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Page 2 of 5 Al-Khyatt et al. Mini-invasive Surg 2018;2:3 I http://dx.doi.org/10.20517/2574-1225.2017.49

INTRODUCTION
Gastroesophageal reflux disease (GORD) is defined as a group of symptoms and/or mucosal injury that
[1]
occurs as a result of reflux of gastric contents into the oesophagus . It is a frequently encountered and costly
medical condition with an estimated annual cost of proton pump inhibitor use of nearly £500 million in
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England alone. The prevalence of GORD and obesity [body mass index (BMI) >30 kg/m ] has increased
[2-6]
significantly over the past three decades in the USA and Europe . GORD is widely prevalent in obese
patients; with increasing BMI considered a risk factor for developing the disease [7-16] . The marked increase in
prevalence of obesity has been associated with an increase in obese patients seeking surgical treatment for
[17]
refractory GORD . The management of GORD in obese patients remains contentious with no consensus
or published guidelines. Data are conflicting regarding the long-term efficacy of fundoplication in obese
individuals compared with normal weight counterparts [18-22] . Nevertheless, most surgeons would agree that
[23]
treatment of GORD in obese and non-obese patients requires different strategies . The aim of this study
was to elicit professional opinions of upper gastrointestinal (GI) surgeons towards the management of
refractory GORD in obese patients.

METHODS
A snapshot 9-item online survey was undertaken between October and November 2015. Members of two
UK specialist associations [Association of Upper GI Surgeons (AUGIS) and British Obesity and Metabolic
Surgery Society (BOMSS)] were contacted via email and invited to participate in the survey [Supplementary
Figure 1]. The questions were designed to characterize training and practice characteristics, experience, and
subspecialty interest of respondents. Professional opinions were sought, regarding the optimal treatment for
obese patients of varying BMI with medically refractory GORD and reasons for treatment choices.

RESULTS
A total of 451 specialist association members were emailed the link to the survey questions. All respondents
were upper GI surgeons, of whom 51% were also bariatric surgeons. There was an even distribution of
duration of practice as consultant surgeon amongst respondents (33% < 5 years, 27% had 5-10 years, 33% had
11-20 years, and 7% had > 20 years experience as consultant). Eighty-two percent regularly performed ≥ 10
laparoscopic and/or anti-reflux procedures per year and 51% admitted to regularly performing ≥ 10 bariatric
procedures per year.

Sixty-one surgeons (79%) considered laparoscopic fundoplication the preferred option for management
of refractory GORD in patients with BMI 30-34.9 kg/m [Figure 1A]. However, only 21% and 11% would
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consider laparoscopic fundoplication as their preferred option for BMI 35-39.9 and ≥ 40 kg/m , respectively
[Figure 1A]. Twenty-one surgeons (20%) considered anti-reflux surgery not a preferred option for refractory
GORD in obese patients. Fifty-eight percent and 80% would discuss bariatric surgery as an alternative
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treatment option for refractory GORD in BMI 35-39.9 and ≥ 40 kg/m , respectively [Figure 1B]. Moreover,
74% and 58% of respondents considered a bariatric procedure the preferred option in patients, respectively,
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with BMI ≥ 40 kg/m with refractory GORD, or BMI ≥ 35 kg/m with significant comorbidities together
with refractory GORD [Figure 1C]. Eighty percent of surgeons agreed laparoscopic Roux en-Y gastric bypass
(LRYGB) was the bariatric procedure of choice for the management of obese patients with documented
GORD [Figure 1D]. Reasons for bariatric surgery not being offered included lack of level one evidence (15%),
lack of national consensus (26%), difficulty in referring patients for bariatric surgery (12%) or patient attitudes
towards bariatric surgery (16%).

DISCUSSION
This snapshot survey sought to elicit UK upper GI surgeon attitudes towards the management of refractory
GORD in obese patients. It demonstrated that upper GI surgeons still preferred fundoplication in patients
with BMI 30-35 kg/m . However, they were less likely to offer fundoplication to patients at higher BMI. The
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