Surg Endosc (2012) 26:177–181
DOI 10.1007/s00464-011-1851-6
The impact of previous fundoplication on laparoscopic gastric
bypass outcomes: a case-control evaluation
Anna Ibele • Michael Garren • Jon Gould
Received: 19 May 2011 / Accepted: 4 July 2011 / Published online: 20 August 2011
! Springer Science+Business Media, LLC 2011
Abstract
Background Gastroesophageal reflux disease (GERD) is
a common comorbid condition in morbidly obese gastric
bypass candidates. Unfortunately, some patients who ulti-
mately present for bariatric surgery have previously
undergone Nissen fundoplication for GERD. Many sur-
geons consider previous fundoplication to be a relative
contraindication to subsequent laparoscopic Roux-en-Y
gastric bypass (LRYGB) due to increased technical com-
plexity and risk. We sought to compare the perioperative
and long-term outcomes of a cohort of patients who had
first undergone fundoplication and ultimately chose to later
pursue LRYGB for morbid obesity (revision) to matched
control patients.
Methods Data were obtained from our prospectively
maintained bariatric surgery database. Patients who
underwent laparoscopic takedown of a previous fundopli-
cation and conversion to LRYGB were compared to con-
trol patients who underwent primary LRYGB. For every
revision patient, two control subjects were randomly
selected from the database after matching for preoperative
body mass index and year of surgery.
Presented in part at the annual meeting of the Society of American
Gastrointestinal and Endoscopic Surgeons, National Harbor, MD,
April 2010.
A. Ibele ! M. Garren
Department of Surgery, University of Wisconsin School of
Medicine and Public Health, K4/728 Clinical Science Center,
600 Highland Avenue, Madison, WI 53792, USA
J. Gould (&)
Department of Surgery, Medical College of Wisconsin, 9200 W.
Wisconsin Avenue, Milwaukee, WI 53226, USA
e-mail: jgould@mcw.edu
and Other Interventional Techniques
Results From July 2002 to April 2011, 14 patients
underwent laparoscopic takedown of a previous Nissen
fundoplication and then underwent LRYGB. During the
same interval, 673 patients underwent LRYGB as a pri-
mary procedure for obesity from which 28 were selected as
controls. There were no conversions to open laparotomy in
any patient. Subjects were similar demographically.
Operating time and duration of hospital stay were signifi-
cantly longer in revision patients. Complications were
more frequent in revisions (36% revisions vs. 7% controls,
P = 0.03). Excess weight loss 1-year after surgery was
excellent in both groups and did not differ (69% revision
vs. 69.6% controls, P = 0.93).
Conclusions Although associated with longer operating
times, longer duration of hospital stay, and complications,
LRYGB after fundoplication is feasible and safe. Long-
term weight loss outcomes are similar to those seen fol-
lowing primary LRYGB. Previous fundoplication is not a
contraindication to LRYGB.
Keywords Revisional bariatric surgery ! Nissen
fundoplication ! Gastroesophageal reflux disease !
Laparoscopic gastric bypass
Gastroesophageal reflux disease (GERD) is a common
chronic condition that affects between 8 and 26% of the
population in the Western world [1, 2]. It is likely that the
prevalence of GERD has increased in recent years based on
a significant increase in the prevalence of serious sequelae
related to GERD such as Barrett’s esophagus and esopha-
geal adenocarcinoma [3, 4]. Obesity has clearly increased
in prevalence in recent years. An estimated 5.7% of US
adults are morbidly obese (BMI C 40 kg/m2) [5]. Obesity
is associated with increased intra-abdominal pressure and
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may be an independent risk factor for GERD [6, 7]. In both
morbid obesity and GERD, surgery is recognized as the
most effective treatment for severe refractory disease. In
the United States, laparoscopic Roux-en-Y gastric bypass
(LRYGB) is the procedure most commonly used for mor-
bid obesity [8, 9], and laparoscopic fundoplication is the
mainstay treatment for medically refractory GERD [10].
Several series have demonstrated that outcomes following
fundoplication in obese patients are not as good as those
observed following fundoplication in nonobese patients
[11]. Some surgeons even consider fundoplication to be
contraindicated in morbidly obese patients and instead
recommend LRYGB for these patients due to documented
high GERD resolution rates following LRYGB [12].
Unfortunately, some patients who undergo fundoplication
for GERD eventually opt to pursue surgical treatment of
their morbid obesity, which may or may not have been
present at the time of the original fundoplication. A prior
fundoplication significantly complicates future bariatric
surgery [13], and many surgeons are reluctant to offer these
patients surgery for their severe obesity. We sought to
compare the perioperative and long-term outcomes of a
cohort of patients who had first undergone fundoplication
and ultimately chose to later pursue LRYGB for morbid
obesity (revisions) to matched control LRYGB patients
who had not previously had a fundoplication (controls).
Methods
Data were obtained from our prospectively maintained ba-
riatric surgery database. Patients who underwent laparo-
scopic takedown of a previous fundoplication and then had
LRYGB for morbid obesity were compared to control
patients who underwent primary LRYGB. For every reop-
erative patient, two control subjects were randomly selected
from the database after matching for preoperative body
mass index (BMI) and year of surgery. We chose to match
patients based on BMI because there is published data to
suggest that very high BMI can be associated with adverse
events following primary LRYGB [14, 15]. We matched
patients for year of surgery to ensure that minor variations
in the technical aspects of the surgery and programmatic
processes (e.g., staffing and inpatient care protocols) had
minimal impact on our findings. The University of Wis-
consin Institutional Review Board approved this study.
All patients were required to participate in an extensive
preoperative education, evaluation, and screening program
as per our bariatric protocols. Morbidly obese subjects with
a previous fundoplication seeking bariatric surgery were
also subjected to routine upper endoscopy and barium
limited upper gastrointestinal radiograph series. Our tech-
nique for primary laparoscopic gastric bypass involves the
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Surg Endosc (2012) 26:177–181
transgastric placement of a circular stapler anvil for the
gastrojejunostomy and the antecolic placement of the
Roux-limb. This technique has previously been described
in detail [14]. For revision patients, attention is first
directed to taking down the previous fundoplication. We
are very careful to preserve the blood supply to the gastric
pouch by minimizing dissection along the proximal lesser
curve as much as possible. In select cases, the fundus is
resected when it is determined that this gastric tissue has
been damaged during the course of dissection or if it
appears ischemic. When possible, the circular stapler anvil
is placed prior to creation of the pouch via gastrotomy in
the remnant stomach, as is done for primary LRYGB. In
difficult cases where a resection of the fundus is required,
the anvil may be passed transorally into an already con-
structed isolated gastric pouch. We routinely place a drain
next to the gastrojejunostomy and gastric pouch staple line
in revision cases. Gastrostomy tubes are not routinely
placed in the gastric remnant, although this is an option in
patients with nutritional concerns and/or a high likelihood
of perioperative complications.
Postoperatively, primary gastric bypass patients are
started immediately on a diet. Protocols are in place that
allow for the rapid advancement of clinical pathways
leading to routine discharge the morning following surgery
in the majority of patients. Revision patients are not
allowed to initiate their diet until the morning of postop-
erative day 1 in the absence of clinical indicators of a leak
(tachycardia, oliguria) and after an upper GI series that
shows no evidence of an occult leak.
Results
From July 2002 to April 2011, 14 patients underwent
laparoscopic takedown of a previous Nissen fundoplication
and then underwent LRYGB. During the same interval, 673
patients underwent LRYGB as a primary procedure for
obesity from which 28 patients were selected as controls.
There were no conversions to open laparotomy in any
patient. In 8 of 14 revision patients, the fundus was
resected at the time of surgery. Subjects were similar in
terms of age (49 years revision vs. 46 years control,
P = 0.75) and sex (93% female revision vs. 75% female
control, P = 0.23). BMI did not differ between groups as
per the study design (43.5 ± 6.4 revision vs.
44.1 ± 6.6 kg/m2 controls, P = 0.73)
Operating time and duration of hospital stay were sig-
nificantly longer in revision patients (Table 1). Complica-
tions occurred more frequently in revision patients. Excess
weight loss 1 year after surgery was excellent in both
groups and did not differ (69% revision vs. 69.6% control,
P = 0.93).
Surg Endosc (2012) 26:177–181
Table 1 Perioperative outcomes for revision and control subjects
OR time (range) (min)
Revisions 160 (120–240)
Controls 77 (60–180)
P value \0.01
OR operating room; LOS length of stay
Early complications (\30 days postoperatively) in revi-
sion patients included one subacute gastrojejunostomy leak
that was managed nonoperatively, one intra-abdominal
bleed that required transfusion of 4 units of packed red cells
and which resolved spontaneously, one pulmonary embo-
lism, and one small-bowel obstruction related to incarcer-
ation of the Roux limb into a pre-existing incisional hernia
and which was reduced and repaired laparoscopically. Late
complications included one gastrojejunostomy stenosis
requiring two sessions of endoscopic dilation (5 total
complications in 14 patients). There was one readmission
within 30 days and one reoperation within 30 days in the
revision group (7%). In the control group, there were three
early complications (\30 days) in two patients. Both of
these patients required surgery to correct bleeding and/or
rule out additional pathology. One of these patients under-
went diagnostic laparoscopy and evacuation of a large ret-
rogastric hematoma. No clear source of ongoing
hemorrhage was identified. This patient was readmitted
several days after discharge from these events with a pul-
monary embolism. A second patient underwent diagnostic
laparoscopy and endoscopy-assisted control of rapid intra-
luminal bleeding at the gastrojejunostomy staple line.
Among the revision patients, 5 (36%) had recurrent
GERD at the time of surgery due to anatomic failure of
their original fundoplication. Another 5 patients with an
intact fundoplication at the time of revisional surgery were
also on GERD medications to help manage symptoms
consistent with recurrent GERD (heartburn) without
objective evidence to support this diagnosis. When com-
pared to patients with intact fundoplications in the revision
study group, patients with a slipped fundoplication were
similar in terms of preoperative BMI (41.5 ± 7 slipped
fundoplication vs. 44.7 ± 6.2 kg/m2 intact fundoplication,
P = 0.26). Perioperative outcomes were similar in terms of
duration of hospital stay (3 ± 1 days slipped fundoplica-
tion vs. 5.5 ± 6.6 days intact fundoplication, P = 0.94),
operating time (174 ± 45 min slipped fundoplication vs.
152 ± 26 min intact fundoplication, P = 0.46), and com-
plications (40% slipped fundoplication vs. 33% intact
fundoplication, P = 0.8). Acid-reducing medications to
treat GERD were utilized in 10 of 14 (71%) revision
patients and 12 of 28 (43%) control patients prior to sur-
gery. One-year after surgery, 2 of 14 (14%) revision
179
LOS (range) (days) Complications
5.1 (1–17) 36%
1.8 (1–5) 7%
\0.01 0.03
patients and 3 of 28 (11%) control patients were using
GERD medications (P \ 0.05 for comparisons of preop-
erative and postoperative GERD medication usage for both
study groups). Among patients with recurrent GERD
related to a failed fundoplication, 100% of these patients
reported resolution of their primary GERD symptom fol-
lowing surgery.
Discussion
Although associated with longer operating times and hos-
pital stay as well as a higher complication rate, LRYGB
after fundoplication is feasible and effective. We observed
that long-term weight loss outcomes are similar to those
seen following primary LRYGB. For those morbidly obese
patients with anatomic failure of a previous fundoplication
and recurrent GERD, takedown of the fundoplication and
conversion to LRYGB resulted in consistent symptom
resolution.
Several previously published studies have documented
an increased complication rate for LRYGB after fundo-
plication, with a morbidity rate of roughly 21–43% [16,
17]. In these same series, many investigators also observed
that conversion of fundoplication to RYGB is an extremely
effective procedure for refractory or recurrent GERD
symptoms. Houghton et al. [13] performed mostly open
conversion of previous fundoplication to RYGB in 19
patients. Major complications occurred in 21% of patients.
A total of 79% of patients reported severe reflux symptoms
prior to RYGB despite the previous fundoplication. Fol-
lowing conversion to RYGB, 94% reported better control
of GERD symptoms than after their fundoplication [13].
Raftopoulos et al. [16] performed laparoscopic revision of
a previous antireflux procedure to RYGB in seven patients.
The mean operating time was 6 h 12 min. Three (43%)
patients experienced major complications. Excess weight
loss was 71% after a mean follow-up of 24 months [16].
Kellogg et al. [17] performed laparoscopic revision of
fundoplication to RYGB in 11 patients, 9 of whom had
GERD prior to revision. There were five minor complica-
tions that occurred \30 days postoperatively (45%) and
five minor plus one major complication (internal hernia)
that occurred [30 days following surgery. Of the nine
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patients with preoperative GERD, 100% had an improve-
ment in symptoms, with 78% realizing a complete reso-
lution of all GERD symptoms [17].
The most commonly described operative technique for
conversion of a previous fundoplication to RYGB is to take
the fundoplication down entirely prior to proceeding with
creation of a gastric pouch and Roux-en-Y anastomosis. An
alternative technique would be to leave the fundoplication
intact and create the gastric pouch just distal to the wrap.
Potential advantages to this method include shorter oper-
ating times and less risk for damage to the proximal
stomach and esophagus during dissection. We strongly
favor taking down the original fundoplication in its entirety
prior to proceeding with RYGB. This allows for the crea-
tion of the properly sized proximal gastric pouch which is
essential for optimal weight loss and reflux control [18]. If
a surgeon were to inadvertently staple across a corner or a
fold of the intact fundoplication in an effort to create a
small gastric pouch, this introduces the possibility of an
isolated, separated pouch of stomach not in continuity with
any other segment of the gastrointestinal tract.
Gastrectomy with Roux-en-Y reconstruction has been
used as a primary antireflux procedure by some surgeons in
complicated patients [19, 20]. The RYGB (with the distal
stomach left in situ) has also been shown to be an effective
surgical treatment for GERD in the morbidly obese [12,
21]. Makris et al. [22] evaluated Roux-en Y reconstruction
as a surgical treatment for failed fundoplication in 22
patients with 1-year follow-up. Satisfaction scores were
high (95% would recommend to a friend) and GERD
symptom severity scores were very low (mild or no
symptoms in most). Major and/or minor complications
occurred in 32% of patients without mortality. A retro-
spective comparison between reoperative fundoplication
and gastrectomy with Roux-en-Y reconstruction for failed
fundoplication revealed that despite having more severe
endoscopic complications of GERD and more previous
fundoplications, the gastrectomy group experienced greater
relief of their primary symptom [23]. In-hospital morbidity,
however, was higher following gastrectomy. Gastrectomy
and RYGB appear to be an acceptable treatment option for
recurrent GERD when another attempt at fundoplication is
likely to fail or is ill-advised, whether the patient is obese
or not. In morbidly obese patients with recurrent GERD
after fundoplication, conversion to RYGB should be the
treatment of choice.
We have demonstrated that conversion of a previous
fundoplication to LRYGB is feasible and effective for both
the treatment of morbid obesity and recurrent GERD in
morbidly obese patients. We have also shown that com-
plication rates, operating times, and duration of hospital
stay for these cases exceed those observed following pri-
mary LRYGB. Ideally, morbidly obese patients with
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Surg Endosc (2012) 26:177–181
medically refractory GERD would be advised to undergo
bariatric surgery rather than fundoplication. Not only is
LRYGB an extremely effective GERD treatment, it also
addresses concomitant obesity-related comorbidity by
achieving significant and sustained weight loss. The patient
is afforded an opportunity to realize significantly improved
health and quality of life through LRYGB [24], which has
been demonstrated to be at least as safe as laparoscopic
Nissen fundoplication in patients with concomitant obesity
[25].
Questions regarding the durability of fundoplication in
morbidly obese patients also exist. Obesity is a well-rec-
ognized contributor to abdominal wall hernia repair failure
[26, 27]. These same factors leading to hernia recurrence
may also contribute to failure of the diaphragm repair
following a fundoplication in morbidly obese patients. In a
study of 224 consecutive patients with 3 years of follow-up
who underwent laparoscopic Nissen or transthoracic Bel-
sey Mark IV fundoplication, symptomatic recurrence was
31.3% in obese patients compared to 4.5% in normal
weight patients [28]. In another study, preoperative severe
obesity was associated with a higher rate of fundoplication
failure, although these conclusions are limited by a small
number of severely obese patients in the cohort [29].
Several studies have been published suggesting that obesity
does not negatively impact the outcomes of fundoplication
for GERD, but these are also limited by extremely small
numbers of severely obese patients (many patients with
class I or class II obesity; BMI \ 35 kg/m2), small overall
numbers, and short follow-up [30–32].
The morbidly obese patient with medically refractory
GERD has at times not previously considered bariatric
surgery, certainly not as a solution to their GERD. These
discussions may require several office visits. A compre-
hensive education and evaluation process for bariatric
surgery by an experienced team in a multidisciplinary
program is the preferred pathway. Unfortunately, even if
the patient, his or her primary care provider, and the ba-
riatric surgery team reach a consensus that bariatric surgery
is the best treatment option for GERD and obesity-asso-
ciated conditions, insurance companies often decline to
provide benefits for LRYGB as a GERD treatment [33].
Many morbidly obese patients who would otherwise be
best served with LRYGB for GERD are forced to undergo
laparoscopic Nissen due to financial limitations and policy
exclusions. This is an unfortunate situation that is likely to
cost insurers and patients in the long run.
In summary, although associated with longer operating
times, longer duration of hospital stay, and complications,
LRYGB after fundoplication is feasible and safe. Long-
term weight loss outcomes are similar to those seen fol-
lowing primary LRYGB. Previous fundoplication is not a
contraindication to LRYGB. Optimally, morbidly obese
Surg Endosc (2012) 26:177–181 181

patients with medically refractory GERD would be advised treatment of gastroesophageal reflux in morbidly obese patients:
to undergo primary LRYGB without an attempt at a initial experience. Obes Surg 14:1373–1380
17. Kellogg TA, Andrade R, Maddaus M, Slusarek B, Buchwald H,
fundoplication. Ikramuddin S (2007) Anatomic findings and outcomes after an-
tireflux procedures in morbidly obese patients undergoing lapa-
Disclosures Dr. Anna Ibele, Dr. Michael Garren, and Dr. Jon Gould roscopic conversion to Roux-en-Y gastric bypass. Surg Obes
have no conflicts of interest or financial ties to disclose. Relat Dis 3:52–57
18. Zainabadi K, Courcoulas A, Awais O, Raftopoulos I (2008)
Laparoscopic revision of Nissen fundoplication to Roux-en-Y
gastric bypass in morbidly obese patients. Surg Endosc
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