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Page 8 of 11 Fontan et al. Mini-invasive Surg 2020;4:29 I http://dx.doi.org/10.20517/2574-1225.2020.09

patients, 70% of patients with preop GERD had no resolution of symptoms after LSG, with 8.6% of patients
[58]
developing de novo GERD after 3 years . In another study with six years of follow up after LSG, 23% of
[59]
patients had GERD compared to 3.6% prior to surgery . However, in a systematic review that included
33 articles with 8092 post-LSG patients, the authors concluded that there was a trend in increased GERD
prevalence following LSG, but no definitive conclusions were attained due to the high heterogeneity of
[60]
the studies . In another study which included 3534 obese patients, the occurrence of de novo GERD
was 9.3% after LSG and 2.3% after LRYGB. Overall, 40.4% of patients who had undergone LSG eventually
showed improvement or remission of GERD, compared to 74.2% of patients in the LRYGB group. The
[61]
pooled analysis showed that, compared with LSG, LRYGB had a better effect on GERD . It is impossible
to concretely state the risk of GERD following LSG due to the lack of well-designed studies and adequate
long-term follow up. Notwithstanding this fact, the data do advocate for the superiority of the RYGB when
compared with the LSG in the care of a population with concomitant GERD and obesity.

One of the contributing factors to the difficulty of treating this population is the lack of a consensus on
the appropriate preoperative evaluation of the anatomy and function of the foregut prior to a weight loss
and metabolic operation. Some authors have advocated for the routine use of EGD and esophagrams,
while others have stated that these are not necessary. Many of these papers were published before the
LSG era when RYGB and laparoscopic adjustable gastric band were the principal operations offered. With
[62]
this in mind, Kavanagh et al. protocolized patients with subjective GERD symptoms to undergo preop
workup including esophagram and EGD. In the cases where the patient desired LSG, further assessment
with esophageal pH testing and high-resolution manometry were ordered. Interestingly, they showed
that pathology was commonly found on testing; based on protocol test results, 24.8% of their patients
[62]
had a change in the procedure selected. Kavanagh et al. set a perfect example of the current trajectory
in patient care within the bariatric surgery field. Despite excellent results with the available standardized
pathways such as “Enhanced Recovery After Bariatric Surgery”, the field is moving toward offering
each patient individualized care based on their comorbidities, functional status, and risk-benefit from
surgery [63-65] . Different calculators can assist surgeons to select the most suitable surgery in order to ensure
the best possible outcome. For example, the individualized metabolic surgery score calculator has been
[66]
proposed for procedure selection based on diabetes severity . It is used to differentiate patients who have
higher odds of improvement/resolution of their diabetes based on disease severity and type of operation.
Another example is set by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement
[67]
Program risk-benefit calculator . This tool helps to guide surgical decision-making and informed
consent. By implementing 20 patient predictors, this calculator offers information on the likelihood that
patients will experience common morbidities and can forecast weight loss and comorbidity resolution.
Whether addressing the chance to cure diabetes and GERD or the potential for perioperative morbidity,
individualized care based on unique patient characteristics represents the future of surgery in an obese
population.

CONCLUSION
Obesity and GERD are both conditions with a significant impact on health-related quality of life and
global health resource utilization. The implications of inadequately treated GERD can lead to dangerous
complications and need for potentially morbid interventions. There are clear limitations in interpreting the
available data due to inconsistency in the definition of GERD. Moreover, the complexity and invasiveness
of objective evaluation of GERD can impede its widespread application. However, when surgical treatment
of GERD is indicated in an obese patient, adequate preoperative evaluation can maximize the probability of
addressing all the patient’s comorbidities. In addition, offering LRYGB rather than LSG or fundoplication
should be strongly considered in this patient population in order to maximize the potential for a positive
outcome.