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The Heart, Lung, and Esophageal Surgery Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
Accepted for publication January 23, 2008.
* Address correspondence to Dr Luketich, The Heart, Lung, and Esophageal Surgery Institute, University of Pittsburgh Medical Center, 200 Lothrop St., Suite C-800, Pittsburgh, PA 15213 (Email: luketichjd{at}upmc.edu).
Presented at the Forty-third Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 29–31, 2007.
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Abstract |
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Methods: Between June 2000 and October 2005, 25 patients with GERD after antireflux surgery underwent RNYNEJ. The endpoints evaluated were improvement in GERD symptoms using the GERD-Health Related Quality of Life (HRQL) scale, overall patient satisfaction, overall patient weight loss, and improvement of comorbid conditions.
Results: There were 4 men and 21 women (mean age 51 years; range, 35 to 74). Seventy two percent had a body mass index (BMI) greater than 30. Forty-four percent had more than one antireflux surgery and 40% had a previous Collis gastroplasty. The perioperative mortality was 0%. Six patients (24%) developed major postoperative complications, including anastomotic leak (n = 2) and Roux-limb obstruction (n = 1). The median length of stay was 6 days. Eighty percent of the patients reported satisfaction at mean follow-up time of 16.5 months. Their BMI reduced from 35.8 to 27.7 (p < 0.001). Seventy three percent of comorbid conditions were improved and the GERD HRQL score improved from 29.9 to 7.3 (p < 0.001).
Conclusions: The RNYNEJ for persistent GERD after prior antireflux surgery is technically challenging with significant morbidity. However, the majority of the patients reported satisfaction with significant improvement in symptoms. Many patients had associated benefits of weight loss and improvement in comorbid conditions. Roux-en-Y near esophagojejunostomy should be considered as an important option for the treatment of intractable GERD after prior antireflux surgery, particularly in the obese.
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Introduction |
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We had previously reported our initial experience in patients who underwent a revision of an antireflux procedure to a Roux-en-Y near esophagojejunostomy (RNYNEJ) [14]. After our original series, two other published reports have examined the conversion of failed fundoplication to RNYGB [15, 16]. Our objective was to evaluate the role of RNYNEJ in the management of intractable reflux symptoms after prior antireflux surgery in this updated series.
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Patients and Methods |
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Results |
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Comment |
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TopAbstractIntroductionPatients and MethodsResultsCommentDiscussionReferences |
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Patients with recurrent symptoms present a difficult challenge for even experienced surgeons in antireflux surgery. These patients with recurrent symptoms have to be studied extensively with repeat BaSw, EGD, pH testing, manometry, and gastric emptying studies. An individualized approach will lead to the best outcomes. Surgical options after failed antireflux surgery include a redo fundoplication, esophagectomy, and a Roux-en-Y diversion. Although an esophagectomy may serve as a last option in a situation where the GE junction cannot be reconstructed, the incidence of reflux after esophagectomy has been reported to occur as high as 60% to 80% [22]. Therefore, for reflux control, an esophagectomy is a suboptimal option. Some have even reported Roux-en-Y diversion after esophagectomy for medically refractory duodenogastric reflux [23]. However, esophagectomy may be indicated in a patient with severe long recalcitrant stricture or Barrett's with dysplasia. Our approach, similar to many series in the literature, is to attempt to reconstruct a fundoplication tailored by preoperative testing and intraoperative findings [8, 24]. Roux-en-Y diversion has been used as an effective antireflux operation dating back as early as 1985 [25, 26]. In addition, in a recent study it has also been shown to regress intestinal metaplasia in patients with Barrett's esophagus [27]. Therefore, there are enough data in the literature to support antireflux effects of Roux-en-Y esophagojejunostomy. Although the overall morbidity from Roux-en-Y compared with fundoplication is higher, we believe there is a subset of patients who have failed an antireflux operation in which RNYNEJ is a better option. There are no specific criteria developed yet, but failed fundoplication in obese patients, especially with other comorbid conditions may be better served with Roux-en-Y. We were more inclined to proceed with RNYNEJ after one failed fundoplication (56%) in morbidly obese patients. All of the patients in this group (56%) were morbidly obese with an average BMI of 39.
During the five-year period between June 2000 and October 2005, our group performed 183 laparoscopic reoperative antireflux procedures, of which 25 patients were converted to RNYNEJ (13.7%). In our practice, the decision to proceed with RNYNEJ is made in many patients preoperatively after thorough discussion with the patients of all surgical options. Deschamps and colleagues [24] similarly reported a 9.2% revision of a failed antireflux procedure to Roux-en-Y antrectomy with truncal vagotomy, mostly as a tertiary procedure when the fundus was inadequate for any repair.
In our original series there was a significant improvement in GERD-HRQL score and all patients were satisfied. Additional benefits of weight loss and improvement in medical comorbidities was observed. However, we reported a morbidity of 42.8% with no mortality. Two other similar studies have been published that address conversion of a failed antireflux procedure to RNYGB [15, 16].
In our present study, we evaluated 25 patients and assessed the safety, feasibility, and efficacy of the procedure with a mean follow-up of 16.5 months (range, 1 to 55). Our mean operative time was comparable with the other series although slightly prolonged. This result may in part be due to our minimally invasive approach, unlike Houghton and colleagues' series [16] in which 90% of the operations were performed using an open technique. In addition, perhaps a slight increase in our operative time can be attributed in part to our retrocolic, retrogastric approach, unlike the antecolic and antegastric approach by Kellogg and colleagues [15]. We observed no obstruction secondary to internal hernias. Our median length of stay of six days falls in between the laparoscopic and the open series. In Kellogg and colleagues' [15] and Houghton and colleagues' [16] series no patient had a prior Collis gastroplasty, and Kellogg and colleagues reported only one patient with two prior antireflux procedures; in contrast, our patients' preoperative surgical history was more complex. Both the leaks (n = 2) in this series occurred in patients with a prior Collis gastroplasty. Further, both of these leaks were contained, occurred in the first seven patients, and were treated nonoperatively. There were no reported leaks in the subsequent eight patients with a prior Collis staple line. We did not observe any leaks in patients who did not have a prior Collis gastroplasty. Thus, in a subset of patients with a prior Collis, the leak rate seemed to be higher although there is a learning curve. We noted three anastomotic strictures, two of which occurred in patients with prior Collis. Complex presurgical history, including multiple dilations can at least in part contribute to high stricture rate (12%). We have recently modified the construction of our proximal anastomosis utilizing a larger 28-mm end-to-end anastomosis (EEA) stapler instead of a 25-mm EEA. This may further reduce our stricture rate, although this has to be analyzed further. We reported an overall morbidity, defined as early major complications, of which 24% is reduced from our original series (42.8%). Although a higher percentage of our patients had multiple reoperations and Collis lengthening, a similar morbidity of 21% with 1 leak was observed by Houghton and colleagues. Kellogg and colleagues reported no major early complications. This perhaps is in part due to a less complex patient population with the lack of a prior Collis gastroplasty and lack of multiple redo antireflux procedures in their patients. One patient required reoperation due to obstruction at the distal anastomosis secondary to intraluminal clot. We observed no mortality in our study in concordance with the other two series [15, 16].
The overall improvement in GERD symptoms was statistically significant as indicated by the change of GERD-HRQL score from 29.9 to 7.3. This finding is consistent with our original series. Houghton and colleagues [16] reported substantial improvement in 15 of 16 patients and observed 88% patient satisfaction. Similarly the series by Kellogg and colleagues [15] reported a 100% improvement of symptoms and a 78% complete resolution of GERD. The success rate of redo antireflux fundoplication varies from 60% to 80% and drops to less than 60% after a second time revision. Forty-four percent of our patients were reoperated on after two previous antireflux surgical procedures: thus, emphasizing the effectiveness of RNYNEJ as an antireflux operation. In addition, only two patients postoperatively were on PPI, both seen in the subgroup of 20% not satisfied with the operation. We observed a statistical drop in BMI from 35.8 to 27.7 and complete resolution of 35% of the comorbidities while 38% were improved. This is also consistent with Houghton and Kellogg and their colleagues' findings. Interestingly, in 28% of our patients who were not obese (BMI < 30), we noted a similar improvement in symptoms and quality of life. All of these patients had more than one fundoplication and their average BMI decreased from 27.5 to 21.9, well within the normal weight (BMI 18 to 25). All of these patients were content with their weight loss and five out of seven were satisfied with the operation. Similar to the entire group, in these nonobese patients, significant improvement in reflux was observed noted by change in GERD-HRQL from 33.4 to 6.8. This may suggest that after multiple revisions of failed fundoplication a Roux-en-Y may be a better option for reflux control.
In conclusion, RNYNEJ after failed antireflux surgery is feasible and can effectively control GERD symptoms. It can be safely performed laparoscopically or in an open fashion, but it does carry a higher morbidity. With the increasing trend of obesity and associated comorbid conditions, additional benefits of significant weight loss with improvement of medical comorbidities can be expected. Roux-en-Y near esophagojejunostomy should be strongly considered in the treatment of obese patients after failed prior fundoplications. It can be also offered to patients in whom the GE junction cannot be reconstructed during a redo fundoplication. Further studies in a prospective fashion need to be performed to confirm our findings. Thoracic surgeons involved in the management of complex redo antireflux procedures should have RNYNEJ in their armamentarium.
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Discussion |
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DR AWAIS: We measured reflux utilizing the GERD HRQL score. Ten of the 25 patients had a preoperatively pH study, of which eight were abnormal. Postoperatively as of now, we have a pH study done in about three patients and all of them had no reflux objectively.
DR SWANSON: What is your current recommendation for obese, a BMI over 30? Do you do Nissens on those patients or not?
DR AWAIS: That's an excellent question. That's a gray zone. In our experience, we offer a Roux-en-Y gastric bypass in patients with a hiatal hernia, reflux, and a BMI greater than 35 based on the NIH guidelines, especially if they have other comorbidities. Now for the obese patient (BMI 30–35), clearly there is data out there supporting either a Roux en-Y or Nissen. Some studies have documented a higher recurrence rate of reflux after a fundoplication in the obese population. Therefore, in obese patients the recurrence rate may be higher. In contrast, there is data out there showing that it's not higher. This obese population has to be investigated in a prospective randomized fashion before we can offer them a Roux-en-Y. The first-time-comers, we perform a fundoplication. After a failed fundoplication, a Roux–en-Y is an excellent option in the obese population as our data suggest.
DR SWANSON: So the 30 to 35 group?
DR AWAIS: We recommend fundoplication.
DR MARK J. KRASNA (Baltimore, MD): First of all, congratulations to you and your colleagues on an excellent presentation.
I just have a quick historical comment and then one question. Ecclesiastes said that "here is nothing new under the sun" and it is true in thoracic surgery that in every generation we see a rekindling of a previous idea. Those of us who trained with Bunky Ellis at Lahey Clinic and those who trained before him at the Mayo Clinic recognize this as two-thirds of the operation that he coined the "acid-suppression/alkaline-diversion operation." It was an operation done by an open laparotomy as well as a left thoracotomy with a partial gastrectomy and then an esophagojejunostomy with a Roux-en-Y.
Although your series includes primarily obese patients, his series, which is almost identical in size with very similar excellent long-term results, were primarily in patients who were not obese.
This leads to my specific question, as part of Dr Ellis's initial description, since all of these patients had either destruction of their GE junction or primary acid reflux symptoms, a partial resection of the stomach enhanced the acid suppression. His way of doing this was by partial resection of the fundus, but your operation offers another opportunity, and that would be a partial resection of the antrum. Have you and your colleagues considered at all doing a more extensive acid-suppression operation, in addition to diversion?
I enjoyed your talk.
DR AWAIS: Thank you very much for the comment and the question.
Essentially our experience with this operation has been tailored by the explosion in obesity and the Roux-en-Y gastric bypass. This is certainly not a new concept, rather a modification of an established idea. The plan is to allow the patient to eat without symptoms and effectively divert all the acid and bile away from the esophagus. It certainly has been shown that a larger gastric pouch can produce acid eventually. So in our experience, we make the pouch as small as possible and we divert the bile by making the Roux limb between 80 and 150 cm based on the BMI of the patient. Whether an antrectomy will add to further acid reduction, I'm not sure of that, but certainly it's a bigger operation. In most cases we do have to resect some fundus because after dissection it is not suitable at times. We try to preserve the stomach, always having a back-up option in the future if an esophagectomy is needed.
DR THOMAS J. WATSON (Rochester, NY): I congratulate you on a nice presentation and your results in a very difficult group of patients. I want to restate the importance having this operation in our armamentarium. Compared to other specialists, we thoracic surgeons are best suited to deal with these complex foregut reconstructions. As anyone who does these sorts of operations can verify, these can be extremely difficult patients in terms of their symptoms, the redo nature of surgery, and the decision for or against operation. We presented a similar series of patients at the last meeting of the Society for Surgery of the Alimentary Tract and found very similar outcomes in terms of symptom response, patient satisfaction, and morbidities. Correlating our experience with yours, I have one suggestion and a couple of questions. My suggestion would be that not all of these patients present with what you call intractable gastroesophageal reflux, as your title would imply. Many of them have problems with poor esophageal emptying manifest as dysphagia or regurgitation, gastroparetic symptoms, such as nausea and vomiting, or intractable pain. I think a better title for your paper might be "Roux-en-Y Gastric Bypass for Failed Fundoplication" rather than "Roux-en-Y Gastric Bypass for Intractable Gastroesophageal Reflux." Again, not all of these symptoms are reflux related.
Now, my questions. First of all, do you ever perform an esophagectomy for failed fundoplication? A lot of such patients have no good option other than extirpation, whether via gastrectomy or esophagectomy. And you said your gastrectomy patients were predominantly obese. How about for the nonobese patient, would you prefer a gastrectomy or an esophagectomy?
DR AWAIS: Thank you, Dr Watson, for the question and the comment.
As we know, the incidence of obesity is increasing in this country. In a patient who is nonobese, a BMI between 18 and 25, we have an extensive discussion with these patients after a redo operation in the clinic, talking about the options of a redo fundoplication, Roux-en-Y diversion, and esophagectomy. So we discuss these options with those patients thoroughly before going to the OR. We have done Esophagectomy earlier in our experience, but I would say that the trend that we see now with obesity, we are doing more and more patients with a Roux-en-Y gastric bypass. To answer your question, perhaps in a patient with normal BMI, one can offer an esophagectomy
DR WATSON: Secondly, if you look at the patients who have undergone redo fundoplication, in terms of their symptomatic outcomes, are they better or worse compared to your gastrectomy cohort?
DR AWAIS: After a first-time redo, the success rate is about 70% to 80%; after a second-time redo, it's somewhere around 60%; followed by less than 50% for a third-time redo. So the outcomes compared to the redo fundoplications are comparable, if not a little better.
DR WATSON: And the final question, to restate what Dr Krasna had stated earlier: I think there are times when you might want to consider removing the distal gastric remnant, not only for acid suppression but also for intractable pain or for patients with gastroparetic symptoms. Have you ever done that?
DR AWAIS: We have done that. Going back to these patients who are redo, third-time operation, the stomach is quite beaten up, and so we have done gastric resection in those patients, but very few. Since we make small pouch which should not produce acid and divert all the bile, our philosophy is to preserve the stomach for potential future utilization.
DR NICHOLAS J. DEMOS (Jersey City, NJ): I enjoyed your paper very much. You touched upon a subject that we have recently witnessed. We do the classical stapled, uncut gastroplasty and fundoplication for reflux. Some of our patients lose a few pounds, but many of them become morbidly obese. They love to eat after their reflux is corrected. Now, would you have any advice as to how to handle it? By unwrapping the fundoplication, we predispose them to reflux again, according to what you have done in a few patients, and in morbidly obese patients, if we unwrap the fundoplication, the small gastric remnant enlarges slowly and they are more amenable to reflux and their ill effects. Would you have any suggestion on what to do in people who do not have recurrent reflux but they have had the fundoplication and now they are morbidly obese?
DR AWAIS: Thank you very much. That's a good question. Patients who are asymptomatic without reflux and who are morbidly obese based on the BMI classification by the NIH can be offered Roux-en-Y diversion. Essentially to do that, I would advise that you take that fundoplication down completely. You don't want to go across a wrap and make a septated pouch. So yes, if the patient desires to lose weight, as a weight-reduction operation, you can offer them Roux-en-Y gastric bypass or esophagojejunostomy in that setting if the BMI is more than 35.
DR MARK B. ORRINGER (Ann Arbor, MI): That was a beautifully delivered paper. I wish I agreed with you, but I don't. The laparoscopic fundoplication is providing us the so-called "Russian doll phenomenon" where you see these little dolls, unscrew one and take another out, and there's another Russian doll inside that you can unscrew and take another out, and so forth. We're now seeing patients who have had one or more laparoscopic redo fundoplications. Their surgeons often don't take down the entire wrap. They just rewrap the existing fundoplication two and sometimes three times. And the surgeon called upon to correct the distal esophageal obstruction that results in these patients has a horrendous task in front of him. A redo antireflux procedure has a reasonable chance of success the first time around; complete takedown of the initial fundoplication is generally feasible. In such patients we add an esophageal lengthening Collis-gastroplasty and then a loose Nissen fundoplication to achieve as tension-free a repair as is possible.
But I am afraid that it is wishful thinking in most cases that a redo fundoplication can be performed with a reasonable long term success rate the second or third time around. Patients have reflux symptoms because they have an esophagus that is sensitive to refluxed gastric contents, and without an esophagus, one cannot have reflux esophagitis. By resecting the stomach in these patients, we are eliminating the best organ with which to replace the organ that is causing most of the symptoms We're attacking the wrong organ! People who have an esophagectomy and cervical esophagogastric anastomosis for the treatment of recurrent reflux after multiple failed antireflux operations may have some postoperative regurgitation, but relatively few have clinically significant reflux symptoms, and their quality of life is good.
I note that in your presentation you talk about how many operations the patients had and what the operative findings were. There is no mention of the endoscopic findings. We're now seeing patients referred to us after gastric bypass operations for obesity done in the presence of Barrett's mucosa. They now need an esophagectomy for adenocarcinoma arising in their Barrett's mucosa, which was overlooked at the time of the gastric bypass procedure. Do you look at the esophagus before surgery in your patients with failed antireflux operations to be certain that you are not resecting a relatively normal stomach and leaving an esophagus with Barrett's mucosa behind? Do any of your patients have Barrett's mucosa?
Our concern about doing a 25 mm EEA stapled anastomosis is that the normal esophagus is 2.5 cm. If you construct a stapled anastomosis that is just 2.5 cm in diameter, as the normal contraction of healing occurs, you are often going to have a patient with dysphagia from a stricture. I think you need to use larger than a 2.5 cm anastomosis to achieve a good long term functional result. I'd like to know about your patients with dysphagia after the 25 mm EEA esophageal anastomosis—their incidence and management. Clearly patients who have a transhiatal esophagectomy and a stomach pull-up have less gastric capacity, and we have found that this is a very effective weight-reduction operation, just as you have described as well. But I worry about dividing the upper stomach. Are the vagi intact after your procedure or not, or are they transected in the process of going across the high stomach? If so, do you do a gastric drainage procedure? And what about the defunctionalized stomach that is detached from the esophagus and is just sitting in there. Is there any long-term morbidity associated with this?
So there are a number of issues that need to be clarified about your approach. The evaluation of the esophagus—would you use your approach if the patient had Barrett's mucosa? Do your patients have dysphagia after a 25 mm EEA stapled anastomosis? Is there a problem with the defunctionalized stomach? Is there a need for a gastric drainage procedure? Again, I hate to see the stomach being "attacked" in the treatment of recurrent reflux when the culprit is the esophagus which is sensitive to refluxed gastric contents. Congratulations again on a thought-provoking presentation.
DR AWAIS: Thank you, Dr Orringer, for your comments and questions.
For your first question, yes, we do on-table endoscopy in all patients. In all 25 patients and anybody who we offer a reflux operation get an on-table endoscopy. Now, I echo your sentiments regarding a 25 EEA stapler. I think we have done a few with a 28 mm stapler, but that depends on the accommodation of the small bowel with the EEA stapler. Sometimes if you drop a 25 EEA in the gastric pouch and you go further downstream and look at the small bowel and you cannot accommodate a 28 mm EEA, you may have a difficult time. So we adopted the approach of doing a 25 EEA. We have seen three strictures in our series of 25. We are extremely aggressive in dilating our patients and look for dysphagia. All our patients have responded to dilation therapy. We do have probably about a 40% rate of dysphagia. But the requirements for more than two dilation are pretty much zero. About 40% of the patients required at least one or two dilations. None of the patients were dilated after two times. Perhaps we can consider and reinvestigate the use of a 28 mm EEA.
DR DANIEL L. MILLER (Atlanta, GA): I was concerned, like Dr Orringer, with regards to your dysphagia. You had almost a 67% dysmotility problem before surgery, and you go on to do this surgery and are leaving the esophagus intact. And then you did not give any data in regards to dysphagia. You have now said 40%. So I think you really have to look at your indication for surgery when there is dysphagia involved and so forth. If not, you're going to come back and have problems on down the road. You need to be more complete in your data. But dysphagia is a very common problem in these patients. I think this might not be the correct operation. Like Dr Orringer said, an esophagectomy, either Ivor-Lewis, high Ivor-Lewis, or a transhiatal would probably be better.
DR AWAIS: Thank you very much for your comments. These are a complex group of patients who had multiple previous operations and prior dilations. In addition they are worked-up extensively preoperatively. We have to tailor the best operation for each patients. We feel if we eliminate all the acid and divert the bile, the esophagus will heal. In regards to the dysphagia, we have to investigate the use of a larger EEA.
DR AHMED M. HALAL (Indianapolis, IN): I'm wondering how many of your patients had Barrett's, and if they do, what options have you given them, considering that esophagectomy will be a difficult option in the future if they progress to severe dysplasia?
DR AWAIS: Well, the issues are reflux and Barrett's. We manage reflux by medication or an antireflux operation. We manage Barrett's by surveillance with endoscopy. So out of these 25 patients, I don't have the exact data on how many had Barrett's, but clearly it's an issue that we have to address on an individual basis. Not all comers who came to us over the 5 year period received a Roux-en-Y operation. Only 13.2% of our patients after a failed Nissen received a Roux-en-Y based on obesity, recurrent symptoms integrity of the vagus nerve and the examination of the cardia intra-operatively. That is consistent with some series.
Dr Claude Deschamps reported a 9.2% conversion rate over a 30-year period, to a Roux-en-Y diversion in their redo fundoplication series. So we are certainly not advocating this operation for all patients, but I think in the obese population in this day and age with recurrent reflux, it's a good option, and you also leave the stomach intact. In case you need an esophagectomy in the future, you always have the stomach as a conduit to be utilized later on. So that is our approach. We certainly do not advocate this over an esophagectomy. I think both are valid options.
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