Impact of obesity treatment on gastroesophageal reflux disease

Perceptual, Aerodynamic and Acoustic Evaluation of Vocal Characteristics in Subjects With Obesity

INTRODUCTION

Obesity has tripled since 1975 and affects health across many domains. Increasing body mass index increases the risk to the obese subject of many non-communicable diseases. The study evaluated the perceptive, aerodynamic, and acoustic parameters that characterize the voice of the obese population.

METHODOLOGY

Eighty adult subjects (40 participants in each obese and control group) aged 18-50 years were enrolled. The perceptual voice analysis was performed using the Consensus Auditory Perceptual Evaluation of Voice. The aerodynamic and acoustic voice analyses were performed using the MIR Spiro lab instrument and Doctor's Speech software. A digital stopwatch was also used to measure maximum phonation time.

RESULTS

Statistical analysis revealed a significant difference (P-value <0.05 and t value >2) between two groups on acoustic parameters, specifically Normalized noise energy and fundamental frequency tremor (F0 tremor). Normalized noise energy and fundamental frequency tremor were greater in the obese group. Moreover, maximum phonation time and expiratory reserve volume were significantly reduced in the obese group.

DISCUSSION AND CONCLUSION

Results of the present study showed poor voice quality and reduced expiratory reserve volume in obese individuals. This could be credited to the adverse effects of accrued adipose on the functioning of the laryngeal and respiratory systems. Increasing body mass index escalates the risk to the obese subjects of many non-communicable diseases.

Banded Versus Non-banded Sleeve Gastrectomy: A Systematic Review and Meta-Analysis

Standard bariatric surgeries include biliopancreatic diversion (BPD), sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and adjustable gastric banding (AGB). Laparoscopic sleeve gastrectomy (LSG) is currently favored due to safety, efficacy, and shorter operation time. However, previous literature shows 75.6% weight regain post LSG. Introducing Laparoscopic band sleeve gastrectomy (LBSG) to maintain pouch size is proposed to improve outcomes and reduce weight regain. This study aims to compare the safety and efficacy of LSG vs. LBSG in obese patients. A comprehensive search strategy was executed to identify pertinent literature comparing LBSG and LSG in obese patients. Eligible studies underwent independent screening, and pertinent data were systematically extracted. The analysis employed pooled risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous variables, each accompanied by their respective 95% confidence intervals (CI). Our systematic review and meta-analysis included 15 studies encompassing 3929 patients. Regarding body mass index (BMI), at six, 12, and 24 months, no substantial differences were found between LBSG and LSG groups (p < 0.05). Still, at 36 months, LBSG exhibited significantly lower BMI than LSG (MD = -2.07 [-3.84, -0.29], p = 0.02). Excess Weight Loss (EWL) favored LBSG at 12, 24, and 36 months with MD of 3.30 [0.42, 6.18], 4.13 [1.44, 6.81], and 18.43 [9.44, 27.42], p = 0.02, 0.003, < 0.00001, respectively). Operative time did not significantly differ between the procedures (MD = 2.95, 95%CI [-0.06, 5.95], p = 0.05). Resolution of comorbidities, overall complications, post-operative bleeding, reflux, and early complications did not significantly differ between LBSG and LSG. However, LBSG showed higher post-operative regurgitation than LSG (RR = 2.38, 95%CI [1.25, 4.54], p = 0.008). LBSG showed a substantial decrease in BMI at three-year follow-up and higher EWL at one, two, and three years. However, LBSG procedures exhibited a higher incidence of post-operative regurgitation symptoms than LSG. No substantial differences were noted in BMI at six, 12, or 24 months, EWL at six months, operative time, bleeding, reflux, or overall complications.

Clinical Outcome and Recurrence of Open versus Laparoscopic Nissen Fundoplication in the Republic of Kazakhstan during 2010-2021

Background

Surgical treatment of recurrent gastroesophageal reflux disease (GERD) negatively affects patients' quality of life (QoL). Determination of risk factors is essential when considering a surgical approach. The present study aimed to evaluate short-term and long-term outcomes of primary laparoscopic Nissen fundoplication (LNF) and open Nissen fundoplication (ONF), as well as the risks of laparoscopic redo fundoplication.

Methods

A retrospective cohort observational study was conducted from 2010 to 2021 at the National Research Center of Surgery (Almaty, Kazakhstan). Depending on the type of primary GERD surgical correction, 475 patients were stratified into two groups, namely LNF (n=117) and ONF (n=358). The outcomes and associated complications of LNF and ONF surgeries were assessed. The odds ratio of recurrent GERD in terms of risk factors was analyzed as well as post-intervention QoL.

Results

Postoperative complications in ONF surgery were 2.7-fold higher than in LNF (P=0.0001). Moreover, intra-operative complications were higher with ONF surgery (7.7%) than with LNF (1.4%) (P=0.002). In cases with persistent clinical manifestations, the rate of redo fundoplication was the same after failed primary LNF and ONF. The risk factors associated with recurrent GERD, leading to redo fundoplication, were obesity (OR=2.16, P=0.473) and male sex (OR=3.0, P=0.272). One-year after LNF, 88.7% of the patients were satisfied with the outcome of the surgery.

Conclusion

Recurrent symptoms of GERD and the rate of redo fundoplication were associated with obesity and the male sex. Obesity was the main risk factor, necessitating stringent selection of patients for surgical management of the disease.

Sleeve gastrectomy morphology and long-term weight-loss and gastroesophageal reflux disease outcomes

BACKGROUND

The relationship between sleeve gastrectomy (SG) morphology and long-term weight-loss and gastroesophageal reflux disease (GERD) outcomes is unknown.

METHODS

All patients (n = 268) undergoing SG performed by 3 surgeons at a single academic institution from January 1, 2010 to December 31, 2012 were included. Long-term weight-loss and GERD outcomes were available for 90 patients which were incorporated in analyses. SG morphology was determined from postoperative day 1 upper gastrointestinal series (UGIS) available from 50 patients. Images were independently categorized using previously published methodology as Dumbbell (38%), Lower Pouch (22%), Tubular (26%), or Upper Pouch (14%) by Radiologist and Surgeon. Radiologist categorization was used when disagreement occurred (8%). Univariable analyses were conducted to explore potential associations between SG morphology, weight loss, and GERD outcomes.

RESULTS

Follow-up was 8.2 ± 0.9 years. Population characteristics included age of 45.1 ± 10.8 years, female sex in 83.3%, and hiatal hernia repair (HHR) performed at index SG in 17.8%. Surgeons did not preferentially achieve a specific SG morphology. Changes from preoperative obesity and associated diseases comprised body mass index (BMI) (49.5 ± 7.6 vs. 39.2 ± 9.4 kg/m²; p < 0.0001), diabetes mellitus (30.0 vs. 12.2%; p = 0.0006), hypertension (70.0 vs. 54.4%; p = 0.0028), hyperlipidemia (42.2 vs. 24.2%;p = 0.0017), obstructive sleep apnea (41.1 vs. 15.6%; p < 0.0001), osteoarthritis (48.9 vs. 13.3%; p < 0.0001), back pain (46.5 vs. 28.9%; p = 0.0035), and medications (4.8 ± 3.3 vs. 3.7 ± 3.5; p < 0.0001). Dumbbell SG morphology was associated with lesser reduction in BMI at follow-up (--6.8 ± 7.2 vs. -12.4 ± 8.3 kg/m²; p = 0.0196) while greater BMI change was appreciated with Lower Pouch SG shape (-16.9 ± 9.9 vs. -8.4 ± 6.8 kg/m²; p = 0.0017). GERD was more prevalent at follow-up than baseline (67.8 vs. 47.8%; p < 0.0001). GERD-specific outcomes included de novo (51.1%), persistent (27.9%), worsened (58.1%), and resolved (14.0%) disease. Ten patients underwent reoperation for refractory GERD with SG morphology corresponding to Dumbbell (n = 5) and Upper Pouch (n = 1) for those with available UGIS. Univariable analyses showed that patients with GERD experienced a larger reduction in BMI compared with patients without GERD (-11.8 ± 7.7 vs. -7.0 ± 5.1 kg/m²; p = 0.0007). Patient age, surgeon, morphology category, and whether a HHR was done at index SG were not associated with the presence of any, de novo, or worsened GERD. Female sex was associated with worsened GERD (96.0 vs. 4.0%; p = 0.0455). Type of calibration device, distance from staple line to pylorus, and whether staple line reinforcement was used were not associated with SG morphology classification.

CONCLUSION

This is the first study assessing the impact of SG morphology on long-term weight loss and GERD. Our data suggest an association between SG morphology and long-term weight loss but not with GERD outcomes. Current technical standards may be limited in reproducing the same SG morphology. This information may help guide the technical optimization and standardization of SG. Surgeons did not favor a specific SG morphology (1). Our results signal to a relationship between radiographic assessment of SG morphology and long-term weight-loss outcomes with Dumbbell classification correlated with lesser reduction in BMI (2a) and Lower Pouch morphology associated with superior weight loss (2b). SG, sleeve gastrectomy; BMI, body mass index.

Independent association of preoperative Hill grade with gastroesophageal reflux disease 2 years after sleeve gastrectomy

BACKGROUND

The sleeve gastrectomy (SG) is associated with postoperative gastroesophageal reflux disease (GERD). Higher endoscopic Hill grade has been linked to GERD in patients without metabolic surgery. How preoperative Hill grade relates to GERD after SG is unknown.

OBJECTIVE

To explore the relationship between preoperative Hill grade and GERD outcomes 2 years after SG.

SETTING

Academic hospital, United States.

METHODS

All patients (n = 882) undergoing SG performed by 5 surgeons at a single academic institution from January 2015 to December 2019 were included. Complete data sets were available for 360 patients, which were incorporated in analyses. GERD was defined as the presence of a diagnosis in the medical record accompanied by pharmacotherapy. Patients with GERD postoperatively (n = 193) were compared with those without (n = 167). Univariable and multivariable analyses were conducted to explore independent associations between preoperative factors and GERD outcomes.

RESULTS

The presence of any GERD increased at the postoperative follow-up of 25.2 (3.9) months compared with preoperative values (53.6% versus 41.1%; P = .0001). Secondary GERD outcomes at follow-up included de novo (41.0%), persistent (33.1%), resolved (28.4%), worsened (26.4%), and improved (12.2%) disease. Postoperative endoscopy and reoperation for GERD occurred in 26.4% and 6.7% of the sample. Patients with GERD postoperatively showed higher prevalence of Hill grade III-IV (32.6% versus 19.8%; P = .0062) and any hiatal hernia (HH) (36.3% versus 25.1%; P = .0222) compared with patients without postoperative GERD. Frequencies of gastritis, esophagitis A or B, duodenitis, and peptic ulcer disease were similar between groups. Higher prevalence of preoperative GERD (54.9% versus 25.1%; P < .0001), obstructive sleep apnea (66.8% versus 54.5%; P = .0171), and anxiety (25.4% versus 15.6%; P = .0226) was observed in patients with postoperative GERD compared with those without it. Baseline demographics, weight, other obesity-associated diseases, whether an HH was repaired at index SG, and follow-up length were statistically similar between groups. After adjusting for collinearity, preoperative GERD (odds ratio [OR] = 3.6; 95% confidence interval [CI], 2.2-5.7; P < .0001) and Hill grade III-IV (OR [95% CI]: 1.9 [1.1-3.1]; P = .0174) were independently associated with the presence of any GERD postoperatively. The preoperative presence of an HH >2 cm and whether an HH was repaired at index SG showed no independent association with GERD at follow-up.

CONCLUSIONS

More than 50% of patients experienced GERD 2 years after SG. Preoperative GERD confers the highest risk for GERD postoperatively. Hill grade III-IV is independently associated with GERD after SG. Whether a hiatal hernia repair was performed did not influence GERD outcomes. Preoperative esophagogastroduodenoscopy should be obtained before SG and Hill grade routinely captured and used to counsel patients about the risk of postoperative GERD after this procedure. Hill grade may help guide the choice of metabolic operation.

Laparoscopic fundoplication versus laparoscopic Roux-en-Y gastric bypass for gastro-oesophageal reflux disease in obese patients: protocol for a randomized clinical trial

BACKGROUND

Laparoscopic fundoplication (LF) is the standard surgical procedure for the treatment of gastro-oesophageal reflux disease (GORD). Laparoscopic Roux-en-Y gastric bypass (LRYGB) is commonly performed to achieve weight loss in obese patients, but it also has anti-reflux properties. Hence, in the obese population suffering from GORD, LRYGB could be an alternative to LF. The aim of this trial will be to compare LF and LRYGB in an obese population presenting with GORD and being considered for surgery.

METHODS

This will be an investigator-initiated randomized clinical trial. The research population will be obese patients (BMI 30-34.9 with waist circumference more than 88 cm (women) or more than 102 cm (men), or BMI 35-40 with any waist circumference) referred to a public hospital for consideration of anti-reflux surgery. The primary aim of the study will be to determine the efficacy of LF compared with LRYGB on subjective and objective control of GORD. Secondary aims include determining early and late surgical morbidity and the side-effect profile of LF compared with LRYGB and to quantify any non-reflux benefits of LRYGB (including overall quality of life) compared with LF.

CONCLUSION

This trial will determine whether LRYGB is effective and acceptable as an alternative to LF for the surgical treatment of GORD in obese patients Registration number: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12622000636752p (https://www.anzctr.org.au/).

Role of Non-pharmacological Interventions and Weight Loss in the Management of Gastroesophageal Reflux Disease in Obese Individuals: A Systematic Review

With the increasing prevalence of obesity, the worldwide risk of gastroesophageal reflux disease (GERD) has also increased. Abdominal obesity increases intragastric pressure, disturbing the integrity of the gastroesophageal junction, thus facilitating reflux. Other than obesity, some lifestyle factors also cause GERD, including smoking, consumption of alcohol and caffeine, late-night meals, and high fat intake. This review study aimed to assess the impact of weight loss and lifestyle modifications on GERD. In this systematic review, the databases used were PubMed, PubMed Central (PMC), Science Direct, and Google Scholar. Boolean system and Medical Subject Headings (MeSH) strategy were used to form suitable keywords. Patients from the pediatric and geriatric populations were excluded from the study and quality assessment was done using different assessment tools. A positive association between obesity and GERD was found. It was also found that the long-term use of proton pump inhibitors (PPIs) causes complications, so lifestyle interventions should be used more than PPIs for treating GERD, especially in obese patients. We concluded that weight loss could lead to the resolution of gastroesophageal reflux disease, and therefore, conservative measures, including dietary modifications such as reducing the consumption of alcohol, caffeine, and chocolate, behavioral changes such as smoking cessation and elevation of the head of the bed, and weight loss, should be used as first-line management for GERD. Although awareness has increased regarding the adverse effects of proton pump inhibitors, future studies are required to assess these negative effects.

The new onset of GERD after sleeve gastrectomy: A systematic review

Background

The main adverse effect is gastroesophageal reflux disease (GERD), with concern on the development of Barrett's esophagus and esophageal adenocarcinoma in the long term. However, the relationship between SG and GERD is complex. The aim of this study is to systematically evaluate all published data existing in the literature to evaluate the effect of sleeve gastrectomy on GERD, esophagitis, BE in order to clarify the long-term clinical sequelae of this procedure.

Materials and methods

This systematic review was conducted in accordance with the guidelines for Preferred Reporting Items for Systematic Review. The work has been reported in line with the PRISMA criteria [19]. We evaluated the quality and risk of bias of this Systematic Review using AMSTAR 2 checklist [20]. Published studies that contained outcome data for primary sleeve gastrectomy associated with the primary and secondary outcomes listed below were included. The UIN for ClinicalTrial.gov Protocol Registration and Results System is: NCT05178446 for the Organization UFoggia.

Results

49 articles were eligible for inclusion that met the following criteria: publications dealing with patients undergoing laparoscopic SG, publications describing pre- and postoperative GERD symptoms and/or esophageal function tests, articles in English, human studies and text complete available.

Conclusions

We have controversial data on LSG and GERD in the literature as there is a multifactorial relationship between LSG and GERD. The most recent studies have shown satisfactory control of postoperative reflux in most patients and low rates of de novo GERD. These data are leading to wider acceptance of LSG as a bariatric procedure even in obese patients with GERD.

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The aim of this study is to evaluate the effect of sleeve gastrectomy on GERD.

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In the literature there are controversial results on the onset of GERD after LSG.

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Satisfactory control of postoperative reflux in most patients and low rates of de novo GERD.

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These data are leading to wider acceptance of LSG as a bariatric procedure even in obese patients with GERD.

The prevalence of, and risk factors for, Barrett's oesophagus after sleeve gastrectomy

Introduction

Sleeve gastrectomy has become one of the most performed bariatric procedures. There is increasing evidence that sleeve gastrectomy patients suffer from gastroesophageal reflux disease and its sequelae such as erosive oesophagitis (EO) or Barret’s oesophagus (BO).

Aim

To evaluate the incidence of EO and BO among patients with normal preoperative oesophagogastroduodenoscopy findings, who underwent sleeve gastrectomy, and investigate factors that may contribute to the development of EO and BO after the surgery.

Material and methods

We conducted a single-centre longitudinal study that included patients who underwent sleeve gastrectomy and completed 5 years of follow-up. Gastroscopies were performed in all patients at the end of the follow-up period. Patient- and treatment-related factors were used to search for risk factors of BO.

Results

From a total of 30 patients, symptomatic reflux was reported by 17 (56.7%) during the follow-up period. At EGD EO was found in 9 of those patients (30%), whereas BE was diagnosed in 8 (27%) patients. The median BMI at the end of the follow-up period was significantly higher among patients with BE than in the groups with EO and with no endoscopic changes: 40.91 ±6.32, 32.42 ±5.53, and 33.25 ±4.41, respectively (p = 0.04).

Conclusions

The prevalence of BO in SG patients is considerable. The risk of BE increases in patients with poor bariatric outcome. Endoscopic surveillance should be considered as part of the follow-up, especially in patients with higher overall risk of BE.

Hill Modified, a Novel Approach: Technique Description and Experience in Patients with Laparoscopic Sleeve Gastrectomy

BACKGROUND

Gastroesophageal reflux disease (GERD) is a common disease among patients with obesity, with an associated prevalence of 39 to 61% between the population who attends a bariatric surgery evaluation. Laparoscopic sleeve gastrectomy (LSG) has become a popular and valid option for obesity treatment, even though the literature is ambivalent regarding the increase or decrease in GERD after this surgery. Thus, it is necessary to propose new surgical techniques as a solution to GERD in patients with a concomitant LSG or with a history of it. Therefore, we present a modified technique based on Hill's gastropexy described originally in 1967.

OBJECTIVE

Describe and propose a surgical procedure for GERD management based on the Hill technique that can be applied in all patients who undergo an LSG or with a history of it.

METHODS

Retrospective observational study with a prospective database in which we described, Hill modified technique in a group of 16 patients with GERD who underwent this procedure concomitantly with an LSG or who presented with GERD after LSG with a 3-year follow-up. The surgical technique is based on an intra-abdominal esophageal length of a minimum of 3 cm and posterior fixation of the gastroesophageal junction to the crus.

RESULTS

Postoperative controls have shown satisfactory results in the control and management of GERD symptoms in this group of patients, with very few to no complications associated with the procedure and without reintervention or medication out of the standard protocol.

CONCLUSION

Hill modified technique can be used and presented as an option for GERD control in patients with LSG.

Genetic evidence that higher central adiposity causes gastro-oesophageal reflux disease: a Mendelian randomization study

Background

Gastro-oesophageal reflux disease (GORD) is associated with multiple risk factors but determining causality is difficult. We used a genetic approach [Mendelian randomization (MR)] to identify potential causal modifiable risk factors for GORD.

Methods

We used data from 451 097 European participants in the UK Biobank and defined GORD using hospital-defined ICD10 and OPCS4 codes and self-report data (N = 41 024 GORD cases). We tested observational and MR-based associations between GORD and four adiposity measures [body mass index (BMI), waist–hip ratio (WHR), a metabolically favourable higher body-fat percentage and waist circumference], smoking status, smoking frequency and caffeine consumption.

Results

Observationally, all adiposity measures were associated with higher odds of GORD. Ever and current smoking were associated with higher odds of GORD. Coffee consumption was associated with lower odds of GORD but, among coffee drinkers, more caffeinated-coffee consumption was associated with higher odds of GORD. Using MR, we provide strong evidence that higher WHR and higher WHR adjusted for BMI lead to GORD. There was weak evidence that higher BMI, body-fat percentage, coffee drinking or smoking caused GORD, but only the observational effects for BMI and body-fat percentage could be excluded. This MR estimated effect for WHR equates to a 1.23-fold higher odds of GORD per 5-cm increase in waist circumference.

Conclusions

These results provide strong evidence that a higher waist–hip ratio leads to GORD. Our study suggests that central fat distribution is crucial in causing GORD rather than overall weight.

Do Preoperative Esophageal pH Monitoring and High-Resolution Manometry Predict Symptoms of GERD After Sleeve Gastrectomy?

BACKGROUND

Predictive factors of evolution or appearance of gastroesophageal reflux disease (GERD) after sleeve gastrectomy (SG) have not been identified to date. We aimed to assess the evolution of GERD symptoms 1 year after SG and to determine preoperative predictive factors using high-resolution manometry (HRM) and ambulatory 24-h esophageal pH monitoring (APM).

METHODS

We included 160 patients who underwent SG between 2013 and 2017 and performed preoperative APM and HRM. Positive APM was defined according to the Lyon consensus. Symptoms of GERD, proton pump inhibitors (PPI) use, weight loss (WL), and diet were recorded in all patients before and 1 year after surgery.

RESULTS

One year after surgery, 58 patients (36.3%) complained of GERD symptoms compared to 52 patients (32.5%) preoperatively (p=0.48). Among patients with preoperative GERD symptoms, only 26/52 patients (50%) still had symptoms, whereas 32/108 (29.6%) asymptomatic patients developed de novo GERD symptoms after surgery. PPI use increased after surgery reaching 36.9% of patients against 15.0% before (p<0.0001). Only preoperative symptoms of GERD were predictive of postoperative symptoms (OR= 2.47 [1.14-5.45]; p=0.023) in multivariate analysis. Preoperative manometric parameters, postoperative diet, and WL were not related to postoperative symptoms. In asymptomatic patients before surgery, silent GERD (positive APM without symptom) was predictive of postoperative GERD symptoms (OR=2.69 [1.00-7.25]; p=0.049).

CONCLUSION

Evolution of GERD symptoms after SG reveals improvement for half of the patients and de novo GERD symptoms in one-third of patients. Predictive factors of postoperative symptoms are preoperative symptoms and positive preoperative APM in asymptomatic patients.

Manometric changes of the esophagus in morbidly obese patients

This prospective study aimed to determine the manometric pattern and the prevalence of esophageal dysmotility in 79 morbidly obese patients selected for laparoscopic sleeve gastrectomy. After clinical evaluation and upper gastrointestinal endoscopy, high-resolution esophageal manometry was performed. The esophageal peristalsis, lower esophageal sphincter (LES) basal pressure, and LES relaxation were evaluated. Demographic data showed a predominance of females (55.70%) and both females and males were in the 5^th decade of life. In addition, approximately 3/4 of the patients (78.48%) were from the urban zone. The mean body mass index of the patients was 46.40±6.0069 kg/m², with a maximum of 61 kg/m². The LES basal pressure was normal in 59.49% of the patients, with a mean value of 31.40±18.43 mmHg. LES basal hypertonia was observed in 26.58%, and LES hypotonia in 13.93% of patients; 46.84% (37 patients) had abnormal manometric findings: 24.05% (19 patients) had EGJ outflow obstruction, 12.66% (10 patients) ineffective esophageal motility, 3.8% (3 patients) distal esophageal spasm, 3.8% (3 patients) Jackhammer esophagus, 2 cases were suggestive for type 2 achalasia but in asymptomatic patients. Ineffective esophageal motility was not associated with diabetes mellitus type 2 or erosive esophagitis according to our data. Hiatal hernia (HH) was manometrically diagnosed in 23 patients (29.11%). Preoperative high-resolution esophageal manometry in obese patients demonstrated a high prevalence of motility disorders, but in asymptomatic patients, thus in the future, we require more studies and larger cohorts to better appreciate the clinical impact.

Bariatric Surgery After Previous Antireflux Surgery Without Takedown of the Previous Fundoplication: a Prospective Study

BACKGROUND

The increased prevalence of reflux disease in obese patients, combined with widespread availability of laparoscopic antireflux surgery, has increased the likelihood that more patients will seek bariatric surgery having previously undergone fundoplication.

OBJECTIVES

This study examined our series of laparoscopic bariatric surgery after previous antireflux surgery without takedown of the previous fundoplication. We discuss our results, our technique and the tips and tricks to avoid complication after this procedure.

SETTING

Private practice.

METHODS

We operated on patients suffering from obesity who had already undergone laparoscopic Nissen. The patients were eligible for bariatric surgery according to the French National Institute of Health's criteria for bariatric surgery. The pre-operative assessment involved gastroscopy with biopsies looking for Helicobacter pylori, oesophago-gastroduodenoscopy, investigation for sleep apnoea syndrome and a full laboratory assessment. The patients took part in their choice of surgery.

RESULTS

The patients' post-operative course was uncomplicated. No patients had symptoms of gastro-esophageal reflux late after surgery and good gastrointestinal comfort was achieved (no pain, no reflux). All of the patients were satisfied. Length of stay was 3 to 5 days. All patients exhibited significant weight loss.

CONCLUSION

Bariatric surgery is possible after fundoplication without taking down the fundoplication. It appears to be a viable alternative in patients seeking weight loss surgery after fundoplication, which is currently assumed contraindicated.

Pathophysiology and treatment options for gastroesophageal reflux disease: looking beyond acid

Gastroesophageal reflux disease (GERD) is a disorder due to the retrograde flow of refluxate into the esophagus. Although GERD is a common clinical diagnosis, its pathogenesis is quite complex. As a result of its multifactorial development, many patients continue to experience adverse symptoms due to GERD despite prolonged acid suppression with proton pump inhibitor therapy. The pathogenesis of GERD involves an interplay of chemical, mechanical, psychologic, and neurologic mechanisms, which contribute to symptom presentation, diagnosis, and treatment. As such, GERD should be approached as a disorder beyond acid. This review will investigate the major factors that contribute to the development of GERD, including factors related to the refluxate, esophageal defenses, and factors that promote pathologic reflux into the esophagus. In reviewing GERD pathogenesis, this paper will highlight therapeutic advances, with mention of future opportunities of study when approaching GERD.

Surgical treatment of therapy-resistant reflux after Roux-en-Y gastric bypass. A case series of the modified Nissen fundoplication

Introduction: Patients with intractable reflux after RYGB have limited treatment options. Here a modified Nissen fundoplication (MNF) as described by N. Kawahara might be the answer.Methods: In this retrospective case study we identified six patients with therapy-resistant GERD after RYGB. All six were treated with a MNF, using the remnant stomach to construct the fundoplication. Short term follow-up 1 month and 6-12 months postoperatively was conducted to inquire about GERD symptoms.Results: Six patients underwent a MNF. Three out of six patients had had a gastric band in their medical history. Upper GI barium swallow test revealed herniation of the gastric pouch in 4/6 patients. After surgery all patients were symptom free and 4/6 completely stopped PPI treatment.Discussion: Mechanisms of new onset or deteriorating GERD after RYGB are herniation of gastric pouch and destruction of the lower esophageal sphincter after banding. Both problems are tackled when constructing a MNF.Conclusion: Complete symptom relief was seen 1 month after MNF. The procedure seems safe, feasible and effective. The study is limited by small sample size and short follow-up yet shows clear improvement of symptoms. Larger trials are needed to establish validity of the MNF.

Best reoperative strategy for failed fundoplication: redo fundoplication or conversion to Roux-en-Y gastric diversion?

BACKGROUND

Failed fundoplication is a difficult reoperative challenge, with limited evidence differentiating outcomes of a redo fundoplication versus conversion to Roux-en-Y anatomy with a gastric diversion (RYGD). The aim of this study was to determine the impact of these reoperative strategies on symptom resolution.

METHODS

A retrospective single institution study of patients with failed fundoplications undergoing conversion to RYGD or redo fundoplication between 2006 and 2019 was conducted. Patient characteristics, preoperative evaluation, operative findings, and postoperative outcomes were recorded and analyzed.

RESULTS

180 patients with symptomatic, failed fundoplications were identified: 101 patients (56.1%) underwent conversion to RYGD, and 79 patients (43.9%) underwent redo fundoplication. Body mass index (BMI) was significantly higher for the patients undergoing RYGD with mean BMI of 34.3 ± 6.9 vs 27.7 ± 3.9 kg/m² (p < 0.001). Patients undergoing conversion to RYGD were also more comorbid than their counterparts, with higher rates of obstructive sleep apnea (17.8% vs 5.1%, p = 0.01), but similar rates of hypertension (54.5% vs 44.3%, p = 0.18, asthma/COPD (25.7% vs 16.5%, p = 0.13), diabetes (10.9% vs 10.1%, p = 0.87), and hyperlipidemia (29.7% vs 36.7%, p = 0.32). Mean operative times were significantly higher for the RYGD (359.6 ± 90.4 vs 238.8 ± 75.6 min, p < 0.0001), as was mean estimated blood loss (168.8 ± 207.5 vs 81.0 ± 145.4, p < 0.0001). Conversion rates from minimally invasive to open were similar (10.9% vs 11.4%, p = 0.92). The incidence of recurrent reflux symptoms was not significantly different (p = 0.46) between RYGD (16.8%) and redo fundoplication (12.8%), at an average follow-up of 50.6 ± 140.7 vs 34.7 ± 39.2 months, (p = 0.03). For the RYGD cohort, patients also had resolution of other comorbidities including obesity 35.6%, OSA 16.7%, hyperlipidemia 10.0%, hypertension 9.1%, and diabetes 9.1%. On average, patients decreased their BMI by 6.8 ± 5.5 kg/m² and lost 69.6% of their excess body weight. Mean length of stay was higher in patients undergoing RYGD (5.3 ± 7.3 vs 3.0 ± 1.9 days, p = 0.01). Thirty-day readmission rates were similar (9.9% vs 3.8%, p = 0.12). The reoperation rate was higher in the RYGD cohort (17.8% vs 2.5%, p = 0.001).

CONCLUSIONS

RYBG and redo fundoplication are equivalent in terms of resolution of reflux. RYGD resulted in significant loss of excess body weight.

Predictive value of preoperative DeMeester score on conversion to Roux-en-Y gastric bypass for gastroeosophageal reflux disease after sleeve gastrectomy

BACKGROUND

Obesity is well known to increase the risk of gastroesophageal reflux disease (GERD). The impact of sleeve gastrectomy (SG) on GERD is still discussed but seems to be associated with the development of de novo GERD or the exacerbation of preexisting GERD.

OBJECTIVE

The objective of this study was to evaluate the impact of preoperative pH monitoring, using the DeMeester score (DMS), on the risk of conversion to Roux-en-Y gastric bypass (RYGB) after SG.

SETTING

University Hospital in Nantes, France.

METHODS

This monocentric study reported the results of a retrospective chart review of 523 obese individuals treated between 2011 and 2018. All patients underwent primary bariatric surgery; 95% had undergone an SG. GERD diagnosis was established with preoperative DMS based on 24-hour esophageal pH monitoring.

RESULTS

Preoperative DMS was identified in 423 patients (86%). Sixty-seven patients (14%) underwent a second bariatric procedure; among them, 36 (54%) have been converted to RYGB because of GERD. There was no significant difference between preoperative DMS (16.1 ± 22 versus 13.7 ± 14, P = .37) in patients undergoing conversion for GERD and the nonconverted ones. The sensitivity, specificity, positive predictive, and negative predictive values of the preoperative DMS for predicting conversion to RYGB were 25%, 66%, 7%, and 4%, respectively. In patients who underwent a conversion for GERD, DMS (P < .002), rates of esophagitis (P = .035), and hiatal hernia (P = .039) significantly increased after SG.

CONCLUSION

Preoperative DMS alone is not predictive of the risk of conversion of SG to RYGB for GERD.

Does weight gain, throughout 15 years follow-up after Nissen laparoscopic fundoplication, compromise reflux symptoms control?

Background:

Gastroesophageal reflux disease is defined by the abnormal presence of gastric content in the esophagus, with 10% incidence in the Western population, being fundoplication one treatment option.

Aim:

To evaluate the early (six months) and late (15 years) effectiveness of laparoscopic fundoplication, the long term postoperative weight changes, as well as the impact of weight gain in symptoms control.

Methods:

Prospective study of 40 subjects who underwent laparoscopic Nissen’s fundoplication. Preoperatively and early postoperatively, clinical, endoscopic, radiologic, manometric and pHmetric evaluations were carried out. After 15 years, clinical and endoscopic assessments were carried out and the results compared with the early ones. The presence or absence of obesity was stratified in both early and late phases, and its influence in the long-term results of fundoplication was studied, measuring quality of life according to the Visick criteria.

Results:

The mean preoperative ages, weight, and body mass index were respectively, 51 years, 69.67 kg and 25.68 kg/m². The intraoperative and postoperative complications rates were 12.5% and 15%, without mortality. In the early postoperative period the symptoms were well controlled, hernias and esophagitis disappeared, the lower esophageal sphincter had functional improvement, and pHmetry parameters normalized. In the late follow-up 29 subjects were assessed. During this period there was adequate clinical control of reflux regardless of weight gain. In both time periods Visick criteria improved.

Conclusion:

Fundoplication was safe and effective in early and late periods. There was late weight gain, which did not influence effective symptoms control.

A population-based survey of gastroesophageal reflux disease in a region with high prevalence of esophageal cancer in China

Background:

The exact relationship between gastroesophageal reflux disease (GERD) and esophageal squamous cell cancer (ESCC) is far from clarification. The aim of this study was to investigate the epidemiology of GERD in a region with high prevalence of ESCC in China.

Methods:

A population-based, cross-sectional study was conducted in a high ESCC prevalent area, Anyang, Henan, China. All subjects fulfilled questionnaires and underwent gastroendoscopy with routine esophageal biopsy. The subjects were divided into GERD subtypes (reflux esophagitis [RE] and non-erosive reflux disease [NERD]) and controls. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated to examine risk factors for RE and NERD.

Results:

A total of 2844 subjects were finally enrolled. The prevalence of GERD (RE + NERD) was 17.3%. Among them, 271 (9.53%) adults were diagnosed with RE. The prevalence of RE increased with age (7.09% in 45–50 years, 8.00% in 51–60 years, and 9.53% in 61–69 years, χ² = 62.216, P < 0.001). Sixty-seven (2.36%) subjects were diagnosed with the silent RE. A total of 221 (7.77%) subjects were diagnosed with NERD. Frequent liquid food consumption (OR [95% CI]: 1.502 [1.076–2.095]) was independent risk factor for RE as well as age, male gender, high body mass index (BMI), ever smoking. Age was independent risk factor for NERD. For silent RE, age, male gender, and frequent liquid food consumption were risk factors.

Conclusions:

In the population with high prevalence of ESCC, a high prevalence of GERD and inverted proportion of RE/NERD were presented. Age was an independent risk factor for GERD. The male gender, high BMI, smoking, and frequent liquid food consumption may be risk factors for RE but not for NERD.

Effect of wu chu yu tang on gastroesophageal reflux disease: Randomized, double-blind, placebo-controlled trial

BACKGROUND

The main symptoms of gastroesophageal reflux disease GERD are heartburn and acid regurgitation. Proton-pump inhibitors (PPI) are considered to be safe and effective for the treatment of GERD. In traditional Chinese medicine, wu chu yu tang (WCYT) is used to treat nausea after eating, vomiting, and diarrhea.

PURPOSE

We designed a randomized, double-blind, placebo-controlled clinical trial to evaluate the therapeutic effect of WCYT on GERD using omeprazole as a PPI for the positive control.

METHODS

Ninety patients with GERD were randomly assigned to the 1) control group (CG), who received an oral administration of omeprazole (20 mg) once per day and given WCYT placebo (3.0 g) three times per day for 4 weeks continuously; or the 2) treatment group (TG), who received oral administration of omeprazole (20 mg) placebo once per day and WCYT (3.0 g) three times per day for 4 weeks continuously.

RESULTS

Seventy-seven patients (37 in CG, 40 in TG) completed the trial. Both Reflux Disease Questionnaire (RDQ) and Gastroesophageal Reflux Disease Questionnaire (GERDQ) scores was less in the second assessment (V2) and in the third assessment (V3) than those in V1 (first assessment; baseline) in the CG and TG groups (all p < 0.001); the score difference of both RDQ and GERDQ between V2 and V1 was similar between CG and TG (p = 1.00, p = 0.54, respectively). The score difference of both RDQ and GERD between V3 and V1 was less in the CG group than those of the TG group (both p = 0.004).

CONCLUSION

WCYT has an effect similar to omeprazole for GERD treatment. Furthermore, this effect resulting from WCYT appeared to be maintained for a longer period of time than did that of omeprazole. A study with a larger sample size and longer study period is needed to corroborate our findings.

[Treatment of reflux esophagitis in patients with cardiofundal, subtotal and total hiatal hernias]

AIM

To analyze treatment of patients with reflux esophagitis and large hiatal hernia.

MATERIAL AND METHODS

There were 85 patients with reflux esophagitis and large hiatal hernia. Laparoscopic repair was performed in 33 patients, laparotomy - in 52 cases. All patients underwent fundo- or gastroplication by A.F. Chernousov, correction of large defect of hiatal orifice by cruroraphy was applied in 55 (64.7%) patients.

RESULTS

Postoperative morbidity was near 10% after laparoscopic and conventional surgery despite more difficult video-assisted endoscopic technique. Complications Clavien-Dindo grade I-II were noted in 4 (12.1%) patients after laparoscopic treatment and in 6 (11.5%) patients after laparotomy. Medication was effective in all cases. Two patients with subtotal hernias had complications Clavien-Dindo grade IIIB after endoscopic surgery: recurrent hiatal hernia followed by severe reflux esophagitis and dysphagia. These complications required redo surgery. Repair of hiatal orifice is always possible without mesh reinforcement. Posterior cruroraphy is feasible and effective in all patients. Incidence of intraoperative and postoperative complications is comparable in both approaches (p<0.05). Mean hospital-stay after laparotomy was 7.3 days, after laparoscopy - 5.8 days.

CONCLUSION

Endoscopic formation of antireflux cuff by A.F. Chernousov is appropriate and effective in patients with reflux esophagitis and large/giant hiatal hernias.

Oral neuromuscular training relieves hernia-related dysphagia and GERD symptoms as effectively in obese as in non-obese patients

BACKGROUND

Many physicians insist patients lose weight before their hiatal hernia (HH) condition and related symptoms including intermittent esophageal dysphagia (IED) and gastroesophageal reflux disease (GERD) can be treated, but it is not proven that body mass index (BMI) has an impact on exercise-based treatment of HH-related symptoms.

AIMS/OBJECTIVES

To investigate whether BMI has significance on IQoro® neuromuscular training (IQNT) effectiveness in treating HH-related symptoms.

MATERIAL AND METHODS

Eighty-six patients with sliding HH and enduring IED and GERD symptoms, despite proton pump inhibitor medication, were consecutively referred for 6 months' IQNT comprising 11/2 minutes daily. They were grouped by BMI which was recorded before and after IQNT, as were their symptoms of IED, reflux, heartburn, chest pain, globus sensation, non-productive cough, hoarseness, and misdirected swallowing. They were also assessed on food swallowing ability, water swallowing capacity and lip force both before and after treatment.

RESULTS

After IQNT, all BMI groups showed significant improvement (p < .001) of all assessments' and symptoms; and heartburn, cough and misdirected swallowing were significantly more reduced in the severely obese.

CONCLUSIONS AND SIGNIFICANCE

IQNT can treat HH-related IED and GERD symptoms as successfully in moderately or severely obese patients as in those with normal bodyweight.

THE ROLE OF THE TRANSDIAPHRAGMATIC PRESSURE GRADIENT IN THE PATHOPHYSIOLOGY OF GASTROESOPHAGEAL REFLUX DISEASE

ABSTRACT Gastroesophageal reflux disease (GERD) is the most common disease of the upper gastrointestinal tract in the Western world. GERD pathophysiology is multifactorial. Different mechanisms may contribute to GERD including an increase in the transdiaphragmatic pressure gradient (TPG). The pathophysiology of GERD linked to TPG is not entirely understood. This review shows that TPG is an important contributor to GERD even when an intact esophagogastric barrier is present in the setting of obesity and pulmonary diseases.

Flavanols are potential anti-obesity agents, a systematic review and meta-analysis of controlled clinical trials

BACKGROUND

The anti-obesity potential of flavonoids has been shown by animal and human studies. In this meta-analysis, we systematically reviewed controlled clinical trials and quantified the effects of flavonoids and flavonoid subclasses on obesity-related anthropometric measures.

METHODS AND RESULTS

PubMed, EMBASE, Scopus, Web of Science, and ProQuest databases were searched to identify trials examining the effect of flavonoids on body mass index (BMI), waist circumference, and body fat percentage. Fifty eight trials passed the eligibility process. Analysis endpoints were calculated as the mean difference between baseline and post-treatment. Flavonoids were in subclasses of flavanols, flavonols, isoflavones, flavanones, anthocyanins, and proanthocyanidins. They were mostly in the form of supplements and dosages varying from 40 to 1300 mg/day. Among flavonoid subclasses, flavanols showed potential for decreasing BMI, in the overall population (mean difference (MD) = -0.28 kg/m², P = 0.04; n = 21) and in the subgroups of Asians (MD = -0.42 kg/m²; P = 0.046; n = 13), ages < 50 years (MD = -0.50 kg/m²; P = 0.008; n = 14), BMI ≥ 25 kg/m² (MD = -0.30 kg/m²; P = 0.049; n = 15), and at doses ≥ 500 mg/day (MD = -0.36 kg/m²; P = 0.049; n = 12). Isoflavones also decreased BMI of non-Asian populations (MD = -0.26 kg/m²; P = 0.035; n = 13) and doses ≥ 75 mg/day (MD = -0.34 kg/m²; P = 0.027; n = 8). In the overall assessment, flavanols also decreased waist circumference (MD = -0.60 cm; P = 0.02; n = 18) but had no significant effect on body fat percentage. The available trials did not reveal significant effects from flavonols, flavanones, and anthocyanins on the specified anthropometric measures.

CONCLUSIONS

Overall results of this meta-analysis showed that flavanols have potential against obesity.

Socioeconomic Inequalities in Gastroesophageal Reflux Disorder: Results from an Iranian Cohort Study

BACKGROUND Despite progress in the health indexes in recent years, health inequalities remain as a global challenge within and between regions and countries. This study is the first to quantify the socioeconomic inequity in gastroesophageal reflux disease (GERD) using the concentration index. METHODS In this cross-sectional study, we used baseline data (7012 subjects) from the Fasa Cohort Study (the Southern Iran). The principal component analysis was used to construct socioeconomic status of the participants. The concentration index and concentration curve were used to measure socioeconomic-related inequality in GERD. Decomposition of concentration index was also done to identify the contribution of each explanatory variable to the wealth-related inequality in GERD prevalence. RESULTS The prevalence of GERD was 16.9% (95% CI: 15.9-17.7%). The overall concentration index for GERD was 0.093 (95% CI: 0.062-0.166]. Correspondingly, this figure for men and women were 0.116 (95% CI: 0.062-0.171%) and 0.091 (95% CI: 0.044-0.137%), respectively. The main contributors of socioeconomic-related inequality in GERD prevalence were socioeconomic status (64.4%), alcohol drinking (29%), and age (8.4%). CONCLUSION GERD is significantly more concentrated among richest people. There was significant socioeconomic inequality in GERD according to some individual factors. These inequalities need to be addressed by policy makers to identify the vulnerable subgroups and to reduce the disease burden in the community.

Management of gastroesophageal reflux disease in adults: a pharmacist's perspective

Gastroesophageal reflux disease (GERD) is a common gastrointestinal diagnosis, a leading reason for endoscopy and cause of potentially serious complications, resulting in significant individual and system-wide health burden. Approximately one quarter of people living in western countries have experienced GERD, and the prevalence appears to be on the rise. Risk factors for GERD include hiatus hernia, obesity, high-fat diet, tobacco smoking, alcohol consumption, pregnancy, genetics, and some medications. The cardinal symptoms of GERD are troublesome heartburn and regurgitation. GERD is identified by taking a patient-centered history and if necessary can be classified by endoscopic investigation. The role of the pharmacist in the management of GERD is to confirm the diagnosis by history taking, confirm there are no alarming signs or symptoms that require referral to a doctor, and recommendation of short-term therapy to control symptoms. Effective pharmacological treatments for GERD include antacids, alginate, histamine H2 receptor antagonists, and proton pump inhibitors. This narrative review includes a comparison of the efficacy and safety of these treatments and pertinent information to help pharmacists advise patients with GERD on their appropriate use.

Reflux, Sleeve Dilation, and Barrett's Esophagus after Laparoscopic Sleeve Gastrectomy: Long-Term Follow-Up

BACKGROUND

Laparoscopic sleeve gastrectomy (SG) has become the most frequently performed bariatric procedure worldwide. De novo reflux might impact patients' quality of life, requiring lifelong proton pump inhibitor medication. It also increases the risk of esophagitis and formation of Barrett's metaplasia. Besides weight regain, gastroesophageal reflux disease (GERD) is the most common reason for conversion to Roux-en-Y gastric bypass.

METHODS

We performed 24-h pH metries, manometries, gastroscopies, and questionnaires focusing on reflux (GIQLI, RSI) in SG patients with a follow-up of more than 10 years who did not suffer from symptomatic reflux or hiatal hernia preoperatively.

RESULTS

From a total of 53 patients, ten patients after adjustable gastric banding were excluded. From the remaining 43, six patients (14.0%) were converted to RYGB due to intractable reflux over a period of 130 months. Ten out of the remaining non-converted patients (n = 26) also suffered from symptomatic reflux. Gastroscopies revealed de novo hiatal hernias in 45% of the patients and Barrett's metaplasia in 15%. SG patients suffering from symptomatic reflux scored significantly higher in the RSI (p = 0.04) and significantly lower in the GIQLI (p = 0.02) questionnaire.

CONCLUSIONS

This study shows a high incidence of Barrett's esophagus and hiatal hernias at more than 10 years after SG. Its results therefore suggest maintaining pre-existing large hiatal hernia, GERD, and Barrett's esophagus as relative contraindications to SG. The limitations of this study-its small sample size as well as the fact that it was based on early experience with SG-make drawing any general conclusions about this procedure difficult.

Debut of Gastroesophageal Reflux Concomitant with Administration of Sublingual Immunotherapy

Gastroesophageal reflux disease (GORD) is an often debilitating condition characterised by retrograde flow of content from stomach into the oesophagus, where the low pH of the stomach acid irritates the mucosa of the oesophagus. The most dominant symptoms in GORD are pyrosis, regurgitation, and dysphagia. Sublingual immunotherapy (SLIT) was first described in 1986. Following this description, the use has greatly increased in the treatment of allergic rhinitis, as an alternative to subcutaneously administered immunotherapy. Side effects are commonly of oropharyngeal and gastrointestinal nature, for example, swelling, itching, irritation, ulceration of the oropharynx and nausea, abdominal pain, vomiting, and diarrhoea. More serious side effects are dominated by respiratory tract and systemic manifestations. A 30-year-old male experienced refractory, relentless, and debilitation GORD subsequent to administration of sublingual immunotherapy for house dust mite in allergic rhinitis. The patient had to stop the SLIT after two weeks of administration due to GORD. The cessation resulted in rapid resolution of symptoms.

Safety and effectiveness of antireflux surgery in obese patients

Introduction The incidence of gastro-oesophageal reflux disease and obesity has increased significantly in recent years. The number of antireflux procedures being carried out on people with a higher body mass index (BMI) has been rising. Evidence is conflicting for outcomes of antireflux surgery in obese patients in terms of its safety and efficacy. Given the contradictory reports, this meta-analysis was undertaken to establish the outcomes of antireflux surgery (ARS) in obese patients and its associated safety. Methods A systematic electronic search was conducted using the PubMed, MEDLINE®, Ovid®, Cochrane Library and Google Scholar™ databases to identify studies that analysed the effect of BMI on the outcomes of ARS. A meta-analysis was performed using the random effects model. The intraoperative and postoperative outcomes that were examined included operative time, conversion to an open procedure, mean length of hospital stay, recurrence of acid reflux requiring reoperation and wrap migration. Results A total of 3,772 patients were included in 13 studies. There was no significant difference in procedure conversion rate, recurrence of reflux requiring reoperation or wrap migration between obese and non-obese patients. However, both the mean operative time and mean length of stay were longer for obese patients. Conclusions ARS in obese patients with gastro-oesophageal reflux disease is safe and outcomes are comparable with those in patients with a BMI in the normal range. A high BMI should therefore not be a deterrent to considering ARS for appropriate patients.

Operative Treatments for Reflux After Bariatric Surgery: Current and Emerging Management Options

Gastroesophageal reflux disease (GERD) is a common disorder that has a well-established connection with obesity. To ameliorate the morbidity associated with obesity, bariatric procedures have become an established pathway to accomplish sustained weight loss. In some procedures, such as with the Roux-en-Y gastric bypass surgery, weight loss is also accompanied by the resolution of GERD symptoms. However, other popular bariatric surgeries, such as the sleeve gastrectomy, have a controversial impact on their effect on reflux. Consequently, increased attention has been given to the development of strategies for the management of de novo or recurrent reflux after bariatric surgery. This article aims to discuss medical and surgical strategies for reflux after bariatric surgery, and their outcomes.