Gastroesophageal Reflux Disease (GERD) and Bariatric Surgery

February 7, 2024

Bariatric surgery remains the most effective treatment for individuals struggling with obesity, offering not only significant and sustainable weight loss, but also providing improvements in various weight-related medical problems. One common medical problem that affects many patients with obesity is Gastroesophageal Reflux Disease (GERD).

Gastroesophageal Reflux Disease (GERD)

GERD is one of the most common gastrointestinal disorders in the United States, where millions of Americans are affected each day. GERD arises when stomach acid and other digestive juices flow back up into the esophagus, causing heartburn, regurgitation and other uncomfortable symptoms. Chronic or untreated GERD can result in damage to the esophagus (with a rare risk of developing esophageal cancer), asthma-like symptoms and cough, dental problems or difficulty sleeping.

Obesity is a major risk factor for GERD, which affects up to 60% of individuals with severe obesity. This occurs as excess abdominal fat increases pressure within the abdomen and weakens the lower esophageal sphincter (LES), the valve that helps prevent reflux.

Treatment options for GERD include dietary and lifestyle modification, anti-reflux medications, and surgical options.

For patients suffering from obesity and GERD, bariatric surgery can provide safe and effective treatment for both conditions. However, its impact on GERD is complex and depends on the specific procedure. Several commonly utilized bariatric surgeries – Roux-en-Y gastric bypass (RYGB), laparoscopic sleeve gastrectomy (LSG), adjustable gastric banding (AGB), and duodenal switch (DS) – each present with distinct effects on GERD:

Considered the most effective bariatric procedure for GERD management, RYGB involves bypassing a portion of the stomach and small intestine, altering the digestive pathway. This effectively reduces stomach acid production and pressure on the LES, leading to significant improvements in GERD symptoms in over 90% of patients.

LSG involves removing a large portion of the stomach, restricting food intake and leading to weight loss. While most studies show an overall improvement in GERD after LSG, there is a small percentage of patients who may have persistent or worsening reflux symptoms. The long-term outcomes on GERD following LSG require further investigation.

AGB involves placing an inflatable band around the upper portion of the stomach, creating a smaller pouch and restricting food intake. While AGB initially shows some improvement in GERD symptoms, its long-term effectiveness is lower than other procedures, and slippage or other complications of the band can worsen reflux. Because of inferior long-term results and potential complications, AGB is rarely performed.

DS combines a sleeve gastrectomy with an intestinal bypass resulting in very significant weight loss. Improvements in GERD are generally tied to weight loss, though some patients may experience persistent or new onset reflux.

Challenges of Bariatric Surgery

While bariatric surgery can be a highly effective treatment for GERD, it is not without its challenges. Careful patient selection is crucial, taking into account pre-existing GERD severity, type of bariatric surgery planned, and individual risk factors. In addition to a careful history, patients with significant pre-existing GERD will generally require a work-up, including an upper endoscopy or EGD. As an example, patients with severe, poorly controlled, or complicated GERD may not be good candidates for a sleeve gastrectomy due to the risk of worsening reflux disease, and they may be better suited for a gastric bypass.

Following bariatric surgery, lifestyle modifications like maintaining a healthy weight, avoiding trigger foods, and adhering to post-operative dietary recommendations are key to preventing GERD recurrence or new-onset reflux.

Additionally, medications are often prescribed to manage stomach acid and further control any remaining reflux symptoms. Weight regain is a risk factor for GERD after weight loss surgery, and if GERD symptoms become severe or difficult to manage after bariatric surgery, then revision surgery options may be available to address both the acid reflux and any potential weight gain. In particular, patients who have had an adjustable gastric band (AGB) or sleeve gastrectomy (LSG) may be excellent candidates for revision surgery to address GERD and/or weight regain.

The relationship between GERD and bariatric surgery emphasizes the need for a holistic approach. While surgery remains an incredibly powerful tool for weight loss and GERD improvement, it is crucial to prioritize comprehensive pre-operative assessment, careful patient selection, appropriate procedure choice, and continuous post-operative care. By understanding the complexities of this relationship and managing both conditions concurrently, individuals can achieve weight loss and GERD relief, paving the way for a healthier future.

Dr. Brian Long specializes in laparoscopic bariatric surgery at the Nicholson Clinic for Weight Loss Surgery.

ABOUT THE AUTHOR Dr. Brian Long specializes in laparoscopic bariatric surgery, performing sleeve gastrectomy, gastric bypass, duodenal switch and revisional procedures. With impressive credentials from prestigious hospitals in Washington DC and helping troops in the Persian Gulf, Dr. Long has most recently been with the Nicholson Clinic for Weight Loss Surgery, one the country’s premier destinations for weight loss, since 2015. The Nicholson Clinic has helped more than 25,000 patients, coming from all 50 states and 11 countries.

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