Laparoscopic Hiatal Hernia Repair and Roux-en-Y Conversion for Refractory Duodenogastroesophageal Reflux after Billroth I Distal Gastrectomy

After distal gastrectomy for gastric cancer, reconstruction of the gastrointestinal tract is necessary. There are various methods of reconstruction, such as Billroth I, Billroth II, and Roux-en-Y [1, 2, 3]. Billroth I or II anastomosis is the most commonly performed procedure because it is simpler than Roux-en-Y anastomosis [4]. However, reflux of duodenal contents into the gastric remnant and esophagus, termed as duodenogastroesophageal reflux (DGER), can occur in patients who have undergone Billroth I or II reconstruction. This can cause serious complications and decrease the quality of life of these patients [2].

DGER is usually treated with medications. Proton pump inhibitors (PPIs) are considered the principal treatment for gastroesophageal reflux disease (GERD) but have shown limited effects for DGER [5]. As a surgical option, laparoscopic fundoplication is an effective and standard treatment modality for GERD. However, fundoplication is not feasible for the remnant stomach because the condition of the blood supply to and size of the remnant stomach differ from those of the normal stomach. Therefore, Roux-en-Y conversion is an alternative surgical option for treating DGER [6, 7]. Here, we aimed to describe the procedure and outcomes of laparoscopic anti-reflux surgery in a patient with intractable DGER after Billroth I reconstruction.

Multiple methods are available to reconstruct the gastrointestinal tract after distal gastrectomy. Typical reconstruction techniques include Billroth I, Billroth II, and Roux-en-Y [1, 2]. Each reconstruction method has its own advantages and disadvantages [2]. Although Billroth I has advantages such as shorter operation time and fewer surgical complications than Roux-en-Y, it also has a major disadvantage of causing reflux symptoms [2, 8, 9]. The stronger anti-reflux capability of Roux-en-Y anastomosis has been demonstrated to contribute to a higher patient quality of life by reducing reflux-related gastritis and esophagitis [2, 3, 9].

DGER occurs when the bile refluxes into the gastric remnant and esophagus, and it may be accompanied by gastric acid reflux. Similar to general GERD, esophageal symptoms, such as heartburn and regurgitation, in addition to extraesophageal symptoms, such as globus sensation, coughing, and hoarseness, are common in patients with DGER [1, 10]. Reflux symptoms can occur not only continuously after gastrectomy but also after more than 30 years [7]. In our case, the reflux symptoms appeared and worsened 14 years after the patient underwent Billroth I gastrectomy, which was likely related to the development of the hiatal hernia. The diagnosis is usually made by evaluation of the past surgical history and symptoms. Although there is no diagnostic gold standard test, several tests to evaluate bile reflux have been suggested such as endoscopy, ambulatory pH monitoring tests, esophageal impedance test, hepatobiliary scintigraphy, and gastroesophageal fluid analysis [11, 12].

DGER is usually treated using medications such as PPIs, bile acid-binding agents, and/or kinetic agents [5]. However, the effectiveness of medical therapy for treating DGER has been shown to be inferior to that for treating typical GERD. Consequently, patients with symptoms refractory to medical treatment may need surgical treatment [12].

In sleeve gastrectomy, which is associated with the development of postoperative GERD, as in Billroth I surgery, conversion to Roux-en-Y gastric bypass has been shown to be effective in treating GERD [6]. However, reoperative surgery for GERD after distal gastrectomy for gastric cancer has been rarely reported [7]. The curative impact of surgical intervention in DGER after distal gastrectomy and Billroth I reconstruction remains unclear. Moreover, the surgical method that should be utilized remains uncertain. The surgical methods that can be used for GERD after distal gastrectomy include conversion to Roux-en-Y anastomosis, fundoplication, and hiatal hernia repair. Although laparoscopic fundoplication with crural repair is a very effective surgical procedure for the treatment of primary GERD, the most effective method among these three procedures is Roux-en-Y conversion, which can stop bile reflux definitively. Additionally, fundoplication and hiatal hernia repair can be considered as subsequent procedures that can be added depending on the situation.

Hu et al. [7] performed laparoscopic Dor fundoplication plus Roux-en-Y conversion in six patients who had undergone Billroth I or II reconstruction and had DGER refractory to medical treatment, and reported excellent symptomatic improvement in 5 out of 6 patients. This is the only report that described anti-reflux surgery after distal gastrectomy. However, they followed a different procedure from our surgery.

We performed laparoscopic Roux-en-Y conversion along with repair of hiatal hernia in our case. We did not perform fundoplication because the gastric remnant was not suitable for fundoplication. Since the entire fundus remained after distal gastrectomy, it was thought that the size of the remnant stomach would be sufficient for fundoplication. However, in reality, a large part of the gastric body had been removed when distal gastrectomy was performed. As a result, the redundancy of the entire remnant stomach was notably reduced; hence, fundoplication seemed difficult to perform on the remnant stomach, although the size of fundus was the same as that in a normal stomach.

In addition, division of the short gastric vessels to mobilize the fundus was not available for the remnant stomach because the lesser curvature of the stomach had been already devascularized during primary distal gastrectomy.

If a case fulfills the indications for the Dor fundoplication without division of the short gastric vessels, it may be performed together with Roux-en-Y conversion. However, fundoplication alone does not solve the problem of duodenogastric reflux. Therefore, fundoplication does not seem to be an essential part of anti-reflux surgery for GERD after gastrectomy. Instead of fundoplication, sufficient lengthening of the intra-abdominal esophagus and repair of hiatal hernia were the important anti-reflux mechanisms in this case.

In our patient, the symptoms related to DGER were completely alleviated after surgery; therefore, medication for DGER was stopped. Our case study suggests Roux-en-Y conversion and hiatal hernia repair as promising options for the treatment of refractory DGER that develops after distal gastrectomy and Billroth reconstruction. However, as with anti-reflux surgery for primary GERD, not all patients will benefit from this type of surgery [13]. Therefore, it is very important to define surgical indications to select patients who can potentially benefit from this surgery.

To determine possible good candidates, based on the experience of anti-reflux surgery for patients with primary GERD, patients with typical esophageal symptoms seem to be more suitable for surgery than patients whose major symptoms include gastritis. Moreover, non-acid reflux should be objectively identified using an impedance pH monitoring test because acid is not a main component of the refluxate. In addition, the outcome of surgery is expected to be better for patients with hiatal hernia. However, determining the indications for this surgery will be possible only after further accumulation of experience regarding the treatment, such as this case report.