Background
Overweight and obese patients represent a large proportion of the patients experiencing recurrent reflux and re-operation after their initial anti-reflux surgery. However, there is lack of a data regarding the influence of increasing BMI on the subjective and objective gastroesophageal reflux disease (GERD) recurrence following re-operative procedures.
Methods
A review of patients who underwent re-operative anti-reflux surgery (Re-ARS) between 2012 and 2023 was performed. Perioperative characteristics and postoperative Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) scores were compared across the three BMI categories: (BMI < 25 kg/m2, 25 ? BMI <30 kg/m2, and BMI ? 30 kg/m2) over a 12-month follow-up.
Intraoperative impedance planimetry (EndoFLIP) measurements were included when it was utilized intraoperatively..
Results
Eighty patients underwent re-operative surgery, of which 24 (30%) had a BMI <25 kg/m2 [Median 22.2 IQR (20.4-24.3) kg/m2], 27 (33.7%) had a BMI between 25 and 30 were [Median 27.5 IQR (25.9-28.1) kg/m2] and 29 (36.2%) had a BMI ? 30 kg/m2 [Median 33.6 IQR (31.8-35) kg/m2]. Patients were comparable across the three groups, with no significant differences observed in preoperative symptoms, barium swallow, endoscopy, and manometry test results.
Lower esophageal sphincter’s distensibility (DI) decreased similarly between groups throughout the procedure with no significant differences in post-induction [BMI <25 kg/m2: 3.2±2 mm2/mmHg vs ? 25 BMI <30 kg/m2: 4.5±3.1 mm2/mmHg vs BMI ? 30 kg/m2: 3.9±2.5 mm2/mmHg, p = 0.44] or post-fundoplication values [BMI <25 kg/m2: 1±0.6 mm2/mmHg vs ? 25 BMI <30 kg/m2: 1.3±0.7 mm2/mmHg vs BMI ? 30 kg/m2: 1.2±0.6 mm2/mmHg, p = 0.46].
There was a significant improvement in GERD-HRQL scores postoperatively compared to preoperative level across the three BMI classes. [BMI <25 kg/m2: pre 31±25.3 vs. post 1.5±0.7, p <0.01, ? 25 BMI <30 kg/m2: pre 28.1±19 vs. post 1.9±0.9, p <0.01, BMI ? 30 kg/m2: pre 41.8±16.4 vs. post 1.9±1, p<0.01]. Additionally, postoperative GERD-HRQL specific scores were similar across the three BMI categories at a median of 12 months follow-up [BMI <25 kg/m2: 1.5±0.7, ? 25 BMI <30 kg/m2: 1.9±0.9, BMI ? 30 kg/m2: 1.9±1, p > 0.05].
The rates of hiatal hernia recurrence on barium swallow [BMI <25 kg/m2: 5.2% vs ? 25 BMI <30 kg/m2: 15.7% vs BMI ? 30 kg/m2: 13.7%, p = 0.32] and endoscopy [BMI <25 kg/m2: 13.3% vs ? 25 BMI <30 kg/m2: 16.6% vs BMI ? 30 kg/m2: 7.1%, p = 0.74] were also similar between groups.
Conclusion
GERD-HRQL scores in patients with higher BMI are expected to improve similarly compared to patients with BMI <25 kg/m2 indicating that Re-ARS may be appropriate for patients across a range of BMIs. Physicians can discuss these findings with high BMI patients who elected to proceed with redo fundoplication.
