Roux-en-Y Diversion Emerging Alternative To Redos for Failed Fundoplication

—By Ted Bosworth

In patients with gastroesophageal disease who fail laparoscopic fundoplication, Roux-en-Y gastric diversion might no longer be the last resort for treating intractable symptoms, according to two sets of data from experienced surgeons.

Used sparingly for decades, the Roux-en-Y procedure has been widely considered a rescue intervention after repeated fundoplication failures, but recent evidence indicates it might be appropriate at an earlier point in selected patients, according to Sumeet Mittal, MD, the surgical director of the Esophageal and Foregut Program at St. Joseph’s Hospital and Medical Center, in Phoenix.

In patients with a failed fundoplication, the first redo procedure performed by experienced surgeons has a generally acceptable likelihood of a good long-term outcome, Dr. Mittal said. However, the rates of success after a second failure are lower, particularly among obese patients or those with other high-risk characteristics, such as esophageal dysmotility.

Roux-en-Y is associated with a high morbidity rate, but this risk might be explained by a greater likelihood of complications in a population that failed previous surgery, Dr. Mittal said. His series of 43 reoperative procedures from a prospectively maintained database challenge where Roux-en-Y fits into the available options.

“Our data build on the narrative that Roux-en-Y in experienced hands in appropriately selected patients has no more, if not less, morbidity than redo fundoplications,” Dr. Mittal said.

In the series, which Dr. Mittal and his colleagues submitted to the 2020 Digestive Disease Week (abstract 1039), outcomes of 28 patients who underwent redo fundoplication were compared with 15 patients who were treated with Roux-en-Y. Average BMI was higher in the Roux-en-Y group (32.7 vs. 28.6 kg/m²; P=0.01), but other baseline characteristics did not differ significantly. None of the redo patients had undergone more than two previous procedures versus 13% of the Roux-en-Y group.

Intraoperative complications (25% vs. 7%) and postoperative complications (21% vs. 7%) were both numerically more common but not significantly different in the redo fundoplication group, the researchers reported. On the basis of the GERD Health Related Quality of Life Questionnaire score, symptom improvement and level of satisfaction were similar. In both groups, more than 65% reported that they were satisfied with the outcome of the surgery.

Dr. Mittal has published repeatedly on the efficacy of Roux-en-Y as a remedial procedure for failed fundoplication, but this study takes the data a step further by indicating that Roux-en-Y is as safe as redo fundoplication in patients considered at high risk for failure, he said. However, he stressed that surgical expertise is an important factor in these results.

Data from a second series of 101 Roux-en-Y patients, also submitted to the DDW (abstract 1038), support this approach. In this series, patients underwent Roux-en-Y for a failed fundoplication at Mayo Clinic, in Rochester, Minn., between 1995 and 2019.

Although there was no attempt in this series to compare Roux-en-Y with redo fundoplication, the surgery offered acceptable outcomes, according to senior author Barham K. Abu Dayyeh, MD, the director of advanced endoscopy at Mayo.

Of the 97 patients (96%) with GERD symptoms preoperatively, 68 (70.1%) had symptom resolution after surgery.

No surgery-related mortality was observed, but 53.5% of patients had surgical complications. About half of them were of grade III to IV severity.

Veeravich Jaruvongvanich, MD, who collaborated with Dr. Abu Dayyeh, pointed out that redo fundoplication is also associated with a high rate of unfavorable outcomes in high-risk patients, so Roux-en-Y can still be considered “an effective alternative.”

After a median follow-up of 56.2 months, GERD, esophagitis, dysphagia and other symptoms generally resolved, but there were exceptions. For example, five of the nine patients with severe dysphagia prior to surgery still had severe dysphagia afterward.

At 48%, less than half of patients were able to fully discontinue acid blockers following Roux-en-Y. Yet, these outcomes can be considered acceptable in a challenging population, according to Dr. Abu Dayyeh. He called the procedure a reasonable option for patients with intractable symptoms, but said “a careful evaluation by a multidisciplinary foregut team is warranted.”

Dr. Jaruvongvanich reported no relevant financial conflicts of interest. Dr. Mittal reported a financial relationship with Biostage. Dr. Abu Dayyeh reported financial relationships with Apollo Endosurgery, Aspire Bariatrics, Boston Scientific, Endogastric Solutions, Johnson & Johnson, Metamodix and Spatz Medical.