Ann Thorac Surg 2006;82:1172
© 2006 The Society of Thoracic Surgeons
Correspondence
Reply
David B. Lautz, MD,
Raphael Bueno, MD
Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115
(Email: rbueno{at}partners.org).
To the Editor:
We appreciate the comments of Houghton and colleagues [1] regarding our case report of a Belsey procedure after a Roux-en-Y gastric bypass [2]. In response, there are a few clarifications to be made. First, we presented this case as a patient who had persistent and documented reflux despite having significant weight loss after a Roux-en-Y gastric bypass (RYGB). We are aware of the mounting data supporting the role of RYGB in the treatment of reflux in the obese population, and we presented this report as an example of the first line of surgical treatment for patients with documented and medically refractory reflux. We have preformed over 1,500 RYGBs at our institution with excellent success in treating those patients who have reflux. However, this patient had persistent reflux symptoms. Recently published data have shown an incidence of postoperative symptomatic and pH probe documented gastrointestinal reflux disease (GERD) of 12.5% and 15%, respectively, when all patients undergoing RYGB for reflux were studied [3]. Our report referenced such a case of persistent GERD despite significant weight loss, and we reported on a possible surgical option in such a circumstance. We realize that the vast majority of patients who are treated with RYGB will not need an anti-reflux procedure. However, for the few who will need one, we present Belsey fundoplication as a therapeutic option.
The second point that was brought up in the letter was a question as to the accuracy of measuring the Roux limb length through the chest cavity. It is not clear to us the relevance of this point. The measurements made in our patient were taken from the initial procedure, and we know of no data suggesting that limb lengths change significantly post-RYGB. In addition, this patient had documented acid (not bile) reflux, so the argument that our Roux and pancreatico-biliary limb lengths were inadequate and the reflux was through the Roux limb because it was too short is inconsistent with the data. We would agree that if the reflux was bilious in nature, we would have considered addressing the limb lengths in such a case. One concern that we did have was the possibility of an occult gastro-gastric fistula, which we ruled out preoperatively.
Finally, with regard to the comments on our pouch size and location, our standard technique is to create a 20-cc pouch, which is routinely assessed by distension of the pouch at the end of the procedure. We essentially construct the pouch in the same fashion that Dr Sarr has described in previous publications [4]. We routinely assess the pouch and check pouch size in any post-RYGB patient with ulcer or reflux-type symptoms, as we did in this case, and we determined that the pouch was appropriately sized. With this sized pouch, it is unlikely that inclusion of parietal cells was the reason for the acid reflux. The Belsey fundoplication that we performed used some stomach outside the pouch, which was technically possible, because we used an open, nondivided technique during the primary procedure. In retrospect, we should have been clearer about these issues in the case report to avoid confusion.
However, for these reasons we believe that Houghton and colleagues' [1] recommendation of downsizing the pouch further and lengthening the Roux limb to 150 cm (in the absence of bile reflux) would not have helped this patient who presently remains symptom free.
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References
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- Houghton SG, Allen MS, Sarr MG. Belsey Mark IV after Roux-en-Y gastric bypass (letter) Ann Thorac Surg 2006;82:1171.[Free Full Text]
- Chen RH, Lautz D, Gilbert RJ, Bueno R. Antireflux operation for gastroesophageal reflux after Reoux-en-Y gastric bypass for obesity Ann Thorac Surg 2005;80:1938-1940.[Abstract/Free Full Text]
- Escudero OJ, Mora F, Sala C, Flor B, et al. Outcome of esophageal function and 24-hour esophageal pH monitoring after vertical banded gastroplasty and Roux-en-Y gastric bypass Obes Surg 2004;14(8):1086-1094.[Medline]
- Balsinger BM, Kennedy FP, Abu-Lebdeh HS, et al. Prospective evaluation of Roux-en-Y gastric bypass as primary operation for medically complicated obesity Mayo Clin Proc 2000;75:673-680.[Medline]
Related Article
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Belsey Mark IV After Roux-en-Y Gastric Bypass
- Scott G. Houghton, Mark S. Allen, and Michael G. Sarr
Ann. Thorac. Surg. 2006 82: 1171.
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