From Nissen Fundoplication to Roux-en-Y Gastric Bypass to Treat Both GERD and Morbid Obesity.

Abstract

Gastroesophageal reflux disease (GERD) is common in obese individuals in around 30%. While fundoplication is the treatment of choice in non-obese individuals with GERD resistant to medical treatment, the laparoscopic Roux-en-Y gastric bypass (LRYGB) is the most effective option in the setting of morbid obesity to treat at the same time both GERD and obesity. We present the case of a 31-year-old woman with a BMI of 37 kg/m2 who underwent an open Nissen fundoplication in 2010 and surgical revision in 2012 with redo of the Nissen fundoplication. She consulted for dysphagia and obesity complicated by invalidating arthrosis. A barium swallow showed esophageal dilatation and cardial stenosis. Manometry revealed incomplete waves and high pressure at the lower esophageal sphincter. We decided to convert the Nissen fundoplication to Roux-en-Y gastric bypass (RYGB). In this video, we show how to revise Nissen fundoplication to RYGB. The intervention starts by complete dissection of the gastric valve and the hiatal region from right to left. Then, a short gastric pouch is created taking care to exclude the gastric fundus that is also partially resected. We perform a hand-sewn gastro-jejunal anastomosis slightly larger than for conventional bypass. A RYGB with 50-cm bilio-pancreatic and 150-cm alimentary limb is then performed. Conversion of Nissen fundoplication to RYGB allows treatment of dysphagia, which may represent a complication of the fundoplication, and is effective for management obesity and GERD. In this video we show important technical steps of this procedure.