What is the gold standard surgical approach for an obese patient with Gastroesophageal Reflux Disease (GERD) and Metabolic Syndrome?

From the Guidelines

The gold standard surgical approach for an obese patient with GERD and metabolic syndrome is Roux-en-Y gastric bypass (RYGB) as it effectively addresses both the obesity and GERD components simultaneously, while also improving metabolic syndrome parameters, as supported by recent guidelines 1. This procedure is recommended due to its ability to create a small gastric pouch, bypass a portion of the small intestine, and establish a new connection between the stomach pouch and jejunum, thereby preventing reflux by separating the gastric pouch from the acid-producing portion of the stomach and creating a new valve mechanism at the gastrojejunostomy. Some key points to consider when evaluating a patient for RYGB include:

• Comprehensive preoperative evaluation including upper endoscopy, esophageal manometry, and 24-hour pH monitoring to confirm GERD diagnosis and rule out other esophageal disorders
• Expected 12-month weight loss is approximately 30% after RYGB, with sustained weight loss at 5 years 1
• Potential complications such as anastomotic leaks, stenosis, postoperative bleeding, and venous thromboembolic events, as well as late complications like internal hernia and marginal ulceration 1
• Lifelong vitamin and mineral supplementation is required, including a daily multivitamin, calcium citrate, vitamin D, vitamin B12, and iron, to prevent micronutrient deficiencies 1 RYGB is superior to sleeve gastrectomy for GERD patients as sleeve gastrectomy can worsen or create new reflux symptoms due to increased intragastric pressure, and RYGB provides greater improvement in metabolic syndrome parameters including diabetes, hypertension, and dyslipidemia through both weight-dependent and weight-independent hormonal mechanisms that improve insulin sensitivity and glucose metabolism.

From the Research

Surgical Approach for Obese Patients with GERD and Metabolic Syndrome

• The gold standard surgical approach for obese patients with gastroesophageal reflux disease (GERD) and metabolic syndrome is Roux-en-Y gastric bypass (RYGB) 2, 3, 4.
• RYGB is considered the most effective surgical treatment option for this population due to its consistent benefits in both weight loss and GERD itself 3.
• However, some patients may still experience refractory GERD after RYGB, and new surgical and endoscopic strategies are being proposed to manage this subgroup of patients 2.
• Other bariatric procedures, such as laparoscopic adjustable gastric banding and one anastomosis gastric bypass, may also be effective in reducing GERD symptoms, but their outcomes are less consistent than RYGB 5.
• The choice of treatment depends on local resources and skills, and patients may need to be referred to a specialist center for further evaluation and management 2.

Considerations for Surgical Treatment

• Surgical treatment for morbidly obese patients with GERD must be selected according to the clinical characteristics of the patient, their eating habits, and patient willingness 5.
• A preoperative workup with shared decision making is essential to determine the best course of treatment for each patient 5.
• Combined anti-reflux and bariatric options, such as LRYGB plus Hiatus hernia repair (HHR), may be a good alternative for patients with hiatal hernias and morbid obesity 6.

Outcomes and Complications

• RYGB has been shown to result in major improvement of GERD through various mechanisms, including weight loss 4.
• However, many patients may experience at least one complication within their follow-up period after RYGB 5.
• The effect of sleeve gastrectomy on GERD is contradictory, and more studies are needed to compare surgical and endoscopic solutions 5.