Vagotomy, Antrectomy, and Roux-en-Y Diversion for Complex Reoperative Gastroesophageal Reflux Disease

Abstract

ObjectiveFailure of conventional surgical therapy for treatment of patients with gastroesophageal reflux disease (GERD) taxes the ingenuity of the esophageal surgeon. This study defines the role of vagotomy, antrectomy, and Roux-en-Y diversion coupled, when necessary, with resection of the esophagogastric junction as an alternative to other surgical procedures currently employed for these complicated cases. Summary Background DataCurrently, the operation in question rarely is performed in the United States. Other procedures, such as interposition of short or long segments of intestine and total esophagectomy with gastric pull-up, are preferred. However, surgeons from Scandinavia, Great Britain, and Europe have published widely on the subject, some even preferring its use as a primary procedure in GERD. MethodsThis report reviews the indications and results of the operation in 36 patients who underwent operation between January 1970 and January 1994. Follow-up evaluation was available for review in 33 patients observed from 1 to 20 years postoperatively (average, 6 2A years). Of these patients, 32 had undergone 66 previous operative procedures on the distal esophagus and stomach ranging from 1 to 6 per patient. There were no hospital deaths, but complications developed in nine patients (25%); only half of these complications were major. Of patients available for follow-up, 85% were improved by the operation, 24 of the 33 having excellent or good results. ConclusionsThe operation of vagotomy, antrectomy, and Roux-en-Y diversion, embodying the principles of acid suppression and alkaline diversion, has proved to be a successful alternative to other operative procedures currently favored in the United States for the treatment of the complex reoperative patient with GERD. 536

Results of surgical treatment for recurrent postoperative gastroesophageal reflux

“…[74][75][76] Ellis et al, 77 in 1996, reported on 101 patients reoperated on for recurrence of esophagitis, and suggested that the best choice is the acid suppression-bile diversion procedure. In our experience, and in agreement with other publications, this alternative appears to be the best and gives the most permanent results [78][79][80] in comparison with the classic fundoplication or its variants such as the Collis-Nissen, Belsey-Collis, or Thal-Nissen procedures. 81 Partial esophageal resections with esophagus gastroanastomosis, colon interposition, or total esophagectomy are operations that have been indicated by other authors for patients with complicated Barrett's esophagus with non-dilatable strictures.…”

Results of laparoscopic reoperation for failed antireflux surgery: does the indication for redo surgery affect the outcome?

“…We have now performed this with success on three occasions with good results (one of these is from this series with a preoperative Visick IV, Table 3) after this redo surgery she is now Visick I. 21,22 There were three of 35 (12%) who required a second reoperation which is similar to the frequency that is reported by the Emory group. 17 While we accept that a follow-up of a year may give a false impression of results, in common with surgeons from Atlanta, we have found it difficult to obtain follow-up greater than 1 year in meaningful numbers of patients.…”

“…For those few patients who have continued, documented reflux following redo laparoscopic antireflux surgery, antrectomy and Roux‐en‐Y reconstruction may be an alternative to further attempts at hiatal surgery, reducing the risk of iatrogenic visceral injury. We have now performed this with success on three occasions with good results (one of these is from this series with a preoperative Visick IV, Table 3) after this redo surgery she is now Visick I 21,22 . There were three of 35 (12%) who required a second reoperation which is similar to the frequency that is reported by the Emory group 17 .…”

Nonesophageal side-effects after antireflux surgery plus acid-suppression duodenal diversion surgery in patients with long-segment Barrett’s esophagus*

“…9,10 Many have employed this operation as a solution after recurrence of symptoms following a classic antireflux operation (360 Nissen fundoplication or cardial calibration with posterior gastropexy) or in selected patients with ulcer or strictures as complications of reflux esophagitis. [11][12][13][14][23][24][25] This procedure has been used as a primary operation for complicated Barrett's esophagus by Fekete and others with excellent results. [26][27][28][29] Washer et al prospectively compared Nissen fundoplication versus antrectomy plus Roux-en-Y gastrojejunostomy in patients with severe esophagitis and reported good results in 65% after Nissen fundoplication versus 95% after acid suppression bile diversion techniques (P < 0.01).…”

“…The results of several recent prospective studies suggest that the acid‐suppression duodenal diversion surgery abolishes acid and duodenal reflux into the esophagus and gives excellent results in patients with long‐segment Barrett's esophagus 9,10 . Many have employed this operation as a solution after recurrence of symptoms following a classic antireflux operation (360 Nissen fundoplication or cardial calibration with posterior gastropexy) or in selected patients with ulcer or strictures as complications of reflux esophagitis 11–14,23–25 . This procedure has been used as a primary operation for complicated Barrett's esophagus by Fekete and others with excellent results 26–29 .…”