We appreciate the constructive comments by García Ruiz de Gordejuela et al.1 on our previously published article. As they mentioned in their letter, conventional anti-reflux treatment is described as an effective treatment option in patients with gastroesophageal reflux disease (GERD) and body mass index (BMI) below 35 kg/m2. Fundoplication reduces the gastric functional capacity and could therefore be considered a partially restrictive bariatric procedure.2 Taking into account the special conditions of the aforementioned patient, who had failure of a previous restrictive endoscopic procedure and persisting type 2 diabetes mellitus and dyslipidemia, a simple fundoplication could have improved the symptoms associated with GERD, but could hardly have achieved greater weight reduction or improved the associated comorbidities. While theoretically after a restrictive endoscopic technique the fundus should barely present anatomical alterations, in this case we observed plication of a considerable segment, rendering a fundoplication technically impossible even if we had considered performing it.
The American Society for Metabolic and Bariatric Surgery (ASMBS) accepts the indication for bariatric surgery in patients with a BMI of 30–35 kg/m2 and comorbidities associated with obesity who have not achieved reasonable weight loss or improvement in comorbidities with non-surgical treatment.3 However, their consensus document does not specify which bariatric technique to perform in these patients, nor does it establish contraindications for malabsorptive procedures. To date, the technique of choice for the treatment of GERD associated with obesity is Roux-en-Y gastric bypass. Nevertheless, when this procedure is used as revision surgery after a failed prior restrictive technique, complete remission rates for diabetes mellitus do not reach more than 35%.4 In our experience with one-anastomosis gastric bypass (OAGB) as a revision technique after restrictive procedures, the complete remission rate for diabetes mellitus exceeds 75% after 10 years of follow-up.5
One of the most controversial points of OAGB is bile reflux. Indeed, there are studies that describe bile reflux rates close to 10%, although these series refer to patients with mini gastric bypass (MGB). While the consensus document of the International Federation for Surgery of Obesity (IFSO) on OAGB agreed that all bariatric procedures with a single gastroenteric anastomosis should be called OAGB,6 the technique we perform presents significant modifications of the original MGB. These include performing a longer gastric pouch, an anastomosis calibrated at 2.5 cm and a side-to-side suture from the biliary loop to the gastric pouch, all of which are done to reduce the risk of bile reflux. In our series, the rate of bile reflux after 12 years of follow-up was 2.2%, and the re-operation rate for this cause was 0.25% of cases.5 The measurement of the total intestinal length allows us to leave a common intestinal loop for absorption that is long enough so that the nutritional status of patients is not compromised during the postoperative period.
Presently, after 2 years of follow-up, the patient described has a BMI of 24.8 kg/m2 and is in complete remission of her diabetes mellitus and dyslipidemia, with no signs of nutritional deficiencies. Despite this, we agree with the authors of the letter that the current available evidence on the indication for performing OAGB in patients with GERD and grade 1 obesity is scarce. However, we believe that this technique can be considered an alternative treatment for patients with these characteristics.
Please cite this article as: Ruiz-Tovar J. Acerca de la enfermedad por reflujo gastroesofágico en un paciente con un índice de masa corporal 30 kg/m2 y gastroplastia vertical endoscópica previa: indicación para un bypass gástrico de una anastomosis: respuesta a la carta al director. Cir Esp. 2020;98:113–114.
