Patterns of Fundoplication Failure: The Affect of Body Mass Index (BMI)

Shunsuke Akimoto, Nandipati C Kalyana, Harit Kapoor, Se Ryung Yamamoto, Pallati K Pradeep, Lee H Tommy, Mittal K Sumeet. Creighton University School of Medicien

Introduction

Antireflux surgery (ARS) has been the preferred treatment option for advanced gastroesophageal reflux disease. Since, ARS is more commonly performed, more patients are presenting with failed fundoplication requiring reoperative intervention. The patterns of these fundoplication failures in obese patients are still not understood. Our objective is to evaluate the patterns of failure in obese patient.

Methods

We retrospectively assessed 137 patients who underwent reoperative intervention for failed fundoplication between Nov 2008 to Dec 2013 at our institution. Patients were classified according to BMI into three groups: BMI<30 (n=65), BMI30-35 (n=39) and BMI>35 (n=25). The data variables collected included: preoperative investigations (high resolution manometry, endoscopy, gastric emptying study and pH study) and intraoperative findings (hiatal hernia, fundoplication status). The pattern of fundoplication failure were classified based on preoperative and intraoperative findings (intact (38, 29.46%), slipped (58, 44.96%), disrupted (32, 24.81%) and twisted (8, 6.20%)). Both univariate and multivariate analysis were performed between the three groups.

Results

Of the 137 patients, 129 patients were analyzed, and 8 patients were excluded due to technical error in the manometry results. The mean age was 56.49 years and there were 37 (28.68%) male patients. Recurrent hiatal hernia was seen in 74.4% (n=96) with 32.56% (n=42) being intrathoracic herniations. Of 129 patients, 59.69% (n=77) underwent redo fundoplication and 40.31% (n=52) underwent Roux en Y reconstruction. Patients with BMI<30 had significantly high IRP (15.4% vs. 12.68% vs. 10.19%; P = 0.053) on manometry, which correlated with high incidence of dysphagia (47.7% vs. 30.8% vs. 16%; P =0.004) in this group compared to other two groups. Patients in BMI>35 group had significantly higher incidence of disrupted fundoplication (40% vs. 25.6% vs. 18.5%; p=0.045) compared to the other two groups. No statistically significant difference was noted in other patterns of failure (slipped and twisted) in between the groups.

Conclusion

Patients with BMI >35 has higher incidence of disrupted fundoplication as a pattern of failure compared to the lower BMI population. Higher intra-abdominal pressure and technically difficult procedure could be possible reasons for higher incidence of wrap disruption in obese patients.

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