Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Apr 7, 2017; 23(13): 2269-2275
Published online Apr 7, 2017. doi: 10.3748/wjg.v23.i13.2269
Gastroesophageal reflux disease and morbid obesity: To sleeve or not to sleeve?
Fabrizio Rebecchi, Marco E Allaix, Marco G Patti, Francisco Schlottmann, Mario Morino
Fabrizio Rebecchi, Marco E Allaix, Mario Morino, Department of Surgical Sciences, University of Torino, 10126 Torino, Italy
Marco G Patti, Francisco Schlottmann, Center for Esophageal Diseases and Swallowing, University of North Carolina, Chapel Hill, NC 27599, United States
Author contributions: Rebecchi F and Allaix ME contributed equally to this work; Rebecchi F, Allaix ME, Patti MG, Schlottmann F and Morino M designed and performed the research; Rebecchi F, Allaix ME and Schlottmann F analyzed the data; Rebecchi F and Allaix ME drafted the paper; Patti MG revised the language; Patti MG and Morino M critically revised the manuscript for important intellectual content; all authors approved the final version of the article for publication.
Conflict-of-interest statement: No conflict of interest.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Mario Morino, MD, Professor, Department of Surgical Sciences, University of Torino, Corso A. M. Dogliotti, 14 - 10126 Torino, Italy. mario.morino@unito.it
Telephone: +39-11-6313159 Fax: +39-11-6312548
Received: November 25, 2016
Peer-review started: November 28, 2016
First decision: December 29, 2016
Revised: January 15, 2017
Accepted: March 15, 2017
Article in press: March 15, 2017
Published online: April 7, 2017

Laparoscopic sleeve gastrectomy (LSG) has reached wide popularity during the last 15 years, due to the limited morbidity and mortality rates, and the very good weight loss results and effects on comorbid conditions. However, there are concerns regarding the effects of LSG on gastroesophageal reflux disease (GERD). The interpretation of the current evidence is challenged by the fact that the LSG technique is not standardized, and most studies investigate the presence of GERD by assessing symptoms and the use of acid reducing medications only. A few studies objectively investigated gastroesophageal function and the reflux profile by esophageal manometry and 24-h pH monitoring, reporting postoperative normalization of esophageal acid exposure in up to 85% of patients with preoperative GERD, and occurrence of de novo GERD in about 5% of cases. There is increasing evidence showing the key role of the surgical technique on the incidence of postoperative GERD. Main technical issues are a relative narrowing of the mid portion of the gastric sleeve, a redundant upper part of the sleeve (both depending on the angle under which the sleeve is stapled), and the presence of a hiatal hernia. Concomitant hiatal hernia repair is recommended. To date, either medical therapy with proton pump inhibitors or conversion of LSG to laparoscopic Roux-en-Y gastric bypass are the available options for the management of GERD after LSG. Recently, new minimally invasive approaches have been proposed in patients with GERD and hypotensive LES: the LINX® Reflux Management System procedure and the Stretta® procedure. Large studies are needed to assess the safety and long-term efficacy of these new approaches. In conclusion, the recent publication of pH monitoring data and the new insights in the association between sleeve morphology and GERD control have led to a wider acceptance of LSG as bariatric procedure also in obese patients with GERD, as recently stated in the 5th International Consensus Conference on sleeve gastrectomy.

Keywords: Sleeve gastrectomy, Gastroesophageal reflux, Morbid obesity, Ambulatory pH monitoring, Esophageal manometry

Core tip: The current evidence about reflux control and the occurrence of de novo gastroesophageal reflux disease (GERD) after laparoscopic sleeve gastrectomy (LSG) is controversial. Recent studies that have objectively evaluated GERD after LSG have shown no significant increase in postoperative GERD. The absence of mid-stomach narrowing and retained fundus, and the repair of a concomitant hiatal hernia seem to be key in reducing the risk of postoperative GERD. We discuss the currently available evidence on the impact of LSG on GERD, focusing on surgical technical aspects and new minimally invasive approaches for the management of postoperative GERD.