Abstract
Background
Background and hypothesis Conversion into a 60 cm Roux-en-Y jejunal loop is the most common remedial procedure in patients with gastroesophageal reflux after Billroth II gastrectomy. While this allows diversion of bilio-pancreatic secretions, symptomatic acid reflux may persist in the presence of a mechanically incompetent lower esophageal sphincter. We hypothesized that magnetic sphincter augmentation (MSA) may relieve symptoms and control esophagitis by reducing both acid and biliary reflux.
Methods
Methods A 70 year-old male patient presented with intractable reflux symptoms and grade B esophagitis 46 years after partial gastrectomy and Billroth II reconstruction for perforated gastric ulcer. The patient underwent extensive diagnostic evaluation. There was a 3 cm hiatus hernia, grade B esophagitis, and hyperemia of the gastrojejunal anastomosis. Biopsies were negative for malignancy and Helicobacter Pylori. pH-impedance testing showed combined acid and non-acid reflux; esophageal peristalsis was normal on high-resolution manometry. After informed consent, the patient preferred the option of laparoscopic MSA versus open laparotomy and Roux-en-Y conversion. Pneumoperitoneum was established with a Hasson trocar. After adhesiolysis, a hiatus hernia with retroesophageal lipoma was identified. The gastroesophageal junction was completely reduced in the abdominal cavity and a posterior crural repair was performed. A tunnel was made between the esophageal wall and the posterior vagus nerve and a no. 16 MSA (Linx®) device was applied.
Results
Results The postoperative course was uneventful and the patient was discharged home on postoperative day one. At 1- and 6-month follow-up visit the patient was off-medication, tolerated a free diet, and did not complain of any reflux symptom. The mean GERD-HRQL score decreased from 26 to 2 compared to baseline. A barium swallow confirmed the complete reduction of the hiatal hernia and the absence of reflux in the Trendelenburg position. Esophagitis was completely healed.
Conclusion
Conclusions To the best of our knowledge, this is the first case of MSA implant for refractory gastroesophageal reflux disease after Billroth II gastrectomy. This simple laparoscopic procedure allowed correction of both acid and biliary reflux.
Disclosure
All authors have declared no conflicts of interest.
