Letter to the Editor Concerning: Petrucciani N, Sebastianelli L, Frey S, Iannelli A. From Nissen Fundoplication to Roux-
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LETTER TO THE EDITOR
Letter to the Editor Concerning: Petrucciani N, Sebastianelli L, Frey S, Iannelli A. From Nissen Fundoplication to Roux-en-Y Gastric Bypass to Treat Both GERD and Morbid Obesity Mehmet Ali Yerdel 1
# Springer Science+Business Media, LLC, part of Springer Nature 2020
Dear Editor I read and watched the multi-media article entitled “From Nissen fundoplication to Roux-en-Y gastric bypass to treat both GERD and morbid obesity” [1] with interest since surgical treatments of reflux and obesity are my main areas of expertise. We have also recently published on the same subject [2] and even more recently, commented [3] on another case series published in Obesity Surgery [4]. I would like to address several points and raise some questions regarding this nice case. The authors must be complimented on easily performing a “complete wrap unfolding” which relieved the dysphagia. However, this practice, in other hands, was shown to result in the vast majority of the life-threatening complications following Roux-en-Y gastric bypass (RYGB) in patients who have had a prior anti-reflux repair, as reviewed in our article [2]. In contrast to standard “hiatal repair + fundoplication,” RYGB cannot be regarded as an anti-reflux operation because surgical treatment of reflux mandates 4 mechanical corrections: reduction of the hernia and the lower esophageal sphincter into the abdomen, tensionless hiatal closure, fundoplication, and reconstruction of the acute angle of “His.” RYGB does not achieve these, and its theoretical benefit comes from the separation of the stomach. Importantly, no convincing long-term data is available showing efficient reflux control with RYGB. On the contrary, an excellent 2019 study on 2454 Swedish obese subjects showed 50% reflux recurrence rate, further questioning the already controversial efficiency of RYGB to treat reflux [5]. Therefore, the authors’ * Mehmet Ali Yerdel [email protected] 1
İstanbul Bariatrics, Obesity and Advanced Laparoscopy Center, Hakkı Yeten Cad, Yeşilçimen Sok, Polat Tower, Şişli, 34394 İstanbul, Turkey
interpretation of current data on RYGB [1] as “it is the most effective option in the setting of morbid obesity to treat at the same time both GERD and obesity” is arguable. Furthermore, there is no even level II evidence suggesting that a successful anti-reflux repair would cure or prevent progression of Barrett’s disease. According to our recent analysis of all available series from different centers in the PubMed database, RYGB was associated with major and/or life-threatening complications in almost one-third of the patients who had a previous anti-reflux repair [2]. The 1% rate for a possible major complication after a primary RYGB increases almost 30-fold if a previous antireflux repair is in place. The practice of “complete wrap unfolding,” a misplaced dogma to prevent the creation of a septated pouch, was frequently condemned for increased morbidity especially in patients with a nonabsorbable meshaugmented hiatoplasty. The ease of unfolding seen in the au
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