title: Does BMI predict recurrence or complications after reoperative reflux surgery? Review of a single center's experience and a comparison of outcomes.
abstract: BACKGROUND
  Obese patients who fail primary surgical management of gastroesophageal reflux present a significant challenge. We reviewed our outcomes with reoperative reflux surgery in obese (body mass index (BMI) >30) and nonobese patients to identify predictors of failure and complications and evaluate whether reoperative fundoplication is the ideal solution for obese patients.
  
  
  METHODS
  We conducted a retrospective review of consecutive patients undergoing reoperation for failed anti-reflux surgery between 1994 and 2013. Medical record review identified preoperative, intraoperative, and postoperative characteristics. Short- and long-term outcomes for obese and nonobese patients were compared using descriptive statistics and logistic regression.
  
  
  RESULTS
  One hundred and nine interventions were identified in 95 patients. Clinical characteristics were similar between obese and nonobese patients. Eighty-eight (83.8%) patients underwent laparoscopic repair, 87 (79.8%) of whom had a Nissen fundoplication. Obese patients were more likely to fail via a slipped wrap (64.7 vs. 40.0%; p = 0.02). No differences were seen in short- or long-term symptomatic relief or major complications. In bivariate analysis, short-term outcomes were predicted by preoperative albumin <3.5 mg/dL (odds ratio (OR), 0.27 (confidence interval (CI), 0.08-0.96); p = 0.04) and laparoscopic conversion (OR, 0.19 (CI, 0.04-1.03); p = 0.05). Laparoscopic conversion was associated with major complications (OR, 7.33 (CI, 1.33-40.55); p = 0.02). BMI was a significant predictor for long-term outcome (p = 0.03) as a continuous variable in sensitivity analyses.
  
  
  CONCLUSIONS
  Obese patients with recurrence after failed anti-reflux operation may be safely treated with a repeat operation. Our data indicate no difference in outcomes for patients with BMI >30, underscoring the importance of preoperative discussion as to the best approach: reoperative fundoplication or a gastric bypass.
authors.affiliation: Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA, elliot.wakeam@gmail.com.
authors.forename: E
authors.initials: E
authors.lastname: Wakeam
authors.forename: J
authors.initials: J
authors.lastname: Wee
authors.forename: A
authors.initials: A
authors.lastname: Lebenthal
authors.forename: S O
authors.initials: SO
authors.lastname: Ali
authors.forename: R J
authors.initials: RJ
authors.lastname: Gilbert
authors.forename: R
authors.initials: R
authors.lastname: Bueno
mesh_terms: D000328:Adult; D000368:Aged; D015992:Body Mass Index; D015331:Cohort Studies; D016001:Confidence Intervals; D005260:Female; D005500:Follow-Up Studies; D018662:Fundoplication / Q000009:adverse effects* / Q000379:methods; D005764:Gastroesophageal Reflux / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009765:Obesity / Q000150:complications / Q000175:diagnosis* / Q000601:surgery; D016017:Odds Ratio; D011182:Postoperative Care; D011183:Postoperative Complications / Q000503:physiopathology / Q000601:surgery; D011237:Predictive Value of Tests; D011300:Preoperative Care / Q000379:methods; D012008:Recurrence; D012086:Reoperation / Q000009:adverse effects / Q000379:methods; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D016896:Treatment Outcome