Obesity adversely affects the outcome of antireflux operations

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Abstract
We hypothesized that obesity was associated with long-term failure of antireflux procedures, and 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) anti-reflux procedures. The aims of this study was to determine the impact of obesity on the success of antireflux operations, and to compare the success rates of transthoracic and laparoscopic approaches in obese patients with gastroesophageal reflux. The records of 224 consecutive patients undergoing antireflux surgery by two surgeons in a university-based tertiary care center were reviewed and patients contacted for follow-up assessment. The patients were classified into groups based on the type of operation performed and the calculated body mass index (BMI): normal (BMI 30). Recurrences were documented by symptoms responsive to acid-suppressive medication and radiologic or pH probe studies. Among the 224 patients included in this study, 187 underwent laparoscopic Nissen fundoplications (LNF) and 37 underwent Belsey Mark IV (BM4) procedures. The mean follow-up period was 37 months. The three groups included 89 (39.7%) patients 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, gender, hiatal hernia size, degree of esophagitis, and comorbid conditions. A total of 26 recurrences occurred, giving 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 not significant vs normal), and 15 in the obese group (31%; pp<.001 vs overweight). The recurrence rate was similar between LNF and BM4 in each BMI subgroup, although in aggregate, the recurrence rate after BMW was greater than after LNF (10/37 vs 16/187; p<0.02). Obesity adversely affects the long-term success of antireflux operations. Although athoracotomy provides optimal exposure of the hiatal structures in obese patients, a transthoracic approach was associated with a higher recurrence rate than LNF. Given the high failure rate of antireflux operations in obese patients, intensive efforts at sustained weight loss should be made before consideration of surgery.