Hill procedure for recurrent GERD post-Roux-en-Y gastric bypass.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) is considered to be an optimal surgical treatment option for GERD in the morbidly obese patient. Nevertheless, a subgroup of patients suffer from recurrent or persistent GERD after their gastric bypass. Unfortunately, limited treatment options are available in these patients. Fundoplication via mobilization of the remnant stomach and radiofrequency treatment of the lower esophageal sphincter have been described with some success. Our objective is to illustrate a safe and durable surgical option in the treatment of patients with medically refractory GERD post-RYGB. METHODS: After placing five trocars in the usual position for a foregut laparoscopic surgery, a lysis of adhesions and standard dissection of the hiatus is performed. The anterior and posterior vagal nerves associated phrenoesophageal tissue bundles are identified. A primary crural repair with interrupted nonabsorbable sutures is performed. Four full-length nonabsorbable sutures are placed sequentially through the anterior and posterior phrenoesophageal bundle, posterior fundus and finally through the pre-aortic fascia. The repair is calibrated on a 44 French bougie. The sutures are tied from medial to lateral in the order of their placement under endoscopic guidance. RESULTS: No peri-procedural complications were encountered. Standard post-antireflux surgery clinical follow-up with the patient completing a validated GERD clinical questionnaire at 1 and 6 months after the surgery demonstrated excellent GERD symptom control without any dysphagia. A pH study and EGD performed at 6 months post-Hill procedure show the absence of pathological reflux with an intact Hill mechanism. CONCLUSION: The Hill procedure is a valid treatment for the post-bariatric surgical patient with GERD in which the gastric fundus is absent or inaccessible thus eliminating standard fundoplication as a reasonable option. This also represents a safe and durable treatment of GERD in this uniquely challenging patient population.

Residual fundus or neofundus after laparoscopic sleeve gastrectomy: is fundectomy safe and effective as revision surgery?

INTRODUCTION: Up to 30 % of patients who have undergone laparoscopic sleeve gastrectomy require revision surgery for inadequate weight loss, weight regain, and/or the development of severe upper gastrointestinal symptoms. The aim of this retrospective study was to evaluate the safety and efficacy of laparoscopic fundectomy (LF) in cases of a residual fundus/neofundus development regarding GERD symptoms. METHODS: The study group comprised 19 patients (17 female; mean BMI 35.4 kg/m(2)) divided into 2 groups. Group A (n = 10) patients with severe GERD and evidence of residual fundus/neofundus, Hiatal hernia with good results in terms of weight loss. Group B (n = 9) patients with severe GERD, a residual fundus/neofundus, inadequate weight loss or weight regain. Fundectomy was indicated when a residual fundus/neofundus was associated with severe GERD symptoms. The presence of a residual fundus/neofundus was assessed by a barium swallow and/or multislice computed tomography. RESULTS: No mortality or intra-operative complications occurred. Five postoperative complications occurred: 2 cases of bleeding, 1 mid-gastric stenosis and 2 leaks (10.5 %). All patients experienced improvements in their GERD symptoms and stopped PPI treatment. Group B exhibited an additional %EWL of 53.4 % at 24 months. CONCLUSION: LF and cruroplasty is feasible and has good results in terms of GERD symptoms control and additional weight loss. The high rate of postoperative complications observed in this series remains a matter of concern. A re-sleeve procedure might be considered as an alternative to RYGB/DS conversion restricted to selected patients.

Revision of Mason's procedure (vertical banded gastroplasty) to Roux-en-Y gastric bypass: role of an associated fundectomy in weight loss outcomes.

BACKGROUND: Vertical banded gastroplasty (VBG) presents a significant rate of long-term complications, and revisions are often necessary. Conversion to Roux-en-Y gastric bypass (RYGB) seems to be preferred, but literature data remain limited. OBJECTIVES: To analyze the indications, safety, results of conversions from VBG to RYGB, and to identify predictive factors of success or failure. SETTING: Two specialized centers of bariatric surgery. METHODS: This bicentric retrospective study included all the patients who benefited from a conversion from VBG to RYGB between 2008 and January 2020. Demographic characteristics, indications, preoperative workups, intraoperative data, complications, and weight loss results were analyzed. RESULTS: During the study period, 85 patients underwent a conversion to RYGB. The mean body mass index (BMI_ before conversion was 40.6 kg/m2. 82.3% of the patients were converted because of weight loss failure and 17.6% because of a complication of their VBG. The global rate of complications was 25%. After an average follow-up of 35 months and a rate of loss to follow-up of 33%, the mean BMI was 33.5 kg/m. The weight loss success rate according to Reinhold's criteria was 64.7%, and resolution of complications was obtained in 89.1%. The association of a fundectomy was a predictive factor of weight loss (odds ratio, .27; P = .04), whereas primary failure of the VBG was a predictive factor of failure. CONCLUSION: Conversion from VBG to RYGB remains the procedure of choice to achieve satisfying weight loss and resolution of functional complications. The addition of a fundectomy appeared to have a significant positive impact on weight loss outcomes.

Laparoscopic Gastric Bypass with Fundectomy and Gastric Remnant Exploration (LRYGBfse): Results at 5-Year Follow-up.

BACKGROUND: The laparoscopic Roux-en-Y gastric bypass (LRYGB) is the gold standard treatment for morbid obesity. After LRYGB, the endoscopic access to the gastric remnant and pancreaticobiliary system is challenging. The laparoscopic gastric bypass with fundectomy and exploration of the gastric remnant (LRYGBfse) was introduced in an attempt to overcome this limitation. The purpose of this study was to analyze the medium-term outcomes and safety of LRYGBfse. METHODS: Observational prospective single-arm multicenter cohort study. Patients with BMI > 35 kg/m2 were included. Previous open abdominal surgery was an exclusion criterion. Postoperative 1, 2, 3, and 5-year weight loss, BMI decrease, and percentage of excess weight loss (%EWL) were recorded. Wilcoxon signed rank sum test was used for paired data. RESULTS: Among 653 enrolled patients, 229 completed the 5-year follow-up. Preoperative median body weight (kg) and BMI (kg/m2) were 133.4 kg (interquartile range (IQR) = 12.0) and 48.2 kg/m2 (IQR = 10.1), respectively. Median 5-year body weight, BMI, and %EWL were 83.7 (IQR = 17.3), 31.2 (IQR = 7.7), and 74.8 (IQR = 23.4), respectively, all significantly improved compared to baseline (p = 0.002, p = 0.001, and p = 0.012, respectively). Comorbid improvement or resolution was observed in 88% of the patients. No major intraoperative complications were reported. Postoperative overall morbidity and mortality rates were 1 and 0%, respectively. Banding removal was necessary in one patient 62 months after the index operation. CONCLUSIONS: The LRYGBfse seems safe and effective with durable results at 5-year follow-up. Endoscopic exploration of the gastric remnant is an additional valuable tool.

Uterine Fundectomy in Patients With Benign Etiology Undergoing Hysterectomy: New Surgical Technique.

BACKGROUND: Hysterectomy is the most common surgical procedure in gynecology, not only in cases of malignancies but also in many benign cases. Many uterine preservation techniques have been introduced as alternatives to hysterectomy. OBJECTIVE: We aimed to propose a new uterine surgical procedure. In this paper, we compare the utility of this new technique to the limitations of current procedures. METHODS: Uterine fundectomy may be considered as a subtotal hysterectomy. In this new technique, the uterine fundus including all pathologic tissue is cut as a reverse trapezoid by monopolar cautery. The upper side of the trapezoid, which includes the whole uterine fundus, is removed, but the fallopian tubes and cornual segment are preserved. A small uterine cavity remains, as well as the endometrial tissue lining it. RESULTS: Patient recruitment for this study began in April 2017 and is expected to end approximately 12 months later. Assessment of the primary outcomes is expected to take place in April 2018. CONCLUSIONS: Uterine preservation is particularly critical in developing new surgical approaches that can lead to a positive impact on patient satisfaction. This protocol outlines the first attempt to prospectively test surgical fundectomy in candidates for hysterectomy for benign indications.

Vertical Gastric Bypass with Fundectomy: Feasibility and 2-Year Follow-Up in a Series of Morbidly Obese Patients.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) is the gold standard procedure for morbid obesity and its results are well known and largely discussed. The major limitation of the procedure is the difficult exploration of the excluded gastric pouch and duodenum. The vertical gastric bypass with fundectomy was recently introduced in attempt to overcome these limitations. To date, its effectiveness is debated and outcomes still unclear. The purposes of this study were to describe the vertical gastric bypass with fundectomy and to analyse its outcomes in term of weight loss, complications, and comorbid resolutions. MATERIAL AND METHODS: Since January 2012 to July 2014, 30 consecutive patients were enrolled and prospectively followed for a 24-month period. All patients underwent the vertical gastric bypass with fundectomy. Follow-up visits were scheduled at 7 days, 1, 6, 12, and 24 months, or whenever necessary. RESULTS: Overall, 24 women and six men were enrolled in the study. Mean preoperative BMI was 38.2 ± 8.5 kg/m2. No intraoperative complications were reported. Postoperative overall complication rate was 10%. Compliance to the 24-month follow-up was 100%. Mean BMI and excess weight loss (EWL%) were significantly lower compared to baseline (p < 0.05). Comorbid improvement or resolution was recorded in the 80% of the patients. CONCLUSIONS: Vertical gastric bypass with fundectomy is feasible and effective with similar results in terms of weight loss, complications, and comorbid improving compared to the classic RYGB. Complete evaluation of the gastric anatomy and easy access to the main duodenal papilla are unquestionable advantages.

Long Term Result of Periesophagogastric Devasculorization in Gastric Fundal Variceal Bleeding

PURPOSE: Gastric variceal bleeding in cirrhotic patient is an emergent, life threatening disease of which the adequate treatment is still in dispute. The periesophagogastric devascularization (PD) would be the alternative operative procedure. The aim of this study is to evaluate the safety and long-term results of PD for the gastric fundal variceal bleeding. METHODS: A retrospective analysis was made of fifty-two patients with gastric variceal bleeding who underwent PD with or without fundectomy from August 1994 to March 2006. We evaluated the clinical characteristics, operative morbidity, mortality and long-term follow up results. RESULTS: The operative morbidity was 34.9% and overall mortality was 17.3%. The Child-Pugh classification at operation, the number of previous varix bleeding episode, the success of preoperative intervention, splenectomy, esophageal transection, and ongoing bleeding at operation had a significant effect on postoperative mortality. Most common cause of postoperative death was hepatic failure. Child-Pugh classification and esophageal transection were significant risk factor for postoperative mortality comparing before and after year 2001. During the mean follow-up period of 33.58+/-27.08 months, there was no recurrent bleeding from gastric varices. The cumulative 5-year survival rate was 64.1%. 0f 14 patients deceased, 6 patients died of hepatocellular carcinoma. Not only there was no death caused by recurrent variceal bleeding, but there was no recurrent gastric variceal bleeding. Hepatic functional reserve and concomitant hepatocellular carcinoma were the most important prognostic factors in the long term survival by multiple regression analysis. CONCLUSION: We concluded that PD reached both low postoperative mortality and recurrent bleeding rate with good long-term survival. So it could be one of the most effective treatment for the gastric fundal variceal bleeding.

Perigastric Devascularization with or without Fundectomy for Gastric Variceal Bleeding

PURPOSE: Catastrophic bleeding of the gastric varices has been considered a life threatening emergency. Sclerotherapy cannot easily control the bleeding, and there is a high risk of rebleeding despite successful intervention. Surgery is often necessary to save the life. The purpose of this study was to elucidate the role of surgery and analyze the factors determining operative mortality in gastric variceal bleeding. METHODS: A retrospective study was performed of 30 patients who underwent operation for gastric variceal bleeding with portal hypertension at Ewha Womans University Mok-Dong Hospital from Jul. 1994 to Feb. 2001. Among them, 23 patients received perigastric devascularization with fundectomy and the remainder received perigastric devascularization alone. RESULTS: There was one case of recurrent bleeding from esophageal varix at 8 months postoperative. This was controlled with sclerotherapy. The overall operative mortality rate was 30.0%. Preoperative hepatic functional reserve was a significant factor. The mortality rate was 0% (0/5) in Child-Pugh group A, 27.8% (5/18) in group B, and 57.1% (4/7) in group C (p<0.05). The preoperative success of intervention influenced postoperative outcomes. There was no mortality in the successfully controlled group (0/5). In the failure group, 5 of 7 patients expired (p<0.05). Preoperative transfusion amount was also a significant factor in determining survival. There was 15.8% (3/19) mortality rate in patients trans fused less than 10 units, and a 54.5% (6/11)rate in those receiving more than 10 units (p<0.05). CONCLUSION: This operative approach was effective for saving lives from an otherwise uniformly fatal disease. The rebleeding rate at the follow-up period was low. Proper selection of patients and an early surgical decision could lower the operative mortality.