Laparoscopic modified Nissen fundoplication over Roux-en-Y gastric bypass and hiatal hernia repair for intractable gastroesophageal reflux

Roux-en-Y gastric bypass (RYGB) is an effective treatment for morbid obesity and gastroesophageal reflux disease (GERD) [ ] Despite majority of patients with resolution of GERD after RYGB, some patients will continue to complain of significant, persistent reflux symptomatology or develop de novo symptoms despite aggressive medical management. Its true incidence is unknown and 1 study showed an improvement in GERD but not resolution in 22% of patients after RYGB with GERD [ ]. Possible mechanisms may include primary lower esophageal sphincter incompetence, disruption of the angle of His, or development of hiatal hernia with intrathoracic migration of the gastric pouch. Those with refractory reflux or de novo Barrett’s esophagitis have limited options. After ruling out bile reflux, augmentation of the lower esophageal sphincter may be the best option. Examples include the Hill procedure, magnetic sphincter augmentation, or using the ligamentum teres or remnant stomach as a fundoplication wrap [ , , , ]. Kawahara et al. [ ] first published this technique in a case report in 2012 the technique of using the remnant stomach as a modified Nissen or a 360° fundoplication over the gastric pouch and lower esophageal sphincter. At our institution, we have performed this technique as a revision for refractory reflux after RYGB with success over several years. This is the first video report to demonstrate this technique.