Hill procedure for recurrent GERD post-Roux-en-Y gastric bypass.
BACKGROUND
Roux-en-Y gastric bypass (RYGB) is considered to be an optimal surgical treatment option for GERD in the morbidly obese patient. Nevertheless, a subgroup of patients suffer from recurrent or persistent GERD after their gastric bypass. Unfortunately, limited treatment options are available in these patients. Fundoplication via mobilization of the remnant stomach and radiofrequency treatment of the lower esophageal sphincter have been described with some success. Our objective is to illustrate a safe and durable surgical option in the treatment of patients with medically refractory GERD post-RYGB.


METHODS
After placing five trocars in the usual position for a foregut laparoscopic surgery, a lysis of adhesions and standard dissection of the hiatus is performed. The anterior and posterior vagal nerves associated phrenoesophageal tissue bundles are identified. A primary crural repair with interrupted nonabsorbable sutures is performed. Four full-length nonabsorbable sutures are placed sequentially through the anterior and posterior phrenoesophageal bundle, posterior fundus and finally through the pre-aortic fascia. The repair is calibrated on a 44 French bougie. The sutures are tied from medial to lateral in the order of their placement under endoscopic guidance.


RESULTS
No peri-procedural complications were encountered. Standard post-antireflux surgery clinical follow-up with the patient completing a validated GERD clinical questionnaire at 1 and 6 months after the surgery demonstrated excellent GERD symptom control without any dysphagia. A pH study and EGD performed at 6 months post-Hill procedure show the absence of pathological reflux with an intact Hill mechanism.


CONCLUSIONS
The Hill procedure is a valid treatment for the post-bariatric surgical patient with GERD in which the gastric fundus is absent or inaccessible thus eliminating standard fundoplication as a reasonable option. This also represents a safe and durable treatment of GERD in this uniquely challenging patient population.
Department of Surgery, Providence Portland Medical Center, 3805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA.
Radu
R
Pescarus
Foundation for Surgical Innovation and Education, 4805 NE Glisan St., Suite 6N60, Portland, OR, 97213, USA.|Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, 3805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA.
Ahmed M
AM
Sharata
Foundation for Surgical Innovation and Education, 4805 NE Glisan St., Suite 6N60, Portland, OR, 97213, USA.|Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, 3805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA.|Department of Surgery, Providence Portland Medical Center, 3805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA.
Christy M
CM
Dunst
Department of Surgery, Providence Portland Medical Center, 3805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA.
Eran
E
Shlomovitz
Foundation for Surgical Innovation and Education, 4805 NE Glisan St., Suite 6N60, Portland, OR, 97213, USA.|Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, 3805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA.|Institut Hospitalo Universitaire Strasbourg, 1, Place de l'Hôpital, 97000, Strasbourg, France.
Lee L
LL
Swanström
Foundation for Surgical Innovation and Education, 4805 NE Glisan St., Suite 6N60, Portland, OR, 97213, USA. Kreavis@orclinic.com.|Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, 3805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA. Kreavis@orclinic.com.|Legacy Weight and Diabetes Institute, 1040 NW 22nd Ave. Ste 520, Portland, OR, 97210, USA. Kreavis@orclinic.com.
Kevin M
KM
Reavis
D005500:Follow-Up Studies; D018662:Fundoplication / Q000379:methods*; D015390:Gastric Bypass / Q000009:adverse effects / Q000379:methods; D005748:Gastric Fundus / Q000601:surgery; D018530:Gastric Stump / Q000601:surgery; D005764:Gastroesophageal Reflux / Q000601:surgery*; D006801:Humans; D009767:Obesity, Morbid / Q000601:surgery*; D011183:Postoperative Complications / Q000601:surgery*; D012008:Recurrence; D012086:Reoperation; D016896:Treatment Outcome
Antireflux surgery; GEJ reconstruction; GERD; Hill procedure; Post-RYGB; Post-fundectomy; Short esophagus