S842 Bariatric Surgery Nearly Doubles 5-Year Reflux and Barrett’s Risk versus GLP-1 Agonists: A Propensity-Matched 81,410-Patient Cohort Analysis

Introduction: Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have emerged as a pharmacologic alternative to bariatric surgery (BS) for weight reduction after U.S. Food and Drug Administration (FDA) approval for obesity. Delayed gastric emptying with GLP-1 RAs and anatomic disruption after BS may each predispose to new onset esophageal disorders. Methods: Using the TriNetX U.S. Collaborative Network, we identified adults with body mass index ≥30 kg/m² who initiated FDA-approved weight loss GLP-1 RAs (liraglutide, semaglutide, or tirzepatide) or underwent sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) from 2015-2020. Patients with prior GLP-1 RA exposure, previous BS, or any history of gastroesophageal reflux disease (GERD), esophagitis, BE, esophageal cancer, scleroderma, pregnancy, or intensive-care admission were excluded. Propensity-score matching balanced 47 demographic, clinical, medication, and laboratory variables. Primary outcomes were de novo reflux esophagitis and GERD 5 years after the index event. Secondary outcomes were de novo BE, esophageal cancer, esophagogastroduodenoscopy (EGD) utilization, and new proton-pump inhibitor (PPI) or histamine-2 (H2) blocker prescriptions. Results: Before matching, 89,422 BS recipients (mean age 48.98 years ± 13.54 years; 72.5% women) and 84,689 GLP-1 RA users (52.99 years ± 12.84 years; 56.2% women) were identified. Post-matching cohorts were well balanced (mean age 51.3 years ± 13.3 years; 65.4% women each). At 5 years, BS conferred higher rates of reflux esophagitis (0.72% vs 0.36%; adjusted odds ratio [aOR] 1.99, 1.63-2.42), GERD (16.92% vs 9.79%; aOR 1.88, 1.80-1.96), and BE (0.46% vs 0.23%; aOR 2.02, 1.57-2.59); esophageal cancer remained rare (0.03% each; aOR 1.18, 0.53-2.64). BS patients more frequently underwent EGD (8.82% vs 3.69%; aOR 2.53, 2.38-2.69), initiated PPIs (29.39% vs 20.83%; aOR 1.58, 1.53-1.63), and required H₂-blockers (15.57% vs 11.00%; aOR 1.49, 1.43-1.56). Subgroup analyses showed the lowest GERD incidence with tirzepatide (6.36%) and the highest with SG (19.14%) relative to GLP-1 RAs. Conclusion: In this large, real-world matched cohort, bariatric surgery—particularly sleeve gastrectomy—nearly doubled the 5-year risk of de novo GERD, esophagitis, and BE compared with GLP-1 RA therapy, translating into greater endoscopic and pharmacologic reflux management. Clinicians should weigh durable weight loss benefits against divergent esophageal risks when counseling patients, and future longitudinal work is warranted to clarify the comparative incidence of esophageal adenocarcinoma.