Bariatric surgeries, which are intended to reduce weight, can also play a role in the treatment of GERD, as they can result in weight loss, restore the cardioesophageal competence, and minimize the gastric reservoir and/or other mechanisms. These can be divided into gastric-specific procedures and gastric with additional malabsorption procedures. Gastric-specific procedures include vertical sleeve gastrectomy and the adjustable gastric band, mostly done laparoscopically. The gastric plus malabsorptive procedures include biliopancreatic diversion with or without duodenal switch and Roux-en-Y gastric bypass (RYGB).

The underlying mechanism for RYGB has been used as a stand-alone reflux procedure: gastric volume reduction and rapid emptying into the small bowel. Several studies have shown that GERD either improves or completely disappears after RYGB. Frezza et al., in a study of 435 patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB), in which 55 % had evidence of chronic GERD, showed that there was a significant decrease in GERD-related symptoms, including heartburn (from 87 to 22 %, P < 0.001), water brash (from 18 to 7 %, P < 0.05), wheezing (from 40 to 5 %, P < 0.001), laryngitis (from 17 to 7 %, P < 0.05), and aspiration (from 14 to 2 %m P < 0.01). The researchers concluded that this procedure provides a very good control of GERD in morbidly obese patients during the 3-year study. The authors proposed that in addition to volume reduction and rapid egress, the mechanism of how LRYGB affects symptoms of GERD is through weight loss and elimination of acid production in the gastric pouch. The gastric pouch lacks parietal cells; thus, there is no acid production, and also, due to its small size, it minimizes any reservoir capacity to promote regurgitation (24).

Similar results have been reported in other studies. Smith et al. found a significant reduction in reflux symptoms after RYGB with or without distal gastrectomy and gastropexy. In their study of 188 patients who were followed up to 4 years, there was a significant decrease in symptoms, as only 14 patients reported the need for medication postoperatively (31).

Jones compared Nissen fundoplication to RYGB in reflux patients with BMI under 35. RYGB was done primarily as an antireflux procedure in 332 patients from 1987 to 1996. Postoperatively only one patient was symptomatic (32). Varela et al. compared laparoscopic fundoplication with laparoscopic gastric bypass in morbidly obese patients in terms of mean length of stay, observed mortality, risk-adjusted mortality, and hospital costs and concluded that LRYGB is as safe as laparoscopic fundoplication in the treatment of GERD in this group of patients (33) and it may provide additional health-related benefits.

Since its FDA approval in 2001, the gastric band has rapidly become a popular bariatric procedure for obese patients due to its simplicity, lack of reconstruction, and perceived safety profile. However, conflicting results have been published about the effect of gastric banding on GERD. A few studies have shown that the incidence of GERD is still increased after gastric banding; however, the majority of the literature suggests that in fact symptoms and pH improve after the procedure. In fact an overly tightened band can induce reflux.

One study, done by Gutschow et al., reported worsening of reflux symptoms. In the study, 31 patients were followed from 1997 to 2003, mean BMI of 46.5 kg/m². Upper endoscopy was performed in 18 patients after 30 months showing a high prevalence of esophagitis. Postoperative esophageal pH-manometry was performed in 16 patients and was pathologic in 43.8 % of the cases. The group concluded that the incidence of gastroesophageal reflux and esophagitis remains increased after laparoscopic gastric banding (34). These results were similar to those by Ovrebo et al., Westling et al., and Suter et al. Overall, the mechanism by which this procedure may lead to poorer outcomes in reducing the incidence of GERD is not well understood. However, it is thought that postoperative reflux may be attributed to an unrecognized hernia at the time of procedure or inappropriate (overly tight) adjustment regimens.

Other studies have shown that laparoscopic adjustable gastric banding improves pH and symptoms. De Jong et al. studied 26 patients who underwent gastric banding. The patients were assessed by 24-h pH monitoring, endoscopy, and barium swallow, preoperatively, at 6 weeks, and at 6 months. The group concluded that this procedure generally decreases GERD symptoms, as they claimed that the antireflux effect of a proximally placed gastric band is due to creating a longer intra-abdominal pressure zone or by pulling the stomach more in the abdomen in the presence of a hiatal hernia. They also hypothesized that the pouch formation is a crucial determining factor in the occurrence of symptoms after the procedure, as newer techniques advocate for a “virtually-no-pouch” procedure with placement of the band at or near the gastroesophageal junction. This high placement can still lead to pouch formation and possible dilatation of the esophagus, which can lead to concomitant esophageal motility disorders. They showed that the presence of a pouch leads to esophagitis (35).

Tolonen et al. also studied the relationship between gastric banding and GERD. The study included 31 patients who underwent gastric banding. The patients were monitored using 24-h pH tests, symptom assessment, and upper GI endoscopy. The number of reflux episodes significantly decreased postoperatively (44.6 ± 23.7 SD to 22.9 ± 17.1 SD, P = 0.0006) after 19 months, symptoms decreased from 48.3 to 16.1 % (P = 0.01), and the diagnosis of GERD on 24-h pH recordings decreased from 77.4 to 37.4 % (P = 0.01). No pouch enlargement was noted on upper GI endoscopy. The researchers concluded that a gastric band that is correctly placed is associated with the effective treatment of GERD symptoms. They also hypothesized that these results were due to incomplete relaxation of the LES. No correlation between gastric band and esophageal motility was discovered. The group also felt that the antireflux effect may be mechanical, as the band may provide a narrowing at the region of the gastroesophageal junction similar to the historical Angelchik prosthesis (36).

Due to the conflicting results of studies looking into laparoscopic adjustable gastric banding and GERD, many surgeons would not recommend this procedure for the treatment of GERD in bariatric patients.

Laparoscopic sleeve gastrectomy has become a new option for the surgical treatment of morbid obesity. It is a gastric-specific operation, but unlike the gastric band, it does not require adjustments nor does it carry the complications of having a foreign object in the body. When compared to laparoscopic Roux-en-Y, it does not have any of the complications such as malnutrition, dumping syndrome, or marginal ulcers. It has been argued that laparoscopic sleeve gastrectomy is a superior procedure in terms of weight loss compared to the gastric band and it has similar low complications and mortality rates compared to the RYGB (37). Although sleeve gastrectomy is emerging as a favorable procedure, there have been conflicting results, as some have hypothesized that this procedure can promote the development of or exacerbate GERD symptoms.

A study by Himpens et al. showed that the de novo appearance of GERD occurred in 21.8 % of patients a year after sleeve gastrectomy. However, the group also noted that after 3 years, GERD symptoms were present in only 3.1 % of the study population. They hypothesized that these results were most likely due to restoration of the angle of His. Also, symptoms in 75 % of patients who were affected before surgery disappeared by 3 years after surgery (38). Another group with similar results contributed the de novo symptoms to too-radical resection of the gastric antrum (39).

A study done by Soricelli et al. showed that sleeve gastrectomy and crural repair in the obese patients are safe techniques. The group studied 378 patients; 60 patients (15.8 %) had symptomatic GERD, and hiatal hernia alone was diagnosed in 42 patients (11.1 %). 73.3 % of these patients had complete remission of GERD symptoms following sleeve gastrectomy, whereas the rest of the patients had decreased use of antireflux medications. In addition, GERD symptoms developed in 22.9 % of patients undergoing sleeve gastrectomy, but none if hiatal hernia repair was performed (40).

As previously mentioned there are conflicting data about the surgical approach for the treatment of GERD in cases of obese patients. Interestingly, there are very few studies that have compared traditional GERD surgeries in this population to bariatric surgery techniques. As laparoscopic gastric bypass is successful in treating both obesity and related disease plus GERD, some surgeons are advocating this surgical procedure as the procedure of choice for morbidly obese patients who also have GERD (41, 42).

Patterson et al. presented one of the few studies that directly compared standard treatment versus bariatric surgery. The group studied 12 patients, 6 undergoing LRYGB (mean BMI 55) and 6 laparoscopic Nissen fundoplication (mean BMI 29.8). The patients underwent preoperative and postoperative esophageal physiologic testing. Both groups experienced a significant improvement in heartburn symptoms postoperatively, as the mean preoperative symptom score improved from 3.5 to 0.5 in the laparoscopic Nissen group (P = 0.01) and from 2.2 to 0.2 in the gastric bypass group (P = 0.003). The group concluded that the two procedures are both effective in treating heartburn symptoms and objective acid reflux in the morbidly obese population (43).

Similar results were reported by Varela et al. The group looked into all patients who underwent either laparoscopic fundoplication or laparoscopic gastric bypass from October 2004 to December 2007 (n = 27,264). The authors compared safety between the two procedures in terms of length of stay, in-hospital overall complications, mortality, risk-adjusted mortality radio, and hospital costs. They concluded that the two procedures were comparably safe in terms of treatment of GERD and recommended that in patients with morbid obesity, laparoscopic gastric bypass should be the preferred procedure of choice due to the favorable effect on other comorbid conditions (44).

Other groups looked into the outcomes of conversion of a failed fundoplication procedure to a gastric bypass. Ibele et al. looked into the impact of takedown of previous fundoplication and conversion to laparoscopic gastric bypass. In their study population, 36 % of patients had recurrent GERD at the time of revision, due to anatomic failure of the original fundoplication, and another 36 %, although with intact fundoplication, had recurrent GERD symptoms. After surgery, all of the patients in this group reported complete resolution of symptoms following surgery (45). Similar results were also reported in a study of 7 patients who originally had a laparoscopic Nissen fundoplication that was converted to a LRYGB, as the study showed significant reduction in symptoms postoperatively (16.7 % vs. 4.4 %) (46).

Kellogg et al. looked into the anatomic findings and outcomes in patients with failed Nissen fundoplication and subsequent conversion to RYGB. The group retrospectively reviewed a database of 1,435 patients who underwent RYGB between 2001 and 2006 and identified 11 patients who had previously undergone fundoplication. The mean BMI prior to gastric bypass procedure was 44 kg/m². Nine of these patients had GERD preoperatively. All patients had 100 % improvement in symptoms, with complete resolution in 78 %. Wrap disruption was present in 45 % of the patients, whereas herniation of an intact wrap occurred in 1 patient (47). Based on these results, many surgeons advocate primary bariatric surgery to avoid the risk of revision to RYGB in the event of wrap failure.