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Shaker et al. Mini-invasive Surg. 2025;9:27 https://dx.doi.org/10.20517/2574-1225.2024.105 Page 5 of 17

Table 1. Proposed mechanisms driving GERD post LSG

Imbalance between increased intragastric and decreased LES pressure (change in angle of His, decrease in basal LES pressure, and increase in
intragastric pressure)
Increase in rates of hiatus hernia
Decreased gastric compliance
Surgical technique (e.g., antral preservation)

GERD: Gastroesophageal reflux disease; LSG: laparoscopic sleeve gastrectomy; LES: lower esophageal sphincter.

The effect of LSG and concomitant hiatal hernia repair on GERD symptoms was also evaluated in a
retrospective study of 58 morbidly obese patients (average BMI 44) . Hiatal hernia was identified in 34.5%
[30]
of patients via upper gastrointestinal series, and during surgery in the remaining patients. Preoperatively,
45% of patients reported GERD symptoms or daily use of anti-reflux medication. Postoperatively, 65% of
these patients remained symptomatic despite achieving > 50% reduction in excess BMI, while 35% reported
resolution of symptoms. Among the 55% of patients who were asymptomatic preoperatively, most remained
asymptomatic. However, nearly 16% developed de novo GERD symptoms postoperatively, requiring daily
anti-reflux medication. Overall, LSG with concomitant hiatus hernia repair resolved preexisting GERD in
only one-third of patients and was associated with new-onset GERD in nearly 16% .
[30]
While prospective, randomized multicenter trials comparing RYGB and LSG have shown similar efficacy in
terms of achieving weight loss, they have also underscored differing indications for reoperation between
these procedures. Internal hernias are the primary cause of reoperations after RYGB, while severe reflux not
responding to medical therapy is the leading cause of conversion from SG to RYGB [31,32] .

In the Swiss Multicenter Bypass or Sleeve Study (SM-Boss) , 217 patients were randomly assigned to
[32]
undergo either LSG or LRYGB, and 5-year follow-up was available for 94%. Excess BMI loss was similar
between LSG and LRYGB at 5 years (61% and 68%, respectively, P = 0.22). Reoperation rates were
comparable in frequency but differed in indication: 16% of LSG patients required reoperation, 56% of which
were for severe GERD, whereas 22% of LRYGB patients required reoperation, with 39% due to internal
hernias. Preoperative GERD was reported in 44% and 46% of patients randomized to LSG and LRYGB,
respectively. GERD symptoms worsened more often following LSG compared to LRYGB (32% vs. 6%, P =
0.006), while symptom improvement was more frequent after LRYGB compared to the LSG group (60% vs.
25%, P = 0.002). Notably, de novo GERD symptoms were reported more often after LSG than after LRYGB
[32% (18/57) vs. 11% (6/56), P = 0.01] .
[32]

[31]
In the Finnish Sleeve vs. Bypass (SLEEVEPASS) study , 240 patients were randomized to LSG or LRYGB,
with 80% completing 5-year follow-up. While LRYGB patients had slightly greater excess weight loss
compared to patients who underwent LSG, this difference did not reach statistical significance (57% vs.
49%). Reoperation was required in 8% of LSG patients, mostly for severe reflux (70%), and in 15% of LRYGB
[31]
patients, primarily due to internal hernias (94%). Other GERD-related outcomes were not reported .

In a non-randomized controlled trial of 75 patients undergoing SG (n = 35) or RYGB (n = 40), GERD
parameters were evaluated in detail using symptoms, endoscopy, and 24-h pH monitoring both pre- and
postoperatively. GERD was defined as reflux esophagitis of Los Angeles Grade ≥ B or increased total acid
exposure (> 6%). Postoperatively, typical GERD symptoms, reflux esophagitis, hiatal hernia, and distal
esophageal acid exposure time were all higher in post-LSG than in post-LRYGB patients. LSG patients with
preoperative GERD continued to have GERD postoperatively and de novo GERD developed in 68% of LSG
patients compared to 17% of LRYGB patients. Predictors of postoperative reflux esophagitis or GERD were