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Natural History of Primary Fundoplication in the Obese: a Multicenter Study
Christopher R. Daigle*1, Mena Boules1, Ricard Corcelles1, Matthew Davis1, Julietta Chang1, Michael Liu1, Raul J. Rosenthal2, Stacy a. Brethauer3, Philip R. Schauer3, Kevin M. El-Hayek1, Matthew Kroh1
1Digestive Disease Institute, Cleveland Clinic, Cleveland, OH; 2Bariatric and Metabolic Institute, Cleveland Clinic, Weston, FL; 3Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH
Purpose
This study aims to present multicenter outcomes on the controversial topic of primary fundoplication for gastroesophageal reflux disease (GERD) in obese patients.
Methods
We retrospectively analyzed all cases of fundoplication for GERD in patients with a Body Mass Index (BMI) ≥ 30 kg/m2 which occurred at one of two tertiary academic hospitals within our institution between 1997 and 2013. Revisional procedures, those associated with a myotomy or paraesophageal hernia component and cases without follow-up were excluded.
Results
In total, 102 patients (32 male; 70 female) with a BMI ≥ 30 kg/m2 underwent primary fundoplication (101 Nissen; 1 Dor) by 1 of 29 foregut surgeons for GERD related to type 1 hiatus hernia (n=87) or incompetent lower esophageal sphincter (n=15). The cohort had a mean age of 50.8±12.2 years, BMI of 34.3±3.5 kg/m2 and median of 4 comorbidities. The majority of cases were laparoscopic (n=82, 80.4%) and had an associated primary crural repair (primary suture repair, n=78; mesh hiatoplasty, n=7; no crural repair, n=17). There was a concomitant Collis gastroplasty for shortened esophagus in 17 (16.7%) cases. There were no mortalities and the mean length of stay was 3.6±3.1 days. There were 2 intraoperative complications (splenic capsule injury, partial thickness colonic thermal injury). Postoperatively, there were 10 (9.8%) complications: 3 prolonged ileus, 2 pulmonary emboli, 2 infected hematomas, 1 pneumonia, 1 wound dehiscence and 1 incarcerated ventral hernia (requiring laparotomy). At a mean follow-up of 44.7±37.7 (median, 29; range, 2-157) months, the cohort had a mean BMI of 32.9±4.7 kg/m2. Of note, 86 (84.3%) subjects had at least 1 year of follow-up, 62 (60.8%) had at least 2 years and 49 (48.0%) had 3 years or more. Sixteen (15.7%) subjects had less than 1 year follow-up, but 4 of them had already experienced objective recurrence. Overall, 12 (11.8%) subjects reported persistent regurgitation, 23 (22.6%) had dysphagia symptoms and 47 (46.1%) had subjective GERD recurrence at follow-up. Objectively, 29 (28.4%) patients had evidence (barium swallow, 24-hour pH, endoscopic, manometry or computerized tomography) of anatomic and/or functional failure. Fifty-two (51.0%) patients were still proton pump inhibitor dependent and 6 (5.9%) were on daily H-2 receptor antagonists. For patients meeting National Institutes of Health (NIH) BMI criteria for morbid obesity (BMI ≥ 35 kg/m2, n=44), the subjective and objective failure rates were 56.8% (n=25) and 34.1% (n=15), respectively. Subjects with a BMI of 30-35 (obesity by NIH definition) experienced subjective and objective failure rates of 37.9% (n=22) and 24.0% (n=14), respectively.
Conclusion
Our multicenter results raise concern regarding the durability of primary fundoplication for GERD in obese subjects (especially in the morbidly obese).
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