The New Onset of GERD After Sleeve Gastrectomy: a Systematic Review
Conditions: Morbid Obesity, GERD
Sponsor: University of Foggia

 
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Cover page 
 
TITLE: 
THE NEW ONSET OF GERD AFTER SLEEVE 
GASTRECTOMY: A SYSTEMATIC REVIEW 
 
RUNNING HEADS: 
Gastroesophageal reflux disease after bariatric 
surgery 
 
NCT Number: not available 
 
Date of document: 14/12/2021 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
2 
ABSTRACT: 
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 and Meta-
analyzes (PRISMA). 
Published studies that contained outcome data for primary sleeve gastrectomy 
associated with the primary and secondary outcomes listed below were included. 
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. 
 
 
Key words: Sleeve Gastrectomy, Bariatric Surgery, Obesity, Gastrectomy, Gastric 
Sleeve, Stomach Staple, Gastroesophageal Reflux, Gastroesophageal reflux, Reflux, 
Metaplasia, Barrett's esophagus, Barrett's esophagus 

 
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INTRODUCTION 
Obesity is classified as  one of the most severe global public health problems. Over 
2.1 billion adults worldwide are considered overweight or obese; 640 million of these 
are classified as obese. Sleeve gastrectomy (SG) has become the most common 
procedure performed in the world since 2014 [1] because it is well defined, it is 
easier to perform than other types of bariatric surgery, the learning curve is shorter, 
the morbidity and mortality rates are low, and it leads to effective weight loss [2]. 
Obese patients develop obesity-related comorbidities including type 2 diabetes 
mellitus (T2DM), hypertension, dyslipidemia, coronary artery disease, certain types of 
cancer, and gastroesophageal reflux disease (GERD) [3–7]. 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 [8–12]. Different mechanisms 
involved: disruption of the angle of His, partial sectioning of sling fibers of the lower 
esophageal sphincter (LES), reduced gastric compliance due to gastric fundus 
removal, occurrence of hiatal hernia (HH), or reduced antral function. In contrast, 
other studies have reported a decreased prevalence of GERD after SG [13–15] 
explained by several mechanisms including weight loss, decreased acid production 
and accelerated gastric emptying. The measured increase in GERD prevalence ranged 
from 2.1% to 34.9% in the analyzed literature. There was marked heterogeneity 
between the studies in regard to a number of factors including preoperative BMI, 
method of evaluating GERD, exclusion criteria, length of follow-up, and operative 
technique [16–18].  
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. 
 

 
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MATERIALS AND METHODS 
This systematic review was conducted in accordance with the guidelines for 
Preferred Reporting Items for Systematic Review and Meta-analyzes (PRISMA). 
A systematic search was performed using electronic searches in EMBASE, Medline, 
Cochrane Library, and Psychinfo. Free text search in all fields was performed for 
"Sleeve Gastrectomy", "Bariatric Surgery", "Obesity", "Gastrectomy", "Gastric Sleeve", 
"Stomach Staple", "Gastroesophageal Reflux", "Gastro - Esophageal reflux "," Reflux 
"," Metaplasia "," Barrett's esophagus "and" Barrett's esophagus". The search 
included all study designs, with additional non-research captured studies identified 
through bibliographic cross-references. 
Published studies that contained outcome data for primary sleeve gastrectomy 
associated with the primary and secondary outcomes listed below were included. 
 
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. The following exclusion criteria were 
used for study selection: abstracts, case series, articles describing laparoscopic SG 
after previous fundoplication, laparoscopic SG with concomitant antireflux 
procedures, laparoscopic SG after previous bariatric surgical procedures, open SG 
and no-english articles (Table 1) [19-67]. 
 
DISCUSSION 
Obesity is one of the risk factors for GERD, which has resulted in a significant increase 
in the incidence of GERD worldwide [68]. 
Obesity has been reported to increase the incidence of GERD with an OR of 1.73 and 
Barrett's esophagus with an OR of 1.24; esophageal adenocarcinoma is the most 

 
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serious complication of GERD (OR, 2.45) [69-70]. 
Numerous studies have been performed in the literature with controversial results 
on the onset of GERD after LSG. 
Albanopoulos et al., Alexandrou et al. and Althuwaini et al. [20-21] showed that LSG 
seemed to precipitate GERD symptoms, dissection near the angle of His, and drastic 
reduction in gastric capacity increased the chance that patients would maintain or 
develop new GERD symptoms.  
The studies by Arman et al., Borbely et al. and Braghetto et al. [24,28,30] found that 
LSG is associated with a significantly higher likelihood that acid-lowering medications 
are needed to control GERD symptoms 12 months after LSG compared with gastric 
bypass. LSG leads to a considerable rate of postoperative GERD. De novo GERD 
consist of approximately half of preoperative silent GERD and completely de novo 
GERD. Most patients with preoperative silent GERD have become symptomatic after 
LSG. Barrett's esophagus could be a late complication after SG and bariatric surgeons 
should be aware of the important association between GERD and obesity. 
 
 
Burgerhart et al [32] confirm that it seems likely that the increase in acid exposure 
after LSG is due to the modified anatomy, which leads to a decrease in the resting 
pressure of Les. The study results support the idea that in patients with significant 
preoperative symptoms of GERD, gastric bypass surgery may be more appropriate 
than LSG. 
Del Genio et al and DuPree et al. [40-41] claim that LSG is an effective restrictive 
procedure that creates delayed esophageal emptying without compromising the 
function of the LES. Retrograde movements and increased acid exposure are likely 
due to postprandial stasis and regurgitation. LSG did not reliably relieve or improve 
GERD symptoms and induced GERD in some previously asymptomatic patients 
Indeed, Flolo et al [44] confirmed that the incidence of GERD more than doubled 

 
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from baseline at 2 years and further increased at a rate of 35% at 5 years. 
De novo gastroesophageal reflux symptoms appear between the third and sixth 
postoperative year. this unfavorable evolution may have been prevented in some 
patients by continuous follow-up outpatient visits beyond the third year. 
The new onset of postoperative GERD is an unfortunate side effect of LSG, and more 
studies reflecting the aggressive closure of healing defects are needed to determine 
if this provides a long-term solution to this problem. 
LSG can increase the prevalence of GERD despite satisfactory weight loss. 
In the study by Menenakos et al. [58] about 25% of patients developed or worsened 
their GERD symptoms, all responsive to PPi treatment (65 out of 261 patients). 
Heartburn was significantly relieved after the postoperative first trimester. Symptoms 
of GERD are especially common in the first few months. Gastroesophageal reflux is 
the main complication. Proton pump inhibitor treatment is mostly effective in 
controlling patients' symptoms. Endoscopic surveillance is desirable in the long term 
for these patients. 
Rebecchi et al and Sharma et al. [63-64] concluded that in obese patients with GERD, 
LSG improves symptoms and controls reflux in most cases, whereas in patients with 
no preoperative evidence of GERD, de novo reflux is rare. Therefore, LSG should be 
considered an effective option for the surgical treatment of obese patients with 
GERD. The presence of GERD cannot be considered a contraindication to sleeve 
gastrectomy. There is improvement in Gerd as assessed by the symptom 
questionnaires. The new onset of GERD detected on scintigraphy may not be 
pathological as there is a decrease in total acid production after surgery; however, it 
still remains an important issue and needs long-term follow-up [72-74]. 
 
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 

 
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shown satisfactory control of postoperative reflux in most patients and low rates of 
de novo GERD. Compared to LSG, obese patients receiving LRYGB had a lower risk of 
new onset or worsening of GERD. Some patients have been converted to LRYGB 
treatment due to severe reflux after LSG. Therefore, we recommend LRYGB as the 
preferred treatment for obese patients with GERD. 
These data are leading to wider acceptance of LSG as a bariatric procedure even in 
obese patients with GERD, provided a tubular cuff is created, as recently stated in the 
5th International Consensus Conference on sleeve gastrectomy [71]. 
In conclusion, bariatric surgery has become safer as surgeons gain experience in 
evaluating and treating obese patients, but careful medical evaluation is mandatory 
before choosing the type of bariatric surgery, especially for those patients who 
already have GERD. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
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Not commissioned, externally peer-reviewed