**5. Conclusions**

Within the limitations of this study, the significance of HPPI in obese Saudi patients residing in the Najran region in SA was demonstrated alongside the significance role of BMI in HPPI. Further research should consider a comprehensive and context specific factors (e.g., environmental and host) contribution to clarify the association of obesity with HPPI.

**Author Contributions:** A.M.A-Z. contributed to study conception and design, conducted the endoscopic procedures, acquired data, reviewed the literature, interpreted the results, wrote the manuscript draft and approved the final draft of the manuscript; A.H.A. Conducted the bariatric sleevectomy, reviewed the manuscript and data analysis; A.A-s. managed data collection; S.A.A. conducted the bariatric sleevectomy, reviewed the manuscript; S.K. reviewed the literature, analyzed the data, interpreted the results and wrote the manuscript draft and approved the final draft of the manuscript, N.A. drafted the original manuscript, participated in literature review and critically commented on the draft.

**Funding:** This research received no external funding.

**Acknowledgments:** We would like to thank Madia Divikaran, Muhammed Farouk, Esam Alharoun and endoscopy nurses Rinu Kurain, Mini Mathew Sharly, minimol and Abdullah Alshahi for their endless efforts and support.

**Conflicts of Interest:** The authors declare no conflict of interest.
