Page 9 - Read Online

Page 2 of 17 Shaker et al. Mini-invasive Surg. 2025;9:27 https://dx.doi.org/10.20517/2574-1225.2024.105

[1]
effective interventions. Obesity is also a known risk factor for gastroesophageal reflux disease (GERD) , a
[2]
multifactorial disorder that is increasing in prevalence, affecting nearly 20% of the global population , and
[3]
present in nearly 51% of patients with severe obesity undergoing evaluation for bariatric surgery .
While a number of surgical treatment options are available to treat obesity, the two most commonly
performed procedures are sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), which account
for 60% and 20% of anti-obesity surgeries, respectively. The adjustable gastric band, which has largely fallen
out of favor due to intolerable side effects, and biliopancreatic diversion procedures, with or without
[4-6]
duodenal switch, each account for less than 2% of cases . Of note, several of the less common bariatric
surgeries, such as biliopancreatic diversion with duodenal switch (BPD-DS) as well as newer approaches
such as single-anastomosis duodeno-ileal bypass with SG (SADI-S), utilize SG as a first step or part of the
[7]
procedure .
Laparoscopic sleeve gastrectomy (LSG) is now one of the most commonly used bariatric procedures for
weight loss. It involves a vertical gastric resection of approximately 75%-85% of the stomach along the
greater curvature to the fundus, without any intestinal bypass. This procedure also removes the primary
source of the hunger-inducing hormone, ghrelin, in the fundus. Candidates for LSG are individuals healthy
enough to undergo surgery with a body mass index (BMI) ≥ 40, or a BMI ≥ 35 with at least one serious
obesity-related health condition, e.g., type 2 diabetes mellitus (DM), obstructive sleep apnea, hypertension,
arthritis, or hypercholesterolemia. Surgical intervention may also be considered for individuals with a BMI
of 30-35 who have poorly controlled type 2 DM. Advantages of LSG include its relative simplicity, safety,
and high efficacy in terms of weight loss and improvement of obesity-related health conditions, and quality
of life. Compared to RYGB, it is a technically easier and faster operation, and in low-acuity patients, it may
[8]
even allow for same-day discharge following the procedure .

Although acute and chronic surgical complications of LSG, including bleeding, staple line leaks, and
[9]
fistulae, have been reported, they are relatively infrequent . Unlike RYGB, LSG carries no risk of internal
hernias and does not preclude future endoscopic exploration of the duodenum or biliary tree, which may be
[10]
necessary in cases such as choledocholithiasis . Additional long-term risks, which can occur within
months to several years after the procedure, include gastric stricture and vitamin or mineral deficiencies.
Importantly, there are increased concerns that LSG may exacerbate preexisting GERD, contribute to the
development of de novo GERD, or increase the risk of GERD-related complications such as Barrett’s
esophagus (BE). GERD is a multifactorial disorder defined as the “presence of gastric contents in the
esophagus that causes troublesome symptoms and/or injury to the esophageal mucosa” . Postoperative
[11]
GERD following LSG is an alarming concern, not only due to its associated morbidity , but also because
[12]
BE is a recognized risk factor for esophageal adenocarcinoma . This review summarizes possible
[13]
pathophysiologic mechanisms leading to GERD, the published prevalence of GERD after LSG, and
strategies for preventing and treating GERD in the setting of LSG.

PATHOPHYSIOLOGY OF GERD WITH LSG
A number of mechanisms have been proposed to play a role in the development of GERD symptoms after
SG, in part through disruption of the “anti-reflux barrier” . Changes in the angle of His during sleeve
[10]
creation, a decrease in lower esophageal sphincter (LES) basal pressures due to resection of the low sling
fibers , and increased intragastric pressure within the narrow, tubular sleeve have all been proposed to
[14]
[15]
create an imbalance between elevated gastric pressure and decreased LES pressure, potentially leading to
postoperative reflux. Increased rates of hiatal hernia, with proximal sleeve migration above the hiatus due to
dissection of the phreno-esophageal ligament, have also been proposed as a mechanism contributing to