title: Laparoscopic gastric bypass after antireflux surgery for the treatment of gastroesophageal reflux in morbidly obese patients: initial experience.
abstract: BACKGROUND
  Laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been proven effective against gastroesophageal reflux disease (GERD) in morbidly obese patients. We present our experience with revision of antireflux procedures to LRYGBP in obese patients with recurrent GERD, weight gain or a combination of both and discuss the indications and technical considerations involved.
  
  
  METHODS
  Between June 2000 and December 2003, 7 morbidly obese patients with a mean BMI of 37.5 kg/m(2) underwent revision of an antireflux procedure to LRYGBP by our group. Important steps of the revision include dissection of the diaphragmatic crura and gastroesophageal fat pad, reduction and repair of hiatal hernia, and complete take-down of the wrap to avoid stapling over the fundoplication which can create an obstructed, septated pouch.
  
  
  RESULTS
  Mean operative time was 6 hr 12 min and length of stay was 4.8 days. There were 3 major complications postoperatively and no deaths. During follow-up, 5 patients developed anastomotic strictures and 2 patients were re-explored for gastric remnant herniation and intestinal obstruction. At a mean follow-up of 24 (3-44) months, mean excess weight loss was 70.7% and 14/20 (70%) co-morbid conditions were improved or resolved. GERD evaluation with the GERD-HRQL scale showed a significant reduction of GERD scores postoperatively (P =0.006).
  
  
  CONCLUSIONS
  Although LRYGBP after antireflux surgery is a technically more difficult procedure with a higher morbidity, it is feasible and effective for the treatment of recurrent GERD and worsening obesity with the additional advantage of weight loss and improvement of co-morbidities.
authors.affiliation: Department of Surgery, Division of Thoracic and Foregut Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15232, USA. raftopoulosi@upmc.edu
authors.forename: Ioannis
authors.initials: I
authors.lastname: Raftopoulos
authors.forename: Omar
authors.initials: O
authors.lastname: Awais
authors.forename: Anita P
authors.initials: AP
authors.lastname: Courcoulas
authors.forename: James D
authors.initials: JD
authors.lastname: Luketich
mesh_terms: D000328:Adult; D000713:Anastomosis, Roux-en-Y / Q000009:adverse effects / Q000379:methods; D015992:Body Mass Index; D005260:Female; D005500:Follow-Up Studies; D018662:Fundoplication / Q000379:methods*; D015390:Gastric Bypass / Q000009:adverse effects / Q000379:methods*; D005764:Gastroesophageal Reflux / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D011183:Postoperative Complications; D012189:Retrospective Studies; D018570:Risk Assessment; D012494:Sampling Studies; D016896:Treatment Outcome; D015431:Weight Loss