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The puzzling argument of antireflux surgery in obese patients with gastroesophageal reflux disease: can the excellent perioperative safety of antireflux surgery make up for better comprehensive long-term outcomes of bariatric surgery?

      The prevalence of obesity has more than doubled in United States over the past 3 decades.
      • Ogden C.L.
      • Carroll M.D.
      • Kit B.K.
      • et al.
      Prevalence of obesity among adults: United States, 2011-2012.
      The increased prevalence of obesity has also corresponded with a parallel increased prevalence of gastroesophageal reflux disease (GERD). In fact, obese patients have a 2.5 times elevated risk of developing GERD symptoms.
      • El-Serag H.B.
      • Graham D.Y.
      • Satia J.A.
      • et al.
      Obesity is an independent risk factor for GERD symptoms and erosive esophagitis.
      Pandolfino et al 1st proposed a physiopathologic mechanism by which obesity may lead to GERD. Pandolfino et al
      • Pandolfino J.E.
      • El-Serag H.B.
      • Zhang Q.
      • et al.
      Obesity: a challenge to esophagogastric junction integrity.
      have shown that increased visceral fat in obese patients may increase their intragastric pressure with a resulting increased gastroesophageal pressure gradient and abnormal esophageal acid exposure. Other studies have also shown that central obesity (a marker for increased visceral fat) is associated with Barrett's esophagus, a known complication of GERD. As shown by Edelstein et al,
      • Edelstein Z.R.
      • Farrow D.C.
      • Bronner M.P.
      • et al.
      Central adiposity and risk of Barrett’s esophagus.
      the odds of developing long-segment Barrett's esophagus were 4.3 for patients with the highest waist-to-hip ratio. With such a strong association between Barrett's esophagus and obesity, the prevalence of esophageal adenocarcinoma in obese patients has also been found to be substantial. An obese individual has an odds ratio of 16.2 for developing esophageal adenocarcinoma compared with an individual with a BMI less than 22.
      • Lagergren J.
      • Bergström R.
      • Nyrén O.
      Association between body mass and adenocarcinoma of the esophagus and gastric cardia.
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