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Ann Thorac Surg 2006;82:1171
© 2006 The Society of Thoracic Surgeons
a Divisions of Gastroenterologic and General Surgery, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905
b Division of General Thoracic Surgery, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905
(Email: houghton.scott{at}mayo.edu; allen.mark{at}mayo.edu; sarr.michael{at}mayo.edu).
We were intrigued by the case report by Chen and colleagues [1]. Although we agree that gastroesophageal reflux disease (GERD) impacts many obese patients [2, 5], performing an anti-reflux operation after Roux-en-Y gastric bypass (RYGB) seems counterintuitive. When performed correctly, RYGB decreases dramatically and virtually eliminates acid present in the proximal gastric pouch, reduces GERD symptoms, DeMeester scores, and use of anti-reflux medications, and should eliminate completely duodeno-esophageal reflux by the Roux anatomy [2, 3, 4, 6]. After RYGB, reflux symptoms improve dramatically (and immediately postoperatively) prior to weight loss, suggesting the effects of RYGB on GERD are independent of weight loss [3]. Patients undergoing RYGB after "successful" fundoplication report improved reflux control postoperatively [6]. The efficacy of RYGB in controlling GERD has lead some to advocate RYGB as the treatment of choice even for obese patients with a body mass index of less than 35 kg/m2 with refractory GERD, who would otherwise not meet the Nation Institutes of Health criteria for "bariatric surgery" [5, 7, 8]. This evidence, although not level I, points to the excellent control of GERD accomplished with a correctly performed RYGB.
With the abundance of evidence supporting the efficacy of RYGB in controlling GERD and GERD symptoms, we are left to ponder why the patient reported by Chen and colleagues [1] required further treatment for reflux despite achieving adequate weight loss after RYGB. Several aspects of the patient's history raise concerns over the technical adequacy of the RYGB. The Roux limb was reported to be 70 cm and the proximal pouch was reported to be 20 cm2. The methods used to obtain these measurements were not included, and we suspect this information was obtained from the previous operative report, not measured objectively, and is thus inaccurate. Indeed, a transthoracic approach makes measurement of Roux limb length virtually impossible. A Roux limb of 70 cm is on occasion not long enough to completely prevent reflux of duodenal contents into the gastric pouch in all patients. Furthermore, a 20 cm2 pouch may not be small enough to prevent the inclusion of parietal cells in the pouch, especially if the pouch was created vertically along the lesser curvature. These parietal cells can produce a significant amount of acid which can then reflux into the esophagus in the presence of an incompetent lower esophageal sphincter, as was present in their patient. Other points of concern were the DeMeester score of 37.7 after RYGB and the fact that the authors were actually able to mobilize enough "stomach" to perform a Belsey Mark IV. These observations indicate that the proximal gastric pouch was far too large and included an area of acid-producing gastric mucosa.
Given this information as previously mentioned, we suggest that the patient may have been better treated with a revision of her RYGB to lengthen the Roux limb to 150 cm and to markedly downsize the proximal gastric pouch.
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  D. B. Lautz and R. Bueno Reply. Ann. Thorac. Surg., September 1, 2006; 82(3): 1172 - 1172. [Full Text] [PDF]
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