Several studies mention the use of gastric bypass as an alternative and superior technique for morbidly obese patients who present with primary GE reflux disease.44,45 Perez et al.46 identified a higher rate of recurrent reflux in obese patients undergoing laparoscopic Nissen fundoplication compared with their normal-weight cohorts. Applying this theory to patients with recurrent symptoms, Heniford et al.25 described using the Roux-en-Y gastric bypass in obese patients with recurrent reflux symptoms after failed anti-reflux surgery. Patients should meet the National Institutes of Health 1991 Consensus criteria of a body mass index (BMI) >40 or >35 when associated with significant comor-bidities. They must have also tried and failed multiple diets. If the recurrent reflux patient meets these criteria, a gastric bypass should be offered rather than simply revising the previous fundoplication.
Laparoscopic gastric bypass is performed with the patient in a split-legged position. Pre-operative DVT prophylaxis and antibiotics are given and a Foley catheter is placed. Five ports are placed as seen in Figure 11.8. The original wrap is taken down completely. Once this is accomplished, a 15- to 30-cc pouch is created based on the lesser gastric curve. This can be performed with an EEA anvil, by visualization, or by using a 36-French orogastric tube. Next, the jejunum is divided approximately 20-30cm from the ligament of Trietz. A 75- to 150-cm Roux limb is measured and a jejunojejunostomy is created with the EndoGIA stapler. Some surgeons base the Roux limb lengths on preopera-tive BMI with BMI >50 necessitating a 150-cm Roux limb and a BMI <50 receiving a 100-cm Roux limb. Other surgeons use the same Roux limb length in every case. The Roux limb is passed antecolic or retrocolic. If an antecolic route is used, the omentum must be divided to ensure a tension-free anastomosis. If the limb is positioned retrocolic, the mesenteric defect is closed with running, nonabsorbable suture to prevent internal herniation through the meso-colic window.
The gastrojejunostomy can be created using the circular stapler, the linear stapler, or a hand-sewn technique. The final anatomy is detailed in Figure 11.9. An intraoperative leak test is performed with either air or methylene blue dye. Because leaks are more prevalent in reoperative surgery, placement of a drain is recommended.
REOPERATION FOR FAILED ANTI-REFLUX SURGERY
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