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

Recently, comprehensive esophageal evaluation, consisting of symptom assessment, upper endoscopy,
esophageal manometry, and 24-hour pH/impedance monitoring, was conducted on 500 obese patients
[55]
being considered for SG, and the results were compared to data from 25 healthy volunteers . Eighty-nine
patients tested negative for GERD (no symptoms, normal upper endoscopy, normal manometry, normal
pH/impedance testing) and underwent SG. Patients who tested positive for GERD underwent SG in
combination with either a form of fundoplication or RYGB; however, the details were not further described.
At the two-year follow-up, only two patients (2.5%) reported de novo GERD symptoms. Further workup
revealed a middle gastric stricture and GERD symptoms resolved post endoscopic dilatation. In the 43
patients who underwent follow-up upper endoscopy, none had evidence of esophagitis or BE. These
findings suggest that the risk of developing de novo GERD post-SG is low in those without preoperative
[55]
GERD symptoms and normal comprehensive esophageal evaluations .
Ultimately, recommendations regarding the workup of GERD have been made based on position
statements that are limited by available data, and are not considered local, regional or even national
standard of care. Workup tends to be driven by institutional culture rather than larger data-driven
[43]
consensus. ASMBS published a position statement in 2021 to this effect . Some experts recommend that all
patients should be assessed for GERD symptoms, but do not take a firm position on whether upper
endoscopy should be performed only on symptomatic patients, recognizing that upper endoscopy
performed in asymptomatic patients may also impact surgical choices. Another consideration is that those
with objective evidence of severe GERD, such as LA Class C or D esophagitis, AET > 6% on pH testing, or
severe GERD symptoms preoperatively, may be better suited for alternative bariatric procedures.

European guidelines advocate routine upper endoscopy preoperatively. In 2020, the Federation for the
Surgery of Obesity and Metabolic Disorders (IFSO) recommended considering upper endoscopy for all
[56]
patients undergoing bariatric surgery, regardless of the presence of upper GI symptoms, due to the potential
for unexpected findings that may alter management. The IFSO also recommended surveillance at 1 year
post bariatric surgery and then every 2-3 years thereafter, particularly after SG, to facilitate early detection of
[56]
BE . Overall, at a minimum, experts in the US recommend a selective approach to upper endoscopy while
European experts recommend routine upper endoscopy. In this regard, careful preoperative planning,
including off-PPI upper endoscopy, may help identify those individuals with GERD, as symptoms have
limited value for diagnosis given low sensitivity and specificity. In addition, severe esophagitis or BE, as
complications of severe GERD, are considered by some to contraindicate SG .
[10]
ALTERNATIVE BARIATRIC INTERVENTIONS TO LSG IN PATIENTS WITH PREEXISTING
GERD
The optimal surgical approach for obesity in patients with GERD remains a matter of debate. While RYGB
has been widely used as the bariatric procedure of choice in obese individuals with GERD, persistent and de
novo GERD symptoms are reported in a subset of RYGB patients [57-59] . A systematic review and meta-
analysis comparing GERD outcomes after LSG and RYGB showed that the odds ratio of developing de novo
GERD was higher in LSG compared to RYGB (OR = 5.10, 95%CI 3.60-7.23, P < 0.0001), but de novo GERD
also occurred in 2.3% of patients post-RYGB . In addition, longer-term follow-up studies indicate a
[60]
previous underestimation of GERD symptoms post-RYGB. A Swedish population-based cohort study of
2,454 patients with RYGB and preoperative GERD symptoms (defined as use of anti-reflux medications)
showed that 68% of patients required long-term treatment for reflux within 5 years . Similarly, a
[61]
prospective study of 180 RYGB patients followed for 12 years reported persistent or de novo GERD in
23.8%, with weight regain identified as a significant predictor of GERD on multivariate analysis (OR = 3.22,
[62]
P = 0.029) . A high percentage of hiatal hernia, hypotensive LES, and esophageal motility disorders have