Robotic anti-reflux surgery (ARS) has been shown to effectively resolve typical reflux symptoms. However, its effectiveness in resolving atypical symptoms is debated. This study aims to assess short and long-term symptom resolution and to identify factors that influence outcomes after robotic ARS.

An analysis was conducted on 720 patients who underwent robotic ARS between 2012 and 2024. The patients were divided into three groups: those with typical symptoms only (n = 342), atypical symptoms only (n = 96), and those with both types of symptoms (n = 282). Symptom resolution was monitored at 1, 3, 6, and 12 months. Univariate and multivariate logistic regression analyses were used to identify factors predicting symptom persistence at both short-term (3 months) and long-term (1 year) follow-up. Kaplan–Meier survival analysis curves were also plotted.

Patients with typical symptoms experienced significant improvement: regurgitation decreased from 55.8% before the operation to 2.21% after 1 year (p < 0.001), and heartburn decreased from 68.5 to 4.82% at 1 year (p < 0.001). Atypical symptoms also improved significantly: cough decreased from 12.9 to 1.43% (p < 0.001), chest pain from 8.9 to 1.82% (p < 0.001), and excessive belching from 4.04 to 0.78% (p = 0.01). Hoarseness improved from 6.91 to 1.17% (p < 0.001), and throat clearing decreased from 3.12 to 0.52% (p < 0.001).

Regression analysis found significant differences in factors influencing symptom resolution between the short and long-term. In the short term, mesh use improved heartburn resolution (p = 0.039) and higher BMI was associated with worse heartburn outcomes (p = 0.048). In the long term, relaxing incisions were linked to increased regurgitation (p = 0.012), while preoperative abnormal barium swallow results were associated with a lower risk of persistent excessive belching (p = 0.017). Preoperative PPI use was found to be protective against long-term bloat persistence (p = 0.013).

Kaplan–Meier survival analysis showed rapid symptom resolution within the first 90 days for regurgitation, heartburn, and excessive belching, with 90% of patients symptom-free by 3 months. Cough and throat clearing showed slower resolution, with improvement continuing up to 1 year.

Robotic ARS effectively treats both typical and atypical symptoms of gastroesophageal reflux disease (GERD). Typical symptoms tend to get better faster, while atypical symptoms may take longer to resolve. There are key differences between short and long-term predictors of symptom resolution. It's important to customize surgical approaches and carefully select patients for the best results after surgery.