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Shaker et al. Mini-invasive Surg. 2025;9:27 https://dx.doi.org/10.20517/2574-1225.2024.105 Page 7 of 17

PREDICTORS OF GERD POST SG
The prevalence and predictors of GERD after LSG were evaluated in 213 patients using the GERD-HRQL
questionnaire administered pre- and postoperatively; objective testing was not performed. Although
preoperative GERD symptoms such as heartburn and regurgitation were frequent, they could not predict
[44]
the new onset or worsening of GERD symptoms postoperatively .

A prospective cohort study of obese patients who underwent 24-hour pH monitoring (n = 47) and
esophageal manometry (n = 30) preoperatively and one year after SG aimed to identify clinical and
manometric factors of GERD (defined as total % of time with pH < 4 exceeding 4.2%). Among patients who
developed de novo GERD (51%), there was a decrease in basal intragastric pressure postoperatively (17.2 ±
3.7 vs. 11.5 ± 3.8, P < 0.001), while maximal intragastric pressure following swallows increased (25.4 ± 9.4 vs.
49.2 ± 22.0, P < 0.05). LES resting pressures remained unchanged pre- and postoperatively and did not
correlate with changes in pH. Overall, no clinical or manometric factors were predictive of de novo GERD
in this study .
[45]

More recently, there has been an attempt to objectively determine whether a preoperative GERD diagnosis
was associated with worsening postoperative symptoms. A single-center case series evaluated the effects of
SG on 20 patients with GERD symptoms, nine of whom had a positive pH study and eleven a negative pH
study. In this small study, conversion to gastric bypass (two patients) only occurred in the cohort with a
positive pH study, and no conversions were reported in those with a negative pH study. Postoperative
quality-of-life scores and GERD symptoms remained similar between the two groups .
[46]

In separate studies, preoperative esophagitis or GERD and increasing age have been identified as predictors
of post-SG esophagitis or GERD . A multicenter cohort study of 1,537 patients who underwent LSG
[33]
assessed GERD using a combination of questionnaire and upper endoscopy. Nearly 25% of patients had
postoperative GERD, 21% of whom had de novo symptoms, and 2% of whom had worsened or unchanged
preoperative symptoms. Multivariate analysis identified antral preservation and gastropexy as independent
protective variables against the development of postoperative GERD, while antral resection and smoking
were identified as risk factors for post-LSG GERD .
[47]
Factors associated with increased severity of erosive esophagitis one year after LSG have also been evaluated.
In a retrospective review of 316 post-LSG patients , 58% developed de novo erosive esophagitis, with severe
[48]
cases occurring in 3%. Multiple logistic regression analyses identified male sex, hiatal hernia after LSG, and
preoperative erosive esophagitis as independent risk factors for the presence of erosive esophagitis after
LSG. When considering factors associated with increased severity of erosive esophagitis, male sex (OR =
2.55, P < 0.001) and hiatal hernia after LSG (OR = 3.17, P < 0.001) were identified as independent risk factors
for increased severity of erosive esophagitis post LSG. Interestingly, the presence of preoperative erosive
esophagitis was negatively associated with increased severity of erosive esophagitis post LSG (OR = 0.25, P <
0.001). Overall, the incidence of severe erosive esophagitis was low among those without significant
preoperative disease .
[48]
Demographic and manometric parameters were evaluated as possible predictors of GERD in a retrospective
analysis of 164 SG patients with GERD symptoms or preoperative esophagitis who underwent high-
resolution manometry . Multivariate analysis identified preoperative GERD symptoms (OR = 2.5, P =
[49]
0.013), female sex (OR = 3.4, P = 0.002), and distal contractile integral (DCI) ≥ 1,623 mmHgscm (OR = 0.3, P
= 0.003) as independent determinants of postoperative GERD . While methodological limitations may
[49]
apply, these results demonstrate the potential utility of thorough preoperative physiologic evaluation.