gastroesophageal reflux disease ( gerd ) is one of the most frequently occurring benign functional disorders in western industrial countries .
the effectiveness of laparoscopic antireflux surgery for recalcitrant gerd has been clearly demonstrated in several series .
these laparoscopic results , in combination with a shorter hospital stay and a more rapid return to normal activities , have promoted the emergence of minimally invasive antireflux surgery as the method of choice for the operative management of gerd .
antireflux surgery has a higher failure rate in mo , which is in direct relation to high body mass index .
the increased intraabdominal pressure and the morbid obesity - related comorbidities lead to a higher failure rate of the standard antireflux procedures in this group of patients . over the past 40 years , surgery has become the most effective long - term treatment for morbid obesity .
the national institutes of health during their consensus development conference on gastrointestinal surgery for morbid obesity in 1991 recognized the role of bariatric surgery in the treatment of highly selected , well - informed , motivated patients who are acceptable operative risks and fail or are likely to fail a medical weight loss program .
bariatric operations allow for substantial weight loss , extended weight maintenance , and control or reversal of obesity - related health problems . several series
have now reported that lrygbp improves gerd symptoms , but few have included standardized quality of life tools .
the objective of this study was to evaluate the efficacy of lrygbp as an antireflux procedure on gerd - related symptoms in morbidly obese patients by using a heart - burn - related quality of life score and other standardized outcomes tools .
patients with recalcitrant gerd and a bmi greater than 35 were offered lrygbp or nissen fundoplication . patients who chose lrygbp
an extensive preoperative evaluation , including history and physical examination , the usage of antacid medication and its efficacy , nutritional and psychiatric evaluation , and indicated specialty consultations , was performed before surgery .
all the patients had an upper endoscopy or upper gastrointestinal imaging to document and evaluate their gerd severity and upper gi anatomy .
laboratory evaluation included complete blood count , serum chemistries , and thyroid function testing ; 24-hour ph monitoring was done in select patients .
patient preparation for surgery consisted of a detailed explanation in written and oral form of the developmental aspect of lrygbp and its benefits and risks , including short- and long - term complications , side effects , nutritional sequelae , and the possibility of conversion to the open procedure .
prophylaxis against venous thrombosis and pulmonary embolus consisted of perioperative pneumatic compression devices and low - dose subcutaneous heparin .
data were collected prospectively and verified retrospectively , then entered into a customized computer database .
data sources included office charts , follow - up notes , hospital charts , and patient interview in the outpatient clinic and phone interviews .
parameters included patient demographics , comorbidity , hospital stay , recovery , complications , weight loss , gerd symptoms , and the need for antacids .
quality of life changes and patient satisfaction were evaluated using the heart burn related quality of life ( hrqol ) and sf-36 quality of life questionnaires .
recovery was defined as the number of days after surgery when patients resumed common activities of daily living , such as driving , shopping , household activities , and employment .
follow - up weights were obtained from the university of pittsburgh surgical weight loss clinic scale with a capacity of 400 kg . on occasion
the patient was placed in a supine position with the surgeon on the right and the assistant on the left , and 2 monitors were above the patient 's shoulders .
after creation of carbon dioxide pneumoperitoneum ( 15 mm hg ) using the open hasson technique , cannulas ( u.s .
the operating table was placed in a steep reverse trendelenburg position . to expose the esophagus and stomach , a 5-mm liver retractor ( genzyme , tucker , ga )
was placed through the inferior right subcostal port , and the left lateral segment of the liver was elevated .
gastric pouch creation was performed . to localize the esophagogastric junction and size the pouch ,
then , a window was created in the lesser omentum near the gastric wall at the lesser curvature . the endo gia stapler ( u.s .
surgical ) , 60-mm length and 4.8-mm staples , was inserted and applied 3 or 4 times to staple and cut the gastric pouch with 3 rows of staples on each side
. a smaller staple size ( 3.5 mm ) was later substituted to reduce staple line bleeds at the transected stomach .
the greater omentum and transverse colon were passed to the upper abdomen to expose the ligament of treitz . to create the roux limb , the jejunum was transected with an endo gia ii stapler ( u.s
surgical ) , 45-mm length and 3.5-mm staples , at approximately 50 cm from the ligament of treitz , where a comfortable length of mesentery exists . a smaller staple size ( 2.5 mm )
the jejunal mesentery was then divided with 2 applications of the endo gia ii stapler , using the vascular load ( 45-mm length , 2.0-mm staples ) . a 6-cm length of penrose drain
a window was created in the meso - colon immediately anterior and lateral to the ligament of treitz to gain access to the lesser peritoneal sac .
the roux limb was then passed in a retrocolic retrogastric fashion to lie next to the gastric pouch ( figure 2 ) .
the gastrojejunostomy was then created using the endo gia ii stapler , and the gastrojejunostomy anastomosis was closed with interrupted 20 surgideck suture material ( u.s .
the gastrojejunostomy and enterotomy site were endoscopically inspected and tested for leakage after insufflation and submerging them in irrigation fluid .
the roux limb was then measured 150 to 180 cm distally , and a stapled side - to - side anastomosis was created with the proximal jejunal limb using 1 application of the endo gia stapler ii ( 60-mm length , 3.5-mm staples ) .
the enterotomy sites were stapled closed , and the mesentery of the jejunojejunostomy was sutured closed ( figure 2 ) .
the laparoscopic port placements and their use during the procedure . the completed gastric bypass : gastric pouch - jejunal anastamosis , the jejunojejunostomy , closure of the mesentery .
pain management consisted of morphine patient - controlled analgesia ( pca ) intravenously as needed .
an upper gastrointestinal series was performed on the morning of the first postoperative day using gastrografin followed by barium .
a clear liquid diet was begun that day , and the patient was discharged from the hospital after demonstrating tolerance for the diet and return of bowel function , usually on the second postoperative day .
patient follow - up was scheduled for every 2 months , with laboratory evaluation every 6 months , until weight loss stabilized ( usually 1 to 1.5 years after surgery ) , then twice per year .
all the patients are routinely treated with a low dose of 150 mg / day ranitidine hydrochloride , to prevent anastomotic ulcers .
the patient was placed in a supine position with the surgeon on the right and the assistant on the left , and 2 monitors were above the patient 's shoulders .
after creation of carbon dioxide pneumoperitoneum ( 15 mm hg ) using the open hasson technique , cannulas ( u.s .
the operating table was placed in a steep reverse trendelenburg position . to expose the esophagus and stomach , a 5-mm liver retractor ( genzyme , tucker , ga )
was placed through the inferior right subcostal port , and the left lateral segment of the liver was elevated .
gastric pouch creation was performed . to localize the esophagogastric junction and size the pouch ,
then , a window was created in the lesser omentum near the gastric wall at the lesser curvature . the endo gia stapler ( u.s .
surgical ) , 60-mm length and 4.8-mm staples , was inserted and applied 3 or 4 times to staple and cut the gastric pouch with 3 rows of staples on each side
. a smaller staple size ( 3.5 mm ) was later substituted to reduce staple line bleeds at the transected stomach .
the greater omentum and transverse colon were passed to the upper abdomen to expose the ligament of treitz . to create the roux limb , the jejunum was transected with an endo gia ii stapler ( u.s
surgical ) , 45-mm length and 3.5-mm staples , at approximately 50 cm from the ligament of treitz , where a comfortable length of mesentery exists . a smaller staple size ( 2.5 mm )
the jejunal mesentery was then divided with 2 applications of the endo gia ii stapler , using the vascular load ( 45-mm length , 2.0-mm staples ) .
a 6-cm length of penrose drain was sewn to the end of the roux limb using the endostitch ( u.s .
a window was created in the meso - colon immediately anterior and lateral to the ligament of treitz to gain access to the lesser peritoneal sac .
the roux limb was then passed in a retrocolic retrogastric fashion to lie next to the gastric pouch ( figure 2 ) .
the gastrojejunostomy was then created using the endo gia ii stapler , and the gastrojejunostomy anastomosis was closed with interrupted 20 surgideck suture material ( u.s .
the gastrojejunostomy and enterotomy site were endoscopically inspected and tested for leakage after insufflation and submerging them in irrigation fluid .
the roux limb was then measured 150 to 180 cm distally , and a stapled side - to - side anastomosis was created with the proximal jejunal limb using 1 application of the endo gia stapler ii ( 60-mm length , 3.5-mm staples ) .
the enterotomy sites were stapled closed , and the mesentery of the jejunojejunostomy was sutured closed ( figure 2 ) .
the laparoscopic port placements and their use during the procedure . the completed gastric bypass : gastric pouch - jejunal anastamosis , the jejunojejunostomy , closure of the mesentery .
pain management consisted of morphine patient - controlled analgesia ( pca ) intravenously as needed .
an upper gastrointestinal series was performed on the morning of the first postoperative day using gastrografin followed by barium .
a clear liquid diet was begun that day , and the patient was discharged from the hospital after demonstrating tolerance for the diet and return of bowel function , usually on the second postoperative day .
patient follow - up was scheduled for every 2 months , with laboratory evaluation every 6 months , until weight loss stabilized ( usually 1 to 1.5 years after surgery ) , then twice per year .
all the patients are routinely treated with a low dose of 150 mg / day ranitidine hydrochloride , to prevent anastomotic ulcers .
from february 1999 to april 2001 , 57 patients with a median bmi of 43 underwent attempted lrygbp at the thoracic division of the university of pittsburgh medical center .
patient demographics ( n=57 ) hiatal hernia or esophagitis , or both , were present in 48 patients ; barrett 's esophagus was documented in 2 .
lrygb was possible in 52 patients ; 5 required open conversion , 3 due to multiple adhesions and 2 for poor exposure .
complications included 1 leak , 1 pulmonary emboli , 2 reoperations for internal roux intestinal limb hernia , and 7 gastrojejunal strictures , which were treated with endoscopic dilatations , average of 1 postoperative dilatation ( range , 1 to 3 ) .
no deaths occurred . at a mean follow - up of 18 months ( range , 3 to 30 ) , all patients report improvement or no symptoms of gerd and a mean weight loss of 40 kg ( range , 16 to 70 ) .
previous and current antacid medication usage is summarized in table 2 . before and after surgery antacid medication usage quality of life scores ( sf-36 ) were above national norms for physical and mental components ( median=55 , mode=50 ) .
the gerd - health related quality of life median score was < 1 ( scale , 0 to 45 , 0=asymptomatic , 45=worse ) ( table 3 ) .
excessive body weight is a significant independent risk factor for a hiatal hernia and is significantly associated with esophagitis .
fisher et al demonstrated a correlation between both weight and body mass index with gastroesophageal reflux . since the early 1990s
, the status of laparoscopic antireflux surgery has moved from experimental to routine , with large experiences now reported by many centers .
furthermore , the outcome in the majority of patients undergoing surgery is good , with relief of reflux symptoms in about 90% of the patients .
laparoscopic surgery for the correction of gastroesophageal reflux has become common throughout the western world , partly because of better patient acceptance due to a perception that surgical procedures are now less invasive and also because of an apparently increasing incidence of reflux presenting as a clinical problem .
our series of patients is the first description and evaluation of the lrygbp as an antireflux procedure .
previously , it was reported that one of the major morbidities after ring vertical gastroplasty is severe acid reflux ; the roux - en - y gastric bypass suggests a solution to this complication although it has never been studied from the perspective of treating gastroesophageal reflux disease .
all the patients in this study had symptomatic gerd , and they opted to be treated with lrygbp to address the initial gerd problem and the other comorbidities associated with their morbid obesity .
they were all treated with low - dose ranitidine hydrochloride postoperatively to prevent anastomotic ulcers ; however , the dosage used is nontherapeutic for gerd symptoms .
the use of antacid medications after the surgery was in less than 10% of the patients , and all of these were on a lower dosage than that prior to the surgery .
all our patients were refractory to medical treatment before surgery , and 53% were on a high dosage and a conventional dosage of proton pump inhibitors .
all the patients were interviewed , and the heartburn - related symptoms were recorded . according to our results , all were free of gerd symptoms after the operation , and it was not always correlated to their excess body weight lost .
our result may suggest that the antireflux mechanism of this surgery is a combination of acid reflux reduction due to gastric stapling or gastroplasty and the reduction of increased intraabdominal pressure by reduction of excess body weight resulting in lower intraabdominal pressure .
thoracic surgeons with laparoscopic expertise should consider lrygbp for treatment of gerd in the mo .
 background and objectives : gastroesophageal reflux disease ( gerd ) is commonly associated with morbid obesity ( mo ) . 
 antireflux surgery has a higher failure rate in mo and addresses only one of the comorbidities present . 
 this paper reviews the results of laparoscopic rouxen - y gastric bypass ( lrygbp ) performed for recalcitrant gerd in mo.methods:patients with recalcitrant gerd and a body mass index ( bmi)>35 undergoing lrygbp were included . 
 lrygb included crural repair , creation of a small gastric pouch ( 30 ml ) , and intestinal bypass ( 150 to 180 cm ) . 
 all patients were followed in clinic and by telephone.results:from february 1999 to april 2001 , 57 patients ( 51 f , 6 m ) with a mean age of 43 ( range , 22 to 67 ) and a median bmi of 43 underwent lrygbp . 
 hiatal hernia or esophagitis , or both , were present in 48 , barrett 's in 2 . 
 lrygbp was possible in 52 patients ; 5 required open conversion . 
 the median hospital stay was 3 days . 
 complications included 1 leak , 1 pulmonary emboli , 2 reoperations for internal roux limb hernia , and 7 gastrojejunal strictures . at a mean follow - up of 18 months ( range , 3 to 30 ) , all patients report improvement or no symptoms of gerd and a mean weight loss of 40 kg ( range , 16 to 70 ) . 
 quality of life scores ( sf-36 ) were above national norms for physical and mental components ( median 55 , norms=50 ) . 
 gerd - health related quality of life median score was < 1 ( scale , 0 to 45 , 0=asymptomatic , 45=worse).conclusion : lrygbp was effective for recalcitrant gerd in mo . 
 lrygbp also led to weight loss and improvement in other comorbidites . 
 surgeons with minimally invasive expertise should consider lrygbp for treatment of gerd in the morbidly obese . 
INTRODUCTION
METHODS
Surgical Technique
RESULTS
DISCUSSION
CONCLUSION