Comparative Outcomes of Anti-Reflux Surgery in Obese Patients with Gastroesophageal Reflux Disease1

Abstract

Introduction: Roux-en-Y gastric bypass (RYGB) has been the preferred operation for obese patients with gastroesophageal reflux disease (GERD); however, some patients are hesitant to undergo bypass. Obese patients have a multifactorial predisposition to GERD, including lower esophageal sphincter (LES) dysfunction and aberrant pressure gradients across their diaphragmatic crura. Among non-obese patients, anti-reflux surgery (ARS) with hiatal hernia (HH) repair and LES augmentation has shown excellent long-term results. We aimed to determine whether patient satisfaction and GERD recurrence differed between obese and non-obese patients who underwent ARS.

Methods: Review of patients who underwent ARS between January 2012 and June 2021 was performed. Perioperative and postoperative characteristics were compared across three BMI groups: BMI < 30 kg/m², 30 kg/m² ≤ BMI < 35 kg/m², and BMI ≥ 35 kg/m².

Results: Four-hundred thirteen patients were identified, of which 294 (71.1%) had BMI < 30 kg/m², 87 (21.1%) were 30 kg/m² ≤ BMI < 35 kg/m², and 32 (7.7%) had a BMI ≥ 35 kg/m². Patients with BMI ≥ 35 kg/m² had higher preoperative manometric and EndoFLIP™ intra-balloon pressure at the LES than those with lower BMIs. This value was increased to a similar level throughout ARS across the three cohorts. Post-operative GERD-specific satisfaction was similar across the three cohorts, as were rates of postoperative reflux and hiatal hernia recurrence on barium swallow; rates of reoperation were low.

Conclusions: ARS with HH repair and LES augmentation may be appropriate for select patients across a range of BMIs, including those with a BMI ≥ 35 kg/m² who are hesitant to undergo RYGB.

Keywords: BMI; GERD; Gastroesophageal reflux disease; Hiatal hernia; Obesity.