Boston, MA02115 (Email: rbueno{at}partners.org).

	Abstract

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Gastroesophageal reflux disease (GERD) affects many morbidly obese patients. The Roux-en-y gastric bypass operation often achieves the simultaneous aims of weight reduction as well as reflux correction. However, some patients continue to suffer from severe gastroesophageal symptoms after successful postoperative weight reduction. There are no reports describing surgical treatments for these patients. Here we report our management of intractable postoperative reflux with a Belsey Mark IV fundoplication performed one year after a successful Roux-en-y gastric bypass operation. The patient tolerated the operation without problems and experienced successful resolution of her reflux symptoms.

	Introduction

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Gastroesophageal reflux often afflicts patients who are morbidly obese [1, 2]. It was originally thought that bariatric operations would accomplish both weight reduction and resolution of gastroesophageal reflux [3, 4]. Roux-en-y gastric bypass is currently thought to be an ideal operation for gastroesophageal reflux disease (GERD) and some surgeons have advocated it as the procedure of choice for all patients [5, 6].

Recently published studies suggest that GERD may not necessarily be adequately controlled with either a vertical banding gastroplasty or a Roux-en-y gastric bypass operation in all patients [7]. A substantial number of patients (up to 22%) who undergo successful Roux-en-y gastric bypass operations continue to complain of heartburn postoperatively [8]. Medical management has been the mainstay for the majority of these patients. However, a number of patients continue to suffer from reflux symptoms despite optimized medical therapy. Here we report the surgical management of a patient suffering from intractable gastroesophageal reflux with a Belsey Mark IV fundoplication one year after a successful Roux-en-y gastric bypass operation for morbid obesity.

The patient is a 34-year-old female with a history of morbid obesity (5 ft 4 inches, 271 lbs, body-mass index [BMI] of 42) and multiple failed attempts at weight reduction including dieting, exercise, and medications. Comorbid complaints included severe heartburn, sleep apnea, and asthma. She underwent Roux-en-y gastric bypass surgery in July 2001 with the construction of a vertically orientated proximal gastric pouch, with a 70 cm jejunal Roux limb, and a jejunojejunostomy 40 cm beyond the ligament of Treitz. The gastric pouch was 6 by 2 cm with a volume of 20 cm³.

The patient tolerated the procedure with no complications and was successful at weight reduction. When she represented in March 2003, her weight was down to 145 lbs, which corresponded to a BMI of 25. However, she had begun experiencing recurrent burning chest pain and dysphagia four months after the operation. An abdominal ultrasound ruled out any pancreatic or hepatobiliary disease and abdominal computed tomography showed no pathology.

She underwent further studies to evaluate possible gastroesophageal reflux. An upper gastrointestinal (GI) endoscopy revealed widely patent gastrojejunostomy and jejunojejunostomy. There was no evidence of hiatal herniation, Barrett's esophagus, or esophagitis, and the gastric mucosa appeared normal. An upper GI series demonstrated proper emptying of the gastric pouch, but severe gastroesophageal reflux. Esophageal manometry showed normal esophageal contraction, but diminished lower esophageal sphincter tone. A 24-hour pH study revealed acid reflux greater than 10% of the time. The calculated composite reflux score was 37.7 (normal less than 14.72, 95th percentile). The patient's symptoms did not improve despite extended trials of antacids and proton-pump inhibitors for over a year.

Because of the previous Roux-en-y gastric bypass, we elected to perform a two-tiered Belsey Mark IV antireflux operation [9]. The length of the stomach pouch was measured and found to be approximately 6 cm and thus of sufficient size. Most of the gastric remnant was utilized. Adhesions from the previous operation did not unduly hinder the dissection.

The patient tolerated the procedure without any complications. She was discharged on postoperative day seven tolerating a liquid diet without reflux or dysphagia. Three months after surgery she presented with mild dysphagia to solids but no weight loss. Upper GI endoscopy was normal and she was successfully managed with endoscopic dilatation. She continues to be asymptomatic without reflux or dysphagia 13 months after surgery.

	Comment

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Gastroesophageal reflux is a common problem among patients who are morbidly obese owing to a higher incidence of associated hiatal hernia as well as to increased intraabdominal pressure which displaces the lower esophageal sphincter and increases the gastroesophageal gradient [2]. Ghassemian and colleagues [10] examined 657 morbidly obese patients with GI radiographic studies and found that 164 had significant hiatal hernia, and 39 had radiographic evidence of esophageal reflux.

It has been thought that bariatric operations would achieve the simultaneous aims of weight reduction and GERD correction [4, 6] and many surgeons are performing bariatric procedures as the treatment of choice for GERD in the morbidly obese. However, recent studies suggest that Roux-en-y gastric bypass operations may not prove a definitive solution for gastroesophageal reflux in all patients. Frezza and colleagues [8] found that 33 (22%) of 152 morbidly obese patients with symptomatic GERD who underwent laparoscopic Roux-en-y gastric bypass operations had significant heartburn after surgery. Since patients undergoing gastric bypass operations are usually young, it is unclear what long-term effects esophageal reflux will have on this population.

We report the case of a patient with a history of severe esophageal reflux that persisted despite a successful Roux-en-y gastric bypass operation and significant weight loss. We have found no other reported treatment for patients with persistent reflux in spite of a successful Roux-en-y gastric bypass procedure. We elected to proceed with a Belsey Mark IV antireflux procedure after one year of failed medical therapy and after radiographic and pH studies confirmed significant reflux in this patient. We found that despite dense adhesions, the mobilization of the gastroesophageal junction by a left thoracotomy did not pose a significant challenge. The short 6 cm gastric pouch was not a contraindication for a successful fundoplication. The patient tolerated the procedure well without complications, recurrent reflux, or significant dysphagia. Other potential surgical options were discarded because of the limited size of the gastric pouch and the preference to avoid a second laparotomy. Endoscopic approaches were considered not sufficiently durable for this young patient.

With the increasing popularity and proliferation of bariatric operations, the incidence of persistent gastroesophageal reflux may continue to rise. This population of patients should be carefully monitored for the development of esophageal dysplasia and reflux, and the Belsey Mark IV fundoplication may prove to be a good and durable surgical option for the treatment of persistent reflux after gastric Roux-en-y bypass operation.

	References

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1. Schauer P, Hamad G, Ikramuddin S. Surgical management of gastroesophageal reflux disease in obese patients Semin Laparosc Surg 2001;8:256-264.[Medline]
2. Barak N, Ehrenpreis ED, Harrison JR, Sitrin MD. Gastroesophageal reflux disease in obesitypathophysiological and therapeutic considerations. Obes Rev 2002;3:9-15.[Medline]
3. Jones Jr KB, Allen TV, Manas KJ, McGuinty DP, Wilder WM, Wadsworth ED. Roux-y gastric bypassan effective anti-reflux procedure. Obes Surg 1991;1:295-298.[Medline]
4. Smith SC, Edwards CB, Goodman GN. Symptomatic and clinical improvement in morbidly obese patients with gastroesophageal reflux disease following Roux-en-y gastric bypass Obes Surg 1997;7:479-484.[Medline]
5. Buckwalter JA. Surgical treatment of morbid obesity with reflux esophagitis Am Surg 1982;48:128-130.[Medline]
6. Jones Jr KB. Roux-en-y gastric bypassan effective antireflux procedure in the less than morbidly obese. Obes Surg 1998;8:35-38.[Medline]
7. Korenkov M, Kohler L, Yucel N, et al. Esophageal motility and reflux symptoms before and after bariatric surgery Obes Surg 2002;12:72-76.[Medline]
8. Frezza EE, Ikramuddin S, Gourash W, et al. Symptomatic improvement in gastroesophageal reflux disease (GERD) following laparoscopic Roux-en-y gastric bypass Surg Endosc 2002;16:1027-1031.[Medline]
9. Orringer M, Skinner DB, Belsey R. Long term results of the Mark IV operation for hiatal hernia and analyses of recurrences and their treatments J Thorac Cardiovasc Surg 1972;63:25-33.[Medline]
10. Ghassemian AJ, MacDonald KG, Cunningham PG, et al. The workup for bariatric surgery does not require a routine upper gastrointestinal series Obes Surg 1997;7:16-18.[Medline]

This article has been cited by other articles:

				S. G. Houghton, M. S. Allen, and M. G. Sarr Belsey Mark IV After Roux-en-Y Gastric Bypass. Ann. Thorac. Surg., September 1, 2006; 82(3): 1171 - 1171. [Full Text] [PDF]

				D. B. Lautz and R. Bueno Reply. Ann. Thorac. Surg., September 1, 2006; 82(3): 1172 - 1172. [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Raymond H. Chen Raphael Bueno Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Chen, R. H. Articles by Bueno, R. Search for Related Content PubMed PubMed Citation Articles by Chen, R. H. Articles by Bueno, R. Related Collections Esophagus - other