Background

Gastroesophageal reflux disease (GERD) and hiatal hernia (HH) are pervasive in the population with obesity; recurrence after fundoplication occurs in up to 15% of patients and poses a clinical challenge. Roux-en-Y gastric bypass (RYGB) is highly effective treatment for GERD in patients with obesity. In the setting of prior fundoplication, preservation of anti-reflux anatomy is safe while reversal is associated with increased complications. We present a patient with obesity and recurrent, refractory reflux after several revisional anti-reflux surgeries.

Methods

A 50-year-old woman with body mass index (BMI) of 33kg/m2 presented with progressive dysphagia and regurgitation while supine. Her surgical history included laparoscopic Nissen fundoplication 17-years prior, revisional fundoplication with HH repair 15-years ago complicated by posterior esophageal perforation. She underwent RYGB with preservation of fundoplication 7-years prior. High-resolution manometry reported absent peristalsis with normotensive lower esophageal sphincter while cross-sectional imaging revealed migration of the fundoplication. Endoscopy revealed esophagitis, intact fundoplication, and 9cm gastric pouch. Concomitant pH studies confirmed 17% acid exposure time while supine. She underwent revision HH repair, fundoplication reversal, anterior truncal vagotomy, and revision of the gastric pouch and gastrojejunostomy. Operative time was <4 hours with no postoperative complications beyond 4-day length of stay. At 3-months, she denied dysphagia or reflux, and lost 21 pounds (BMI 29kg/m2).

Conclusions

Refractory reflux and recurrent HH is a challenging problem in patients with obesity and prior revisional surgeries. Re-operative anti-reflux surgery with fundoplication reversal and parietal cell separation was safe and effective.