Loose fundoplication utilising the excluded stomach into OAGB improves HRQoL vs OAGB alone

The combination of a loose fundoplication utilising the excluded stomach into one-anastomosis gastric bypass (OAGB) demonstrates a notable enhancement in HRQoL compared with OAGB alone, for patients experiencing obesity and significant reflux.

According to the study’s authors by researchers from Homerton University Hospital, London and Ain Shams University, Cairo, this combined approach yielded lower GERD-Health-Related Quality of Life (GERD-HRQL) scores (indicating improved symptom management), higher Visick grades (indicating increased patient satisfaction), and decreased reliance on PPIs while sustaining effective long-term weight loss.

Gastroesophageal reflux disease (GERD) frequently persists despite weight reduction, thereby diminishing anticipated improvements in quality of life following bariatric surgery. While OAGB is metabolically effective, it may not completely manage reflux symptoms. This study assessed whether the incorporation of a modified fundoplication could enhance symptom control and health-related quality of life (HRQoL) compared with OAGB alone.

A prospective randomised comparative study was conducted involving 60 patients diagnosed with obesity and GERD. Participants were randomly allocated into two groups for a follow-up period of two years: Group A underwent OAGB only, and Group B received OAGB with modified fundoplication. Outcomes were evaluated based on preoperative and postoperative upper GI and manometry findings, as well as postoperative GERD-HRQL scores.

In comparison to OAGB alone, fundoplication demonstrated superior symptom control (Visick 2.10 ± 0.71 vs. 3.57 ± 0.73; p = 0.001) and resulted in a shorter duration of PPI use (2.43 ± 0.62 vs. 3.13 ± 0.68 months; p = 0.001). The GERD-HRQL scores showed significant improvement following fundoplication at six months (48.33 ± 7.91 to 31.57 ± 3.90; p < 0.001), and this improvement was sustained up to 24 months, whereas the changes observed after OAGB alone were not statistically significant. At the 24-month mark, endoscopic evaluation revealed an intact wrap with no evidence of GERD, and manometry confirmed restoration of LES function.

The primary outcome was the change in GERD-HRQL score from baseline to six, 12, and 24 months. Secondary outcomes included Visick grade at follow-up, duration of postoperative PPI use, objective reflux control on endoscopy (esophagitis, bile reflux, cardia competence, and small hiatus hernia), and HRM (LES hypotension, IRP, and restoration of the HPZ).

Outcomes

Age and BMI were comparable between groups with no statistically significant differences. The sex distribution showed a higher proportion of females in Group A, but this difference did not reach statistical significance (p=0.052), indicating a small-to-moderate effect size and acceptable baseline balance. Between-group comparisons of baseline comorbidities were nonsignificant (all p>0.05), indicating small effect sizes and balanced groups.

Baseline endoscopic findings were comparable between groups. The prevalence of esophagitis (LA A/B) did not differ significantly (p=0.436) and there were no between-group differences in the occurrence of hiatus hernia (p=0.765) or cardia incompetence (p=0.224). The proportion of patients with abnormal IRP or a hypotensive LES did not differ significantly between groups (p=0.767), nor did the prevalence of a small hiatus hernia with hypotensive LES (p=0.723) or a short intra-abdominal oesophagus with dual pressure peaks (p=0.741). Effect sizes were uniformly small, further confirming balance before intervention.

At 24 months, Group A showed incompetent cardia (8/30), mild-to-moderate esophagitis LA A/B (8/30), biliary esophagitis (1/30), and small hiatus hernia (<2 cm) (8/30). In Group B, intact fundal wrap with no GERD/esophagitis was seen in 28/30 patients, mild esophagitis in 5/30, incompetent cardia in 2/30, and endoscopic (not clinical) recurrence of small hiatus hernia in 2/30.

At 24 months, Group B showed restoration of LES function: adequate LES relaxation in 28/30, increased HPZ at the LES below the Z-line in 30/30, mild IRP elevation in 6/30, and small hiatal hernia with hypotensive LES in 2/30. In Group A, incompetent cardia/abnormal IRP/hypotensive LES <10 mmHg persisted in 22/30, and small hiatus hernias with hypotensive LES persisted in 8/30.

“These patient-centred benefits are supported by consistent objective findings, such as reduced endoscopic signs of reflux and improved manometric sphincter function, suggesting durable restoration of the anti-reflux barrier,” the authors concluded. “Overall, modified fundoplication offers a viable strategy to improve HRQoL in patients at risk of postoperative reflux. Larger studies with extended follow-up and pH-impedance monitoring are necessary to confirm durability and refine patient selection.”

The findings were featured in the paper, ‘Quality of Life Outcomes After Fundoplication-Augmented One-Anastomosis Gastric Bypass: A Randomized Comparative Study’, published in Cureus. To access this paper, please click here