Association of GERD with Sleeve Gastrectomy: An Unintended Consequence

Bariatric surgery is a highly effective treatment for obesity that yields durable weight loss with significant improvement or resolution of T2D and other weight-related chronic cardiometabolic diseases. While the advantages of laparoscopic sleeve gastrectomy (LSG), the most performed bariatric surgery procedure, include procedural simplicity, short operating time, lower complication rate, durable weight loss, and significant improvement including remission of type 2 diabetes, a major drawback is gastroesophageal reflux disease (GERD). The purpose of this review is to summarize the prevalence of and predictors of GERD after LSG, physiological mechanisms that explain the risk, and novel surgical management and strategy. Studies note high rates of de novo GERD and worsening of pre-existing GERD following LSG; however, estimates vary due to inconsistent definitions and length of follow-ups across the cohorts. Physiological studies demonstrate that LSG increases intragastric pressure and esophageal acid exposure in conjunction with specific anatomic alterations, which together can explain the rise in reflux seen postoperatively. Preoperative reflux, including undiagnosed preoperative GERD, is the strongest predictor of postoperative GERD. For patients with persistent GERD symptoms, conversion to gastric bypass is a common treatment, and experimental work suggests that adaptations of principles from fundoplication to sleeve anatomy can offer a pathway to minimize LSG-induced reflux. Future studies should be aimed at determining which elements of the antireflux barrier that must be preserved or reconstructed to reduce reflux after LSG. Additionally, there is a need to fully understand how the mechanics of fundoplication can be adapted and applied to sleeve anatomy to create a reliable antireflux barrier.