Abstracts
1999 Digestive Disease Week

# 2109 OBESITY IS A MAJOR CAUSE OF FAILURE FOR BOTH TRANSABDOMINAL AND TRANSTHORACIC ANTIREFLUX OPERATIONS
A R Perez, A C Moncure, David W Rattner, MA Gen Hosp, Boston, MA

We hypothesized that 1) obesity was associated with long term failure of antireflux procedures and 2) that in obese patients antireflux operations were easier to perform via thoracotomy and therefore likely to have a higher success rate than transabdominal (laparoscopic or open) antireflux procedures performed in such patients. The records of 224 consecutive patients undergoing antireflux surgery by 2 surgeons in a university based tertiary care center were reviewed and patients contacted for follow up. The patients were classified into groups based on the type of operation performed and the calculated body mass index (BMI): normal (BMI<25), overweight (BMI 25-29.9) and obese (BMI>30). Recurrences were documented by symptoms responsive to acid suppressive medication and radiological or pH probe studies. Differences between groups were analyzed with ANOVA and the Fisher's exact test. Among the 224 patients included in this study, 187 patients underwent laparoscopic Nissen fundoplications(LNF) and 37 underwent Belsey Mark IV(BM4) procedures. The mean follow-up was 37 months. 89 (39.7%) patients were classified as having normal weight, 87(38.8%) as overweight and 48 (21.4%) as obese. Normal, overweight, and obese patients were similar in terms of age, sex, hiatal hernia size, degree of esophagitis, and co-morbid conditions. Likewise there were no significant differences in these characteristics between patients undergoing LNF and BM4. There were a total of 26 recurrences for an overall recurrence rate of 11.6%. There were 4 recurrences in the normal group ( 4.5%), 7 in the overweight group (8.0%)(p =ns v. normal) and 13 in the obese group (27%) (p <.001 v normal , p<.01 v overweight). The recurrence rate was similar between LNF and BM4 in normal and overweight patients but was higher in obese patients undergoing BM4 (7/13)(54%) than LNF (8/35)(27%) p<0.05. We conclude that obesity adversely affects the long term success of antireflux operations and that this effect is not reduced by the type of antireflux procedure performed. Given the high failure rate of antireflux operations in obese patients intensive efforts at sustained weight loss should be made prior to consideration of surgery.

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