Tobacco use is not associated with increased risk of recurrent reflux 5 years after laparoscopic anti-reflux surgery

Introduction: Tobacco use worsens gastrointestinal reflux disease (GERD). Smoking cessation improves GERD symptoms, but its impact on the efficacy of laparoscopic anti-reflux surgery (LARS) is unclear. In this retrospective cohort study, we hypothesized that non-smokers would demonstrate greater long-term improvements in disease-specific quality of life than active smokers.

Methods: Data were maintained in an IRB-approved prospective database, and patients were stratified according to tobacco use. Postoperative follow-up occurred in clinic and long-term follow-up via telephone interview. Outcomes measured were gastroesophageal health-related quality of life (GERD-HRQL) and GERD symptom scale (GERSS) scores, proton pump inhibitor (PPI) cessation, and satisfaction with surgery.

Results: Two hundred and thirty-five patients underwent primary LARS, and 31 (13%) were active smokers with 18 median pack-years [10-30]. Baseline PPI use (96% vs. 94%, p = 0.64), presence of a hiatal hernia (79% vs. 68%, p = 0.13), esophagitis (28% vs. 45%, p = 0.13), and DeMeester score (41.9 vs. 33.6, p = 0.47) were similar. Baseline GERD-HRQL and GERSS scores and their post-surgical decreases were also similar between groups. PPI cessation was achieved in 92% of non-smokers and 94% of smokers (p = 0.79), and GERD-HRQL scores decreased to 4 [1-7] and 5 [0-12], respectively (p = 0.53). After 59 [25-74] months, GERD-HRQL scores were 5 [2-11] and 2 [0-13] (p = 0.61) and PPI cessation was maintained in 69% and 79% of patients (p = 0.59). Satisfaction with surgery was similar between smokers and non-smokers (88% vs. 87%, p = 0.85). Female gender was significantly associated with increased improvements in GERD-HRQL (p < 0.01) and GERSS scores (p = 0.04) postoperatively but not at long-term follow-up. Patients without a hiatal hernia were less likely to achieve long-term PPI cessation compared to those with a hernia (OR 0.23, p < 0.01).

Conclusions: After 5 years, smokers demonstrate similar symptom resolution, PPI cessation rates, and satisfaction with surgery as non-smokers. Active smoking does not appear to negatively impact long-term symptomatic outcomes of LARS.

Keywords: Anti-reflux surgery; Fundoplication; Gastroesophageal reflux disease (GERD); Paraesophageal hernia; Smoking; Tobacco.