Is Roux-en-Y gastrojejunostomy an adequate anti-reflux operation after esophagogastric myotomy?

BACKGROUND

Roux-en-Y gastrojejunostomy (RYGJ) is viewed as a salvage operation for fundoplication failure or obesity-related reflux, and we questioned it is long-term effectiveness in patients undergoing esophagogastric myotomy.

METHODS

From an operative report database, we identified 37 patients who underwent a combination of Roux-en-Y gastrojejunostomy and esophagogastric myotomy, and retrospective chart review was performed. Dysphagia was the main presenting symptom, reported in 33 patients (89%), followed by regurgitation in 23 patients (62%) and reflux in 16 patients (43%). Sequence of operations was as follows: Myotomy then revisional Gastro-Jejunostomy (MGJ, N = 16); Concomitant Primary (CP, N = 6); Concomitant Revisional (CR, N = 8); and RYGJ then Myotomy (RM, N = 7). Of the MGJ group, five had Serra Doria esophagocardioplasty.

RESULTS

The median age was 57 years with 76% female. Preoperative BMI > 35 kg/m2 was observed in 18 patients (49%): CP, 100%; CR, 63%; MGJ, 31%; RM, 14%. There were no perioperative leaks or reoperations. The median follow-up was 18 months (range 0 to 146). Esophageal salvage was accomplished in 34 patients (92%). Late reintervention was required in 10 patients (27%). In the MGJ group, two patients required esophagectomy, and three patients underwent reoperation for other indications: one for recurrent hiatal hernia, one for internal hernia, and one for removal of a remnant gastrostomy tube. In the CR group, two patients underwent dilations and one patient received botulinum toxin injection. In RM group, one patient underwent dilation, and one required esophagectomy. Surveillance endoscopy showed no erosive esophagitis in 18/22 patients (82%), and one patient had new Barrett's esophagus. Current proton pump inhibitor (PPI) use was observed in 20 patients (54%). At last follow-up, 26 (69%) of patients were symptom-free. In patients with preop BMI > 35 kg/m2, mean total body weight lost was 20.9%. No group had lower rates of reintervention, esophagitis, or PPI use.

CONCLUSION

Most patients undergoing a combination of RYGJ and myotomy experience relief of their symptoms, with esophageal salvage possible in the majority. RYGJ is an adequate anti-reflux operation after esophagogastric myotomy and offers reasonable weight control in obese patients.