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Shaker et al. Mini-invasive Surg. 2025;9:27 https://dx.doi.org/10.20517/2574-1225.2024.105 Page 11 of 17

Table 2. Alternatives to LSG in obese patients with GERD

RYGB
LSG combined with an anti-reflux procedure (e.g., posterior or anterior fundoplication)
ESG
LSG: Laparoscopic sleeve gastrectomy; GERD: gastroesophageal reflux disease; RYGB: Roux-en-Y gastric bypass; ESG: endoscopic sleeve
gastrectomy.

is guided by expert opinion. A group of 46 recognized bariatric and metabolic surgical experts from 25
countries participated in a Delphi consensus to provide an algorithm for clinical decision-making in cases
under consideration for revisional surgery after SG for insufficient weight loss, weight regain, and GERD .
[67]
The consensus was that multidisciplinary evaluation (91.3% agreement) along with at least 12 months of
medical and supportive management (73.9% agreement after round 2) should be performed prior to
reoperation for GERD after LSG. Most experts agreed on the importance of upper endoscopy (95.6%
agreement) and upper GI series (82.6% agreement) prior to reoperation, although consensus was not
reached regarding additional diagnostic evaluation such as pH monitoring or esophageal manometry,
despite two rounds of voting. In cases of symptomatic GERD after SG and adequate weight loss, the
consensus was that continuing medical treatment for at least 1-2 years (86.9% agreement) and RYGB (97.7%
agreement) were acceptable. Despite two rounds of voting, consensus could not be reached regarding the
suitability of magnetic sphincter augmentation with LINX. In cases of symptomatic GERD after SG and
inadequate weight loss or with weight regain, recognizing the contribution of persistent obesity to GERD
symptoms, 97.7% agreed that RYGB was an acceptable option. Finally, in cases of symptomatic GERD after
SG and excessive weight loss, 97.8% agreed that RYGB was an acceptable option. Cruroplasty/HH repair
was considered acceptable by nearly 57% of experts, but consensus could not be reached despite two rounds
of voting. Similarly, magnetic sphincter augmentation was considered an acceptable option by up to 53.3%
of experts in cases of symptomatic GERD after SG and excessive weight loss, but no consensus was reached.

Overall, when considering revisional surgery following LSG, reevaluation with EGD or upper GI series was
widely regarded as warranted, while controversy remained regarding whether additional testing was
essential. In addition, in cases where medical therapy was deemed inadequate, the only revisional surgical
[67]
approach to achieve expert consensus was RYGB . Studies informing the importance of medical
management and evidence supporting the escalation to additional endoscopic or surgical intervention post-
LSG such as magnetic sphincter augmentation or revisional RYGB are described below.

In individuals who develop de novo reflux after LSG with adequate weight loss, expert consensus supports
[67]
that the use of medical management is appropriate and reasonable, typically with PPIs as described in
guidelines for GERD management . In fact, medical therapy has proven to be quite effective at managing
[68]
GERD symptoms post LSG. A multicenter cohort study of 379 LSG patients who had GERD
postoperatively found that, after excluding postoperative anatomic abnormalities as the etiology of
[47]
symptoms, medical treatment with PPIs was effective in 79% of cases (n = 300). All patients experienced
resolution of symptoms within two years, allowing for discontinuation of the PPI .
[47]

More recently, potassium-competitive acid blockers (PCABs) such as vonoprazan have become available for
the treatment of both erosive and nonerosive GERD. A randomized controlled trial of 1,024 adults with
erosive esophagitis demonstrated that vonoprazan 20 mg daily was noninferior, and superior to the PPI
lansoprazole 30 mg daily for healing of erosive esophagitis, particularly in the patient group with severe
esophagitis (LA Grades C/D). The study also demonstrated that vonoprazan 20 or 10 mg was noninferior,
and superior to lansoprazole 15 mg for maintenance of healing . The safety profile of vonoprazan over 5
[69]