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Page 8 of 17 Shaker et al. Mini-invasive Surg. 2025;9:27 https://dx.doi.org/10.20517/2574-1225.2024.105

Quantification of physiologic parameters of the gastroesophageal junction impedance planimetry
TM
[50]
technology utilizing EndoFLIP has also been used to identify predictors of GERD following SG . In a
retrospective review of 28 patients who underwent robotic SG, individuals with de novo or worsening
GERD demonstrated higher post-sleeve distensibility index (DI) and lower post-sleeve LES pressure
compared to asymptomatic patients . In contrast, a prospective pilot study of nine LSG patients, evaluated
[50]
pre-, intra-, and postoperatively, demonstrated that GERD was associated with higher preoperative GEJ
distensibility, while postoperative DI did not correlate with GERD .
[51]

Overall, symptoms alone are insufficient predictors of GERD severity following LSG. It is not surprising,
however, that objective evidence of preoperative GERD, particularly high-grade erosive esophagitis or a
disrupted anti-reflux barrier, appears to be more prognostic of poor postoperative outcomes. Identifying
patients at greatest risk for developing de novo GERD after LSG remains an active area of investigation and
will likely benefit from studies detailing the results of comprehensive preoperative evaluation.

PREOPERATIVE EVALUATION FOR GERD IN PATIENTS UNDERGOING SG
The need for evaluation of GERD prior to SG remains a topic of debate, with conflicting data in surgical
literature regarding determining which patients should be formally evaluated and which diagnostic
modalities should be used. In 2016, a publication reported findings from an international expert panel of
120 bariatric surgeons surveyed in 2014, and compared the results to an earlier expert survey from 2011 and
a survey of 103 general surgeon members. Compared to the general surgeon group, fewer members of the
expert panel considered GERD to be a contraindication to SG (23% vs. 52%, P < 0.001), whereas more of the
expert panel considered BE a contraindication (80% vs. 31%, P < 0.001). In terms of workup for GERD,
fewer experts in 2014 recommended that patients with GERD should have pH monitoring and manometry
prior to surgery, when compared to 2011 (33% vs. 50%, P = 0.033). Overall, the consensus was that GERD
should not be considered an absolute contraindication to SG, while BE was more strongly viewed as a
contraindication by bariatric experts than by general surgeons .
[52]
The American Society for Metabolic and Bariatric Surgery (ASMBS) updated its position statement on SG
as a bariatric procedure in 2017. It suggested that, aside from expert opinion, there was limited evidence to
support excluding patients with preexisting GERD from undergoing SG. Regardless of the strategy used to
screen or evaluate for GERD preoperatively, counseling for GERD-related outcomes has been
recommended for all patients undergoing SG .
[27]

The ASMBS has provided an opinion on the role of upper endoscopy before and after SG. Routine
preoperative upper endoscopy was justifiable as it can identify not only GERD-related complications but
also actionable gastric abnormalities that may be missed in the remnant. Therefore, the decision to perform
endoscopy was left to the discretion of the surgeon. Postoperative upper endoscopy was recommended in
patients with gastrointestinal symptoms, including GERD, and also considered in asymptomatic patients for
[43]
the detection of BE .

A meta-analysis by Bennett et al. involving 48 studies and 12,261 patients showed that preoperative upper
endoscopy led to changes in surgical management in 8% of cases, and medical management in 28% of cases.
Overall, given that the proportion of EGD findings that resulted in significant management changes was
low, the authors concluded that preoperative EGD could be considered selective and optional . Similarly, a
[53]
meta-analysis by Parikh et al., consisting of 28 studies and 6,616 patients, showed that preoperative upper
endoscopy led to a change in clinical management in only 8% of the cases .
[54]