Why Choosing the Roux-en-Y Gastric Bypass in a Morbid Obese with a History of a Failed Nissen Fundoplication Is Not a Do
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LETTER TO EDITOR/LED REPLY
Why Choosing the Roux-en-Y Gastric Bypass in a Morbid Obese with a History of a Failed Nissen Fundoplication Is Not a Dogma Antonio Iannelli 1,2,3
&
Sébastien Frey 1,2
&
Niccolo Petrucciani 4
# Springer Science+Business Media, LLC, part of Springer Nature 2020
Dear Editor, We thank the authors for the interest to our work on failed Nissen fundoplication in the setting of morbid obesity converted to Roux-en-Y gastric bypass (RYGP) [1]. Interestingly, the authors pinpoint the “dogmatic policy” of dismantling the Nissen valve in the setting of conversion to RYGP. Although we agree that this surgery bears an increased risk of postoperative complications, we remind that this patient was referred to the senior author (AI) who has a large experience in antireflux and redo bariatric surgery [2, 3]. Furthermore, this patient did not have any previous mesh repair, which reduced significantly the risk of adhesions. Another assertion of the authors concerns the ischemic issues of the pouch or the gastric remnant that may result from dismantling the antireflux valve. While the gastric remnant is vascularized by short gastric arteries, the pouch relies mostly on the descending esophageal arteries and in some degree on the left diaphragmatic artery. The short gastric arteries are not involved in the vascular supply of the gastric pouch unless it includes the fundus. However, doing so would result in a
* Antonio Iannelli [email protected] Sébastien Frey [email protected] Niccolo Petrucciani [email protected] 1
Université Côte d’Azur, Nice, France
2
Digestive Surgery and Liver Transplantation Unit, Archet 2 Hospital, University Hospital of Nice, 151 Route Saint Antoine de Ginestière, BP 3079 Nice Cedex3, France
3
Inserm, U1065, Team 8 “Hepatic Complications of Obesity and Alcohol”, Nice, France
4
Department of Medical and Surgical Sciences and Translational Medicine, Faculty of Medicine and Psychology, Sapienza University of Rome, Sant’Andrea Hospital, Rome, Italy
horizontal pouch that should be avoided. If the remnant stomach is not injured during the dissection and if its vascular supply is not jeopardized, there is no need to remove it. As the risk of stricture is increased when the vascular supply of the pouch relies only on the descending esophageal arteries, the gastro-jejunostomy should be fashioned larger [4]. The issue of the management of GERD in patient candidates to bariatric surgery is debated. While the authors find arguable that RYGP is currently the most effective option to treat GERD and obesity at the same time, there is a large rational behind this sentence that, however, should not be taken as a dogma. RYGP remains an excellent weight loss procedure that also works against the reflux of gastric content into the esophagus, when it is performed in accordance with the principles shown in our video: a short and narrow gastric vertical pouch that results in a dramatic reduction of the gastric acid secretion; the reduction of the lower esophagus into the a
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