Transoral Incisionless Fundoplication after Band Removal
A 53 year -old female patient presented to Houston Heartburn and Reflux Center with severe GERD related symptoms of several year duration. She had a Lap Band placed for morbid obesity around 10 years ago. Patient had been over-restricted in hopeless attempt to promote weight loss resulting in pseudo-achalasia, hiatal hernia development and GERD. Subsequently, her Lap Band was removed, and a concomitant sleeve gastrectomy was performed. Following surgery, patient did not lose weight and her GERD related symptoms got worse. She was evaluated by a gastroenterologist who elected to perform Transoral Incisionless Fundoplication, TIF, to manage her GERD. TIF was completed but patient acid reflux symptoms persisted.
I have discussed in several previous blogs the need to stage band removal and sleeve gastrectomy. I will not discuss this point in this current blog. I am going to concentrate on GERD management following Lap Band removal especially in light of esophageal dysmotility. Pseudo-achalasia secondary to Lap Band over-restriction is a serious problem with complicated pathophysiology. Blind application of novel anti-reflux modalities of dubious efficacy is better avoided. TIF has not been studied in patients with pseudo-achalasia and hiatal hernia formation secondary to over-restriction. In fact, TIF is barely effective for early stages of GERD in patients with normal esophageal motility. TIF neither restores normal anatomy like a hiatal hernia repair, nor it creates an anti-reflux barrier like a Nissen fundoplication. Indeed, TIF is a misnomer since it does not result in any form of a fundoplication; the gastric fundus remains in place following TIF.
Repeat upper endoscopy on our patient showed multiple loose T shaped fasteners in the cardia, large hiatal hernia and distal esophagitis. The angle of His was obliterated and whatever TIF is supposed to have achieved was no longer present. Endoscopy further demonstrated a large retained gastric fundus with preserved antrum and a good part of the distal gastric body. The last finding explains poor weight loss.
Redo sleeve gastrectomy with hiatal hernia repair is a great solution. This approach however has not been evaluated in the presence of pseudo-achalasia. I am concerned of incomplete reflux control with poor esophageal function. Furthermore, TIF spikes around the cardia prevent proper fundus resection with a linear stapler and increase the risk of leak. Hiatal hernia repair with gastric bypass is a great option. Insurance may not approve the bariatric portion especially if BMI is less than 35. A third option is hiatal hernia repair with Toupet fundoplication especially that a large portion of the gastric fundus was not resected. Patient chose the latter approach and underwent the procedure with no complications. Intra-operatively, moderate to severe adhesions around the GEJ were encountered secondary to TIF spikes. Post-operatively, patient reported complete GERD symptom resolution. She was free of proton pump inhibitor intake and recurrent food regurgitation.