Background Roux Y Gastric Bypass (RYGB) is the preferred primary bariatric surgical option in patients with preoperative gastro oesophageal reflux disease (GERD). It is also the preferred revisional bariatric surgery after when GERD develops after an alternate primary bariatric surgery. However reflux after RYGB although uncommon can present due to a variety of factors. Management can be challenging. Aim/Hypothesis A modified version of the Belsey IV fundoplication can be done laparoscopically to reconstitute the antireflux barrier in the absence of a Fundal remnant in the gastric pouch after RYGB. Methods We present a single patient experience/case study where there was evidence of recurrent GERD in spite of a successful RYGB in terms of weight loss and comorbidity resolution. A 42 year old female with a BMI > 40 and metabolic co-morbidities and GERD was deemed fit for RYGB. After a technically uneventful RYGB with standard limb lengths ( Roux 120cms and BP limb 70 cms) there was significant weight loss ( > 70% EBWL) and co-morbidity resolution. However her symptoms of GERD persisted. An gastroscopy confimed esophagitis and a barium swallow showed evidence of GERD with a small hiatal hernia and a 3-4 cms Candy cane limb. There was no evidence of a gastrogastric fistula. Revisonal surgery was done which revealed no significant candy cane limb. A small (<2cms) hiatal hernia was found. Complete esophageal mobilization and a hiatal hernia repair was done in a standard fashion. Furthermore the anterior wall of the long gastric pouch was invaginated to obtain an approximate coverage of 200 degrees in a single layer Belsey technique. The procedure was completed laparoscopically. Results The post-operative period was uneventful. Patient reported complete absence of reflux after surgery and remains off PPI in the short term. Temporary dysphagia was noticed in the first few weeks after surgery which improved with expectant treatment. Conclusion A Laparoscopic modified Belsey type fundoplication serves as an effective method to treat GERD after a RYGB if other potential causes of GERD are excluded.

Background It is known that posture (Supine Vs Sitting) variations can affect the dynamics and manometric characteristics of the OG junction and Oesophageal motility. Aims To study the effect of the Head Down (HD) upside down posture on the esophageal motility characteristics and dynamics of the OG junction using High resolution manometry. This would partially replicate the effect of Obesity (High Intraabdominal pressure) on the OGJ. Methods A single crazy (but sane) volunteer who had no symptoms of GORD served as the model for this unique experiment. A high-resolution manometry was performed using a solid-state transducer catheter with 36 channels. The study was performed in the sitting, supine and head down posture. Basal characteristics recording followed by wet swallows of 5ml of water and completed by rapid water swallows was done in each posture. Analysis was performed in the standard fashion using Chicago classification metrics. Further correlation of findings with a multipostural barium video oesophagogram is awaited. Results The procedure was completed satisfactorily in all the three postures. Satisfactory progression of swallows in a peristaltic sequence was obtained in all the 3 postures. However it was noted that there was a sequential change in the following parameters from the sitting to the supine to head down postures. Increased residual and contraction pressures in the Cricopharyngeal high pressure zone more pronounced in the HD position. Decreased amplitude of contraction of peristaltic sequences Decrease in slope of the peristaltic wave in the HD posture Diminished resting pressure in the HD position Exaggerated separation of the crural diaphragm (CD) and LES on the HD position Increased intragastric pressures in the HD position. Conclusion The above experiment is the first reported of Oesophageal function and OGJ dynamics in a completely unaided head down position using high resolution manometry and video fluoroscopy. The findings may serve to imitate the effect of Obesity on the OJ junction

Background Roux Y gastric bypass (RYGB) is the preferred bariatric surgical option in patients with Gastro oesophageal reflux disease (GORD). However, de novo GORD after RYGB although uncommon is possible and present challenges in further management. Proposed mechanisms have been a large gastric pouch or a short alimentary limb. Objective Analyse anatomical causes of De Novo GORD post RYGB Methods Data of patients who presented with new onset GORD after RYGB were collected and analysed. Results Specific and remediable anatomical factors contributing to de novo GORD was found in 8 patients post RYGB (3 Males and 5 Females). Onset of symptoms ranged from 1.16-15 years. Mean age was 53.14 and mean BMI 37.39. One patient had R-Y gastric bypass for peptic ulcer disease in the past. Diagnostic work up included; Barium swallow (85.7%), CT Abdomen (42.9%), OGD (57.1%). Diagnosis of candy cane (CC) syndrome was seen in 50 % of cases (n=4) followed by Gastro-gastric fistula (n=1), gastric pouch herniation (n=1) and pouch herniation with CC syndrome (n=2). Excision of excess CC limb achieved resolution in symptoms of reflux. 4 patients are awaiting surgical anatomical correction. Conclusion De novo GORD after RYGB can be challenging. These patients need thorough anatomic and physiologic assessment to identify potentially correctable anatomical causes. A long CC, herniated gastric pouch, gastro-gastric fistula are anatomical causes identified in our study. Identification and evaluation of this sub group of patients has not been reported in the past but are likely to be increasingly encountered.

Introduction The Upper GI cancer Multidisciplinary team (MDT) has become an essential and integral part of the cancer treatment pathway in the management of Oesophagogastric (OG) cancer. There exists an need for the MDT management of complex benign diseases of the oesophagus which can be equally rewarding if proper decision making for treatment is achieved in this potentially challenging group of patients. Methods We explore the utility of a Benign Complex MDT model consisting of Surgeons, Gastroenterologists, radiologists and GI Physiologists in a tertiary teaching hospital setting. A retrospective review of 72 patients who were discussed in the Complex Benign UGI MDT over a 2 year was undertaken. The referral pattern, decisions and outcomes have been analysed. All results were analysed using SPSS version 23. Results are reported in median +/- ranges or percentages where applicable. Results Patients had median age of 57 years with 62.5% being women. 30/72 (41.7%) patients had previous surgery. Majority of the referrals were made by surgeons 61/72 (84.7%) followed by gastroenterologist 10/72 (13.9%). Dysphagia was the predominant symptom in 34/72 (47.2%) patients followed by reflux in 31/72 (43%) patients and 19.4% patients had a combination. The purpose of an MDT referral was expert advice in 45/72 (62.5%) and consideration of surgery in 23/72 (31.9%) patients. The recommendations of the MDT was further clinic review (30%), further investigation (30.5%), surgery (18%), discharge (11%). MDT changed patient’s management in 30/72 (41.7%) cases. Conclusion Our results show that surgery was recommended less frequently after initial MDT discussions in patients who were initially referred for potential surgical advice. The management of complex benign conditions of the oesophagus can be challenging particularly after initial interventions. A MDT approach to the management of these patients can be recommended as equally vital to their management on recommending/avoiding further surgical or endoscopic interventions.

Background It is not uncommon to get de novo GERD after certain types of bariatric surgery. Sleeve gastrectomy (SG), Adjustable Gastric Band ( AGB) and the One anastomosis gastric bypass (OAGB) have been frequently implicated to cause GERD. Roux Y gastric bypass (RYGB) is usually proposed as a curative procedure in patients who develop GERD after a LSG or LAGB. Hypothesis The alteration in mechanics around the Oesophagogastric junction (OGJ) after all types of bariatric surgery predispose to the development of GERD in varying proportions including the RYGB. Aims To theoretically explore the changes around the OGJ in the 4 most common types of bariatric procedures: AGB, SG, OAGB and RYGB Methods and results The following 6 variables that are frequently implicated in causing reflux are equated with each procedure and a score produced to quantify the potential effect on the OGJ. Elimination of the angle of HisInterruption of the Sling fibresInterruption of the Phreno-oesophageal membranePredisposition to the herniation through the hiatus.Effect on the Lower Oesophageal Sphincter residual pressure.Creation of a high-pressure zone below the LES promoting reflux. Based in a standardised technique of performing the 4 common operations, the following scores were obtained. AGB affected 5/6 variables, SG affected 6/6 variables, RYGB affected 5/6 variables and OAGB affected 5/6 variables that influence the antireflux barrier mechanism around the OG junction. Conclusion All bariatric surgeries technically affect the dynamics around the OGJ and indirectly reduce the efficacy of the antireflux barrier mechanisms. The varying contribution of certain individual factors may affect the relative incidence of GERD after surgery after different types of bariatric surgeries. The common recommendation that RYGB serves as a magic bullet against GERD is to be taken in context of the above mechanisms in action.