RESUMO
Background The objective of this study is to demonstrate the safety and feasibility of anti-reflux gastric bypass (ARGB) as a treatment for symptomatic massive paraesophageal hernias (PEH) in the obese population. Both gastroesophageal reflux disease (GERD) and PEH are particularly prevalent in the obese patient population, and obesity adversely affects the long-term outcomes of all anti-reflux procedures. Methods This is a single-center, retrospective review of 17 obese adults who underwent ARGB for the treatment of massive PEH between September 2019 and December 2021. Massive PEH was defined as >5 cm in a singular direction, and obesity as BMI ≥30 kg/m2. Patients without preoperative diagnostic testing were excluded. We reviewed and analyzed patient demographic data, postoperative symptom resolution, weight loss, and complications using descriptive statistics, change from baseline, and comparison of proportions. Results Sixteen of the 17 subjects were female. The median age was 48, and the median BMI was 39.10 kg/m2 (30.0-49.3 kg/m2). The average PEH size on imaging was 6.48 (H) x 6.25 (W) cm. The resolution of heartburn was 93.8% (p<0.001), and the resolution of nausea and vomiting was 80.0%. The mean postoperative length of follow-up was 9.12 months. Median excess body weight loss percentages at one, three, six, and 12 months were 16.43% (p<0.001), 35.92% (p<0.001), 40.64% (p=0.001), and 58.58% (p<0.01), respectively. Five patients experienced adverse events requiring additional intervention or hospitalization. There were no symptomatic hernia recurrences or mortality. Conclusion This study demonstrates that ARGB is feasible and potentially effective in treating symptomatic massive paraesophageal hernias in the obese patient population. Further investigation is needed to determine efficacy and long-term outcomes compared to standard surgical repair.
RESUMO
Introduction: Obesity is a risk factor for gastroesophageal reflux disease (GERD) and hiatal hernia (HH). Fundoplication is the standard operation for GERD with HH. Roux-en-Y gastric bypass (RYGB) is the procedure of choice for obese patients with either GERD or a large HH, but neither are indications for RYGB. To delineate bypass surgery as a treatment option for obese patients with HH and GERD, we propose new terminology, antireflux gastric bypass (ARGB). ARGB differs from RYGB by utilizing varying efferent limb lengths for GERD treatment. We hypothesized that ARGB would have higher GERD resolution, lower HH recurrence, and improves weight loss when compared with fundoplication. Methods: A retrospective cohort study was performed, evaluating patients undergoing repair of large HH (>5 cm) with obesity from January 2013 to February 2021. The primary outcome was GERD resolution, secondary outcomes include HH recurrence and weight loss. Multivariate logistic regression adjusted for age, body mass index (BMI), and hernia size by nonlinear mixed modeling. Results: Forty patients underwent fundoplication, and 16 patients underwent ARGB. Fundoplication patients had a larger mean hernia size (8.7 × 6.3 cm versus 6.6 × 6.4 cm), whereas ARGB patients had a higher BMI (39.2 versus 34.2 kg/m2). Recurrence showed nonstatistically significant lower incidence with ARGB and no significant difference in GERD resolution. Weight (P < .0001) and excess body weight (P < .0001) loss were superior with ARGB. Conclusions: Obese patients with large HHs and GERD treated with ARGB had similar GERD resolution, lower HH recurrence, and improved weight loss when compared with fundoplication. ARGB is an acceptable treatment option for obese patients with a massive paraesophageal hernia in the setting of GERD.
