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Page 12 of 17 Shaker et al. Mini-invasive Surg. 2025;9:27 https://dx.doi.org/10.20517/2574-1225.2024.105

years has recently become available. In a cohort of Japanese patients who achieved healing of erosive
esophagitis with either vonoprazan 20 mg daily (n = 139) or lansoprazole 15 mg daily (n = 69), participants
were then placed on maintenance therapy with vonoprazan 10 mg daily or lansoprazole 15 mg daily for a
duration of 260 weeks. Although serum gastrin levels were higher in those treated with vonoprazan, there
were no reports of malignant alterations or neuroendocrine tumors in either group. The incidence of
[70]
adverse events was also similar between these groups . While longer-term studies assessing its efficacy and
cost-effectiveness have not yet been performed, and issues with affordability and insurance coverage for
vonoprazan make its widespread use unclear, PCABs represent a promising option particularly in cases of
severe esophagitis post-LSG.

Regurgitative GERD following LSG, in particular, may not be responsive to PPIs. In patients who have
achieved adequate weight loss post-LSG but with severe GERD, augmentation of the LES with the
laparoscopically placed magnetic sphincter device Linx may be an option as a rescue therapy. However, as
[67]
mentioned above, consensus regarding this approach has not been reached by expert surgeons . A
retrospective analysis evaluated 22 post-LSG patients with persistent GERD symptoms requiring daily anti-
reflux medications who subsequently underwent laparoscopic MSA. The mean interval time to placement
was 43.6 months, with follow-up ranging from 6 to 12 months . No adverse events including erosions or
[71]
device-related mortality were reported. GERD-HRQL scores improved significantly following MSA (from
43.8 to 16.7, P < 0.0001), and most patients (82%) were able to discontinue anti-reflux medications (P <
[71]
0.049) .

An observational, multicenter single-arm prospective study evaluated the safety and efficacy outcomes of
MSA in 30 LSG subjects with persistent GERD symptoms for > 6 months requiring daily PPI . Patients
[72]
were followed for 12 months post-implantation. Dysphagia and pain occurred in 6.7% of participants but
self-resolved. Two subjects required device removal, one at 2 weeks and another at 4 months. GERD-HRQL
scores improved by 81% (P < 0.001), PPI usage decreased by 96% (P < 0.001), and total distal acid exposure
time normalized or decreased by more than 50% in 44% of patients (from 16.2% at baseline to 11% at 12
[72]
months, P = 0.028) . While these results are promising, larger, well-designed prospective or randomized
controlled trials are still needed to evaluate long-term safety, efficacy, and cost-effectiveness. Although there
is no consensus on its use post-LSG, magnetic sphincter augmentation with LINX may be considered a
rescue option in carefully selected candidates.

Radiofrequency therapy administered via the Stretta system was approved by the FDA in 2000 for the
treatment of GERD. However, systematic reviews and meta-analyses for the efficacy of radiofrequency
therapy on the LES have yielded inconsistent results with regard to its effectiveness in treating GERD [73,74] .
The available data on bariatric patients are equally unsatisfying. A retrospective review of 15 patients with
GERD symptoms following LSG evaluated outcomes after Stretta therapy . In this small cohort study,
[75]
mean HR-QoL scores were unchanged between pre- and post-Stretta at 6 months. PPI use was discontinued
in 20% of patients and reduced from twice to once a day in 27%. However, most patients (67%) remained
dissatisfied with the results. Importantly, there was one case of hematemesis post-Stretta, requiring re-
endoscopy . Overall, the efficacy of Stretta remains uncertain even in the bariatric population.
[75]
Other alternatives that have been explored in smaller studies and case presentations include electrical
stimulation of the LES and endoscopic anti-reflux mucosectomy (ARMS), wherein scar tissue is generated
[76]
at the level of the EGJ via EMR/ESD . The safety and efficacy of LES electrical stimulation were
[77]
investigated in a multicenter study involving 17 post-SG patients with GERD symptoms partially responsive
to PPI across six centers . The median follow-up was 12 months. Significant improvement was observed in
[76]