Impact of Obesity on Clinical, Physiologic, and Durability Outcomes After Antireflux Surgery in a 2,388-Patient Cohort

OBJECTIVES: To evaluate the effect of obesity on subjective and objective outcomes after antireflux surgery (ARS). SUMMARY OF BACKGROUND DATA: Obesity has traditionally been viewed as a relative contraindication to ARS with some guidelines favoring Roux-en-Y gastric bypass in this population. The concern that increased intra-abdominal pressure may compromise durability is physiologically plausible, but supporting clinical evidence is limited. METHODS: Consecutive patients undergoing primary fundoplication or magnetic sphincter augmentation (MSA) between 2011 and 2024 were analyzed. Patients were stratified by body mass index (BMI) <35 kg/m² or ≥35 kg/m² (obese). Preoperative characteristics and postoperative outcomes were compared, including symptom control, objective reflux parameters, and anatomic integrity. RESULTS: A total of 2,388 patients were included, of whom 309 (12.9%) had BMI ≥35. Obese patients had larger hiatal hernias (P<0.001) and higher DeMeester scores [48.7 (34.8) vs. 44.1 (35.0), P=0.030]. At 1 year after surgery, GERD-HRQL scores improved in both groups and were comparable [10.7 (12.8) vs. 10.1 (13.0)], as were patient satisfaction (81.6% vs. 83.3%) and PPI independence (85.1% vs. 85.5%) (all P>0.05). These findings remained similar at 3 years. Five-year anatomic integrity (75.8% vs. 78.2%) and revisional surgery rates (4.5% vs. 5.3%) were similar between groups (all P>0.05). However, obese patients undergoing MSA had lower rates of pH normalization (48.1% vs. 71.0%, P=0.001). CONCLUSION: Patients with BMI ≥35 presented with more advanced reflux but achieved comparable symptom improvement, satisfaction, and PPI independence after ARS. Anatomic integrity and revision rates were similar, with reduced pH normalization observed only in the MSA subgroup. These findings support ARS in obese patients and suggest BMI alone should not determine surgical candidacy.