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Page 4 of 5 Al-Khyatt et al. Mini-invasive Surg 2018;2:3 I http://dx.doi.org/10.20517/2574-1225.2017.49

improved by LRYGB. For these reasons, most experts consider LRYGB a better treatment modality than
traditional anti-reflux surgery in managing GORD as it also treats underlying obesity and associated
2
comorbidities [26,27,29] . The benefits of LRYGB in BMI < 30 kg/m patients is less clear and needs further
study [26,27,29] .

[27]
In this survey, the attitudes of UK surgeons was consistent with previous published international studies .
[27]
In a similar online survey by Pagé et al. who examined the opinions of Members of the Society of
American Gastrointestinal and Endoscopic Surgeons (SAGES) regarding the management of GORD in
2
the setting of obesity, most surgeons would offer laparoscopic anti-reflux surgery for patients with BMI < 35 kg/m
and symptomatic GORD, while LRYGB was considered the procedure of choice for those patients with BMI
[27]
> 35kg/m 2[27] . However, Pagé et al. suggest that morbidly obese patients with GORD, who would otherwise
be best served with LRYGB, actually underwent Nissen fundoplication or no procedure at all due to financial
limitations and policy exclusions. In contrast, UK surgeons would not consider bariatric surgery as their
choice mainly due to the lack of national consensus and guidelines. Restrictions in commissioning in the
UK may also have an impact if a significant number of patients were to undergo bariatric surgery primarily
to manage reflux. The results of this survey may help inform surgeon practices pending development of
much needed national consensus guidelines.

Limitations of this study include an 18% response rate, and that the opinions of specialty associations may
not be representative of the wider UK surgical community. Finally, this study was designed to elicit surgeon
opinions and attitudes and was not a randomised study comparing the two approaches.

In conclusion, this survey demonstrated bariatric surgery, specifically LRYGB, to be considered the preferred
2
treatment option for BMI ≥ 35 kg/m patients with refractory GORD. There is a need for published national
guidance to inform clinical practice on the management of GORD in patients with severe and complex
obesity.

DECLARATIONS
Authors’ contributions
Manuscript preparation and data acquisition: Al-Khyatt W, Awad S, Leeder P
Data analysis and parasitological classification: Al-Khyatt W
Literature search: Al-Khyatt W
Data acquisition: Al-Khyatt W
Anatomopathological classification: Al-Khyatt W, Awad S, Leeder P
Study design and definition of intellectual content: Al-Khyatt W, Awad S, Leeder P

Data source and availability
All data are stored in a password protected hard drive and available on request via the corresponding author.

Financial support and sponsorship
Sherif Awad has received unrestricted educational and travel grants from Fresenius Kabi, Nestle Nutrition,
Medtronic, Ethicon EndoSurgery, Merck Sharp &Dohme, Fischer &Paykel Healthcare Ltd, and BBraun. He
has received honoraria and consultancy fees from Apollo Endosurgery, Merck Sharp &Dohme and Fischer
&Paykel Healthcare Ltd. He has also completed a bariatric fellowship funded via an educational grant from
Ethicon EndoSurgery (paid to the institution). Paul Leeder has received unrestricted educational grants from
Ethicon, Medtronic and Allergan. He has received honoraria from Karl Storz and Allergan.

Conflicts of interest
The authors have no direct conflicts of interest to declare.