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Eskander et al. Mini-invasive Surg 2024;8:32 https://dx.doi.org/10.20517/2574-1225.2024.71 Page 7 of 10

months after SG, because of the remaining severe GERD symptoms. In general, it is estimated that 10% to
20% of patients suffer from symptomatic reflux after the SG, regardless of whether they have preoperatively
[26]
symptomatic GERD . A nationwide, cohort study conducted in the United States has reported that among
[1]
4,832 patients underwent SG, and 44.5% patients had GERD preoperatively . After SG, only 15.9% cases
had complete resolution of GERD, while the rest patients (84.1%) still continued to have symptomatic
GERD; among them, 9% cases even worsened subsequently. Meaningfully, the results of the study
demonstrated that the overall incidence of reflux after SG was nearly 45%.

A recently published multicentric study evaluating systematic endoscopy up to 6 years after SG by
Sebastianelli et al. showed scary results . The prevalence of Barrett esophagus after SG was 18.8%. The
[20]
prevalence for GERD symptoms, esophagitis and use of PPIs heightened statistically relevant from 22%, 10%
and 22% before SG to as high as 76%, 41% and 52% at follow-up, respectively.

However, these findings may be overstated, as a recent study from Johari et al. showed that possible
misinterpretation from endoscopic findings may contribute to this high rate, finding that many cases
interpreted as Barrett esophagus are in fact a tubularized gastric mucosa, demanding further studies to
[27]
evaluate the real incidence of de novo reflux and Barrett alterations . Hawasli et al. have demonstrated the
effectiveness of laparoscopic anterior fundoplication with posterior crura approximation for patients who
[28]
presented with GERD after LSG . They reported that the mean excess BMI loss was 75.5% ± 22.9%, and
reflux was resolved in all patients after surgery. One patient re-experienced GERD symptoms and one
required re-sleeving.

Nowadays, different kinds of gastric fundoplication such as Nissen, modified Rossetti, and Dor
fundoplication have been gradually and successfully combined with SG and been performed for morbidly
obese patients with or without preoperative symptomatic GERD, to control and/or prevent symptoms of
reflux after surgery. The above-mentioned procedures have all achieved satisfactory outcomes, but with
differences in complexity and procedure-related complications.

Several studies have demonstrated an increased incidence of leaks and septic complications in patients who
underwent N-Sleeve [9-13] . In a recent and largest series, Nocca et al. reported a series of 356 patients
submitted to N-Sleeve beyond their learning curve, with a reduced leak and perforation rate (2.24%, eight
patients) in addition to two late wrap perforations at 8 and 9 months postoperatively . Olmi et al. have
[29]
[8]
reported SG and modified Nissen-Rossetti fundoplication for 220 patients with obesity . The incidence of
patients without symptomatic GERD was 93.7% and 99% at 6 and 24 months postoperatively, respectively.
Meanwhile, this study reported 5.5% cases with postoperative wrap perforation and leak. In a further
prospective randomized study by the same group comparing 140 SG with 139 patients with SG and Rossetti
fundoplication, there was no difference in weight loss but still a significantly higher occurrence of wrap
perforation and leaks in the fundoplication group (4.4% vs. 0.7%) , contrasting with the few moderate or
[30]
major complications in our study.

In 2016, Nelson et al. in Orlando [14-16] described and evaluated the anterior fundoplication SG procedure
(SLEEVE-DOR) in 31 cases, where the fundus was rotated anteriorly and sutured to the left and right crus
and the arcuate ligament. In 4 months after surgery, 93% patients (30/31) were free from GERD symptoms,
which was comparable to the results of our study. The weight loss results had a mean %EWL of 47% at 4
months postoperatively. Moreover, del Genio et al. have performed LSG with anterior fundoplication (D-
SLEEVE) for 32 cases . At 14 months after surgery, all of them were free from GERD symptoms, and the
[17]
2
postoperative BMI and %EWL were 32.1 kg/m and 59%, respectively. However, both studies and our