Laparoscopic Fundoplication Using the Excluded Stomach Versus Conversion to Roux-en-Y Gastric Bypass for Refractory...

Background/Objectives: Reflux remains one of the main limitations of one-anastomosis gastric bypass (OAGB), potentially impairing postoperative quality of life and requiring revisional surgery in refractory cases. Conversion to Roux-en-Y gastric bypass (RYGB) is currently considered the standard surgical treatment, although it involves additional anatomical modifications and potential morbidity. Fundoplication using the excluded stomach has recently emerged as a novel alternative approach. To compare the safety and efficacy of conversion to RYGB versus fundoplication using the excluded stomach in the management of refractory reflux after OAGB. Single-center retrospective study in a private bariatric surgery center. Methods: All consecutive patients who developed reflux refractory to optimized medical therapy after OAGB between January 2013 and January 2023 were included. The choice of revisional procedure-conversion to RYGB or laparoscopic fundoplication using the excluded stomach-evolved over time as the fundoplication technique was progressively introduced into clinical practice, reflecting a non-randomized, time-dependent allocation-a major limitation of this comparison. Primary outcomes were reflux resolution and postoperative complications. Secondary outcomes included reflux recurrence and the need for further surgical intervention. Reflux symptoms were assessed using the Reflux Symptom Index (RSI). Results: A total of 43 patients were included: 27 in the RYGB group and 16 in the fundoplication group. At 12 months, complete resolution of reflux symptoms was observed in 55.6% of patients in the RYGB group versus 93.7% in the fundoplication group (p = 0.02). Persistent reflux requiring reoperation occurred in 10 patients (37%) in the RYGB group, while no reoperations were required in the fundoplication group (p = 0.006). Late complications were significantly higher after RYGB conversion (25.9% vs. 0%, p = 0.035), mainly due to internal hernias. RSI scores significantly improved in both groups, with no significant difference in postoperative values. Conclusions: Fundoplication using the excluded stomach appears to be a feasible alternative to Roux-en-Y conversion for refractory reflux after OAGB, with favorable short-term outcomes. Given the non-randomized, time-dependent allocation, these findings are hypothesis-generating and require confirmation in larger, randomized studies.