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Impact of Obesity on Clinical, Physiologic, and Durability Outcomes After Antireflux Surgery: A 2,171-Patient Cohort Study
*Shahin Ayazi, *Sven Eriksson, *Ping Zheng, *Michelle Bojalad, *Ahmed Aly, *Vineeth Sadda, David L. Bartlett
Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania
Objectives:Obesity has traditionally been viewed as a relative contraindication to antireflux surgery (ARS), with some guidelines favoring Roux-en-Y gastric bypass in this population. The concern that increased intra-abdominal pressure may compromise the integrity or durability of fundoplication or magnetic sphincter augmentation (MSA) is physiologically plausible but not well supported by clinical data. This study evaluated the effect of obesity on subjective, objective, and long-term outcomes after ARS.
Methods:Consecutive patients who underwent primary ARS at our center between 2011 and 2024 were reviewed. Patients completed the GERD-HRQL questionnaire and underwent pH-monitoring before and 1 year after surgery. Patients were grouped by BMI <35 kg/m
2 or ≥35 kg/m
2. Demographics, preoperative clinical characteristics and 1-year postoperative outcomes were compared between BMI groups. Patients were followed with endoscopy for up to 5-years to assess for anatomical failure.
Results:There were 2,171 patients who underwent ARS (65.6% fundoplication; 34.4% MSA), of which 276 (12.7%) had BMI ≥35. Hiatal hernia was more prevalent in patients with obesity (81.7% vs 74.2%, p=0.011). Preoperative GERD-HRQL scores were higher with obesity (38 [23-51] vs 31 [16-48], p=0.002), as were DeMeester scores (37.9 [23.1-55.1] vs 32.4 [18.8-50.0], p=0.017).
The comparison of outcomes between BMI groups is summarized in
Table. At 1-year GERD-HRQL scores significantly improved in both BMI groups (each p<0.001) and were comparable. There was also no difference in heartburn, regurgitation or the development of postoperative dysphagia or gas-bloat symptoms. Patient satisfaction with surgical outcome and freedom from PPIs were high and comparable.
Obesity was associated with higher postoperative DeMeester scores and lower pH-normalization. However, obesity was only associated with lower pH-normalization after MSA (56.9% vs 76.1%, p=0.003) and not fundoplication (77.4% vs 77.8%, p=0.953). The pH-normalization rate stratified by BMI for each procedure is shown in
Figure.
Failure rates and need for revisional surgery did not differ between groups. Time to failure was longer in patients with obesity (p=0.033). Additionally, patients with BMI ≥37.5 kg/m
2 likewise showed no difference in failure (p=0.725) or need for revision (p=0.379) rates compared with lower-BMI patients.
Conclusion:Obese patients presented with more severe GERD yet achieved symptom improvement, satisfaction, and PPI discontinuation equivalent to non-obese patients. Fundoplication outcomes were unaffected by BMI, and although MSA showed lower pH normalization in higher-BMI patients, this had no clinical or anatomic consequences. Durability and revision rates were comparable across BMI groups. These findings demonstrate that ARS is effective and durable in obese patients, and BMI alone should not limit candidacy or dictate procedural choice, though it may inform counseling on expected physiologic outcomes with MSA.
