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Shaker et al. Mini-invasive Surg. 2025;9:27 https://dx.doi.org/10.20517/2574-1225.2024.105 Page 13 of 17

median GERD-HRQL scores post-procedure (P < 0.001), and distal esophageal acid exposure decreased
[76]
from 13.2% to 5.8% (P = 0.01). At the final follow-up, 41% had completely discontinued PPIs . A case
[78]
report of ARMS described a 71-year-old female who underwent SG in 2013 and presented worsening
GERD symptoms despite twice-daily PPI use. Her primary symptom was regurgitation. She was not a
candidate for RYGB due to comorbidities including COPD and dilated cardiomyopathy. At 7-month
follow-up post-ARMS, she had improvement in her GERDQ score from 11 to 8, and normalization of pH
testing using DeMeester scores (17.7 to 5.8). Acid exposure time was not reported in this study . While
[78]
evidence remains limited, these procedures may hold promise for the management of bariatric patients. In
particular, for patients who are either unwilling or medically unsuitable to undergo RYGB, continued
exploration into these alternative approaches is warranted.

As previously noted, in cases where medical therapy is inadequate, the only revisional surgical approach to
achieve consensus among experienced bariatric surgeons in the Delphi process was RYGB. An earlier meta-
analysis and systematic review examining GERD outcomes following LSG and RYGB included four studies
that reported conversion rates, with the proportion of conversion from LSG to LRYGB for GERD ranging
[60]
from 1.82 to 8.91% . Improvement and/or resolution of GERD symptoms has also been investigated with
revisional RYGB following LSG. A retrospective, 3:1 propensity score-matched cohort study compared
outcomes between primary RYGB (n = 332) and conversional RYGB following LSG (n = 149), with a 2-year
[79]
follow-up . GERD (LA Classification Grade A-D esophagitis) with or without weight loss failure, was the
[79]
indication in 30% of conversional RYGB cases . Although symptoms were not reported, post-conversional
[79]
RYGB revealed LA Grade A esophagitis in 7.4% of patients , which does meet current diagnostic criteria
for GERD . Notably, no cases of de novo GERD were reported in this study during the follow-up of only 2
[80]
years. While it is clear that in a subset of patients post-primary RYGB, GERD symptoms either occur de
novo or do not resolve , this cohort study supports the Delphi consensus agreement to offer LSG
[59]
[67]
[79]
patients with medically refractory GERD a conversion to a RYGB [Table 3].
CONCLUSIONS
GERD and obesity coexist in many patients, and the prevalence of both conditions continues to rise. One of
the most common methods for treating obesity is LSG, which is effective for inducing weight loss,
improving associated comorbidities, and enhancing quality of life. However, LSG is also associated with an
increased risk of de novo and/or worsening GERD. The mechanisms leading to worsening and/or de novo
GERD post LSG are multifactorial and may, in certain instances, be obviated by a surgical approach. Careful
selection of patients for LSG through preoperative evaluation for GERD may avoid the risk of severe GERD
following the procedure, although the best approach (upper endoscopy alone or coupled with additional
testing) has yet to be defined. Patients with preexisting GERD, particularly those with severe esophagitis or
large hiatal hernias, should be counseled about the increased risk of GERD worsening following LSG. In
such cases, they should be considered a priori for alternative weight loss/bariatric options such as RYGB, or
LSG in conjunction with hiatal hernia repair or fundoplication, with a discussion of the associated benefits
and risks. For those patients who develop de novo or worsening GERD post-LSG, management should be
based in part on the success of weight loss and the severity of GERD. Consensus-supported treatment
options include medical management, which now encompasses both PPIs and PCABs. For suitable and
willing candidates, conversion to RYGB remains a surgical option. Potentially alternative and currently
exploratory approaches such as magnetic sphincter augmentation or LES sphincter stimulation could be
considered as rescue options. Ultimately, precise phenotyping and careful patient selection are critical to
minimizing, and/or at the very minimum, appropriately addressing the risk of de novo or worsening GERD
following LSG [Figure 1].