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Page 6 of 11 Fontan et al. Mini-invasive Surg 2020;4:29 I http://dx.doi.org/10.20517/2574-1225.2020.09

Figure 4. High resolution manometry showing a hiatal hernia and abnormal contraction propagation

medical management, have extra-esophageal manifestations, have complications of GERD, or have a
personal preference or medical reason to avoid life-long PPI use. The gold standard laparoscopic Nissen
fundoplication and the more recent Linx procedure have been shown to be very successful and equally
effective in multiple studies [46,47] . The literature shows rates of symptomatic recurrence of heartburn less
than or equal to 10%, improvement in regurgitation higher than 85%, and long-term satisfaction rates over
[45]
90% . These numbers reflect outcomes in the general population. However, when patients are stratified
and segregated by their BMI, results are not as favorable.

The long-term durability of anti-reflux procedures in obese patients is a topic of controversy. The lack of
definitive consensus is in part related to the fact that most of the studies available lack statistical power, fail
to adequately represent morbidly obese patients, and, most importantly, have limited information on long-
term outcomes. The preponderance of the data suggests that durability and efficacy is decreased in obesity
[48]
[Table 1]. Perez et al. noted an overall symptomatic recurrence rate of 31.3% in obese patients who
underwent Nissen or transthoracic Belsey Mark IV fundoplication compared to 4% in normal-weight patients.
[49]
In a study conducted to determine risk factors for failure of anti-reflux surgery, Morgenthal et al. identified
a BMI greater than 35 as a significant risk factor for failure. Interestingly, in an obese cohort undergoing
salvage gastric bypass after a failed fundoplication, the incidence of wrap disruption appeared to be higher
than the rate of an intact herniated wrap. This observation suggests that the mechanism of failure in obese
[50]
patients may be different than in the non-obese population .
When compared to Laparoscopic Roux-en-Y Gastric Bypass (LRYGB), the rates of LSG have increased over
[51]
the last decade. It is now the most commonly performed weight-loss metabolic surgery in the world .
LSG has become popular among surgeons due to its relatively simple technique, lack of anastomoses and
fewer potential associated complications. This is problematic, secondary to the significant correlation
between obesity and GERD as well as the ill-defined role that the LSG has in the treatment of this cohort.
Currently, there is no consensus on the management of GERD in the obese population as it relates to
which operation is best, but the data suggest that the RYGB is a superior operation when considering
GERD-related outcomes. This is perhaps best illustrated by the fact that postoperative GERD was the most