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Page 10 of 17 Shaker et al. Mini-invasive Surg. 2025;9:27 https://dx.doi.org/10.20517/2574-1225.2024.105

been reported in individuals with persistent GERD post RYGB [57,58] . The pathophysiological mechanisms
underlying these symptoms seem to be multifactorial [58,62] and extend beyond the scope of this review.
Therapeutic management of patients with severe GERD after RYGB remains a challenge and may include
modified Nissen or Toupet fundoplication, Hill procedure, or use of a magnetic sphincter augmentation
device (e.g., Linx) [58,59] . Of course, there may be factors beyond GERD that will dictate the bariatric
procedure of choice. Some patients may not even be candidates for an anastomotic type of procedure such
as RYGB. In these patients, SG may be the only viable option despite the presence of GERD.

LSG combined with an anti-reflux procedure including various fundoplication techniques (posterior 360°,
posterior 270°, or anterior 180°) has been proposed as an alternative approach to improve LES barrier
function. A systematic review and meta-analysis of five studies (four retrospective cohort studies and one
randomized, controlled trial) including a total of 539 patients (BMI ≥ 35) compared GERD-related
outcomes and safety between LSG plus fundoplication (LSG + F) and LSG alone . Overall, LSG + F
[63]
resulted in improved GERD remission at the expense of less weight loss and higher postoperative
complications. Major complications included gastric perforation, bleeding, leak, and dysphagia in the LSG +
F group (OR = 2.56; 95%CI 1.12-5.87). The included studies were limited by the lack of objective GERD
assessment, relying instead on symptoms and/or PPI use, and were marked by heterogeneity in GERD
[63]
evaluation methods . While these results suggest that LSG combined with fundoplication may be a
promising alternative bariatric procedure for patients with GERD, further research is warranted to clarify
the overall clinical benefit, better define the risk profile, and determine the positioning of its use in the
bariatric surgery toolbox.

A number of endoscopic bariatric therapies are also available for weight loss. In patients with known GERD
or its complications, some experts suggest avoiding LSG and instead favoring options such as endoscopic
sleeve gastrectomy (ESG) . Endoscopic interventions such as ESG have been shown to produce significant
[64]
weight loss and improve comorbidities . Unlike LSG, ESG is considered an “anatomy-sparing” technique,
[65]
as it preserves the natural components of the EGJ uninterrupted. In this endobariatric procedure, a gastric
sleeve is created by plicating the greater curvature of the stomach, from the level of the incisura to the
gastric cardia .
[66]

Results of comparative analysis of surgical (e.g., RYGB and SG) and endoscopic (e.g., ESG) bariatric
interventions with respect to GERD and other outcomes are of particular interest. A meta-analysis of seven
comparative studies involving 6,775 patients directly comparing ESG (n = 3,413) and LSG (n = 3,362)
[66]
showed that ESG achieved clinically meaningful total body weight loss (TBWL) percentages at 6, 12, and 24
months, although these were lower than those achieved with LSG (15.2% ± 6.3%, 19.1% ± 7.9%, and 16.4% ±
10.1% vs. 18.8% ± 7.5%, 28.9% ± 8.2%, and 22.3% ± 8.3%, respectively; P < 0.0001). The incidence of adverse
events was lower with ESG compared to LSG (0.7% vs. 1.7%), although this difference did not reach
statistical significance. Importantly, the incidence of new-onset GERD was significantly lower following
ESG compared to LSG (1.3% vs. 17.9%, RR = 0.10, P = 0.006) . Overall, these studies support the
[66]
consideration of ESG as an alternative bariatric option, particularly in patients with mild-to-moderate
obesity. However, it is important to note that only observational studies were included in this meta-analysis.
Thus, prospective, and preferably RCTs, are needed to validate these results. Overall, in patients with
preexisting GERD for whom LSG should not be offered, several alternative bariatric surgical options can be
considered [Table 2].

EVALUATION AND MANAGEMENT OF GERD POST-LSG
The evaluation and management of GERD after bariatric surgery remains an active area of investigation and