Laparoscopic fundoplication, either complete (Nissen) or partial (Toupet) has well-documented efficacy for GERD. Other less popular procedures include the Hill repair and various endoluminal procedures. The Nissen fundoplication is associated with 90–94 % postoperative patient satisfaction and overall outcomes during long-term follow-up when employed to treat medically refractory GERD [18–21]. At 5-year and 10-year follow-up of laparoscopic Nissen and Toupet fundoplications revealed that 93 % of the patients were free of significant reflux symptoms at 5 years after surgery and 89.5 % of the patients were still free of significant reflux at 10 years of clinical follow-up. The symptom-free status was higher following Nissen (93.3 %) than Toupet (81.8 %). However, both procedures resulted in respectable levels of GERD amelioration compared with similar patients being treated with medication (proton pump inhibitors) alone [22].

Concerns exist regarding the long-term durability of the fundoplication in the morbidly obese population. Evidence regarding the impact of obesity on surgical outcomes and recurrence of GERD is however variable. In a study following 224 patients for 3 years after fundoplication, Perez et al. noted a higher recurrence rate following surgery in obese patients. The increasing recurrence rates corresponded with increasing BMI. Recurrent GERD was noted in 4.5 % of patients with BMI less than 25 kg/m², 8 % recurrence for BMI 25–30 kg/m², and 27 % recurrence for BMI greater than 30 kg/m² [23]. In contrast another study following 194 patients for a mean of 3.2 years after Nissen fundoplication found that there was no correlation between increasing BMI and a poorer overall outcome regarding recurrence of GERD after dividing the patients into 3 groups: normal weight (BMI < 25 kg/m²), overweight (BMI 25–29.9 kg/m²), and obese (BMI > 30 kg/m²) [24]. A multivariate analysis assessing symptomatic outcomes after laparoscopic antireflux surgery in 199 consecutive patients undergoing complete fundoplication revealed that obesity was not predictive of worse outcomes during a mean follow-up of 15 months [25]. Likewise Winslow and colleagues identified no association between BMI and complications or anatomic failure three years following surgery. The majority of 505 patients (84 %) in the study were either overweight or obese, yet the complication and failure rates were comparable to those reported for individuals of normal weight [26]. There have been longer follow-up reports supporting these findings as well. In one study 481 patients were studied. One hundred three (21 %) had a normal BMI, 208 (43 %) were class I obese, 115 (24 %) were class II obese, and 55 (12 %) were class III–IV obese. Mean follow-up was 7.5 years. Conversion to an open operation and requirement for revision surgery were not influenced by preoperative weight. Operating time was longer in the obese patients (mean 86 vs 75 min) yet clinical outcomes improved following surgery regardless of BMI [27]. Yet another pattern has been reported from the group at Emory University in which initial data from a large cohort suggested that obesity did not initially adversely affect postoperative GERD recurrence rates [28]. However during 11-year follow-up analysis of the cohort, durability issues emerged. Although patients with class I obesity remained similar to normal habitus patients in regards to GERD recurrence, those with class II–III obesity demonstrated an odds ratio of failure nearly 5 times that of their normal weight counterparts [29]. Overall, the preponderance of data supports that a standard antireflux surgery in the obese and morbidly obese is very effective but is probably more difficult to perform and probably is slightly less effective and/or long lived than when performed in normal weight patients. What is certain is that fundoplication improves only the function of the LES without addressing other health concerns and comorbid conditions of the morbidly obese. With that in mind, an operation that addresses GERD as well as weight associated comorbid conditions in the obese patient would be the optimal solution.

As opposed to standard antireflux surgery, which reconstructs the gastroesophageal valve, bariatric procedures affect reflux through other mechanisms. These include the reduction in gastric acid production, reduced gastric refluxate volume, diversion of biliopancreatic juices, and the induction of weight loss. Of the laparoscopic procedures commonly used for weight loss, only Roux-en-Y gastric bypass has a consistent impact on GERD other than the general benefit of weight reduction. Laparoscopic malabsorptive operations such as biliopancreatic diversion with duodenal switch have no effect on GERD and therefore would be a contraindicated procedure for a primary GERD treatment [30] (Table 16.1).

The Roux-en-Y Gastric bypass is the most commonly performed bariatric procedure in the United States and is the only bariatric procedure with a consistently beneficial effect on GERD. It consists of three components. The proximal stomach is divided to create an approximately 30–50 cm³ pouch. A Roux limb is then created 40–100 cm beyond the ligament of Treitz and anastomosed to the gastric pouch. The proximal jejunal limb (biliopancreatic limb) is then anastomosed to the Roux limb 100–150 cm distal to the gastro-jejunostomy (Fig. 16.1). The restrictive gastric pouch and malabsorptive bypass of the gastric remnant and proximal small bowel combine to induce significant weight loss (less than that seen with BPD-DS and more than that seen with adjustable gastric banding and sleeve gastrectomy). The gastroesophageal junction however is not augmented. Acid exposure to the distal esophagus is markedly reduced since the gastric pouch contains fewer parietal cells resulting in reduced acid production in the gastric remnant and potential refluxate volumes are less. Biliopancreatic juices are also diverted which may also be a benefit particularly in patients with Barrett’s esophagus (Table 16.1). Overall, the Roux-en-Y gastric bypass has been shown to be the most reliable operation to treat severe GERD in the obese patient population.

Frezza et al. followed 152 morbidly obese patients with GERD for 12 months following Roux-en-Y gastric bypass and reported a significant decrease in GERD symptoms: heartburn (from 87 to 22 %), water brash (from 18 to 7 %), wheezing (from 40 to 5 %), laryngitis (from 17 to 7 %), and aspiration (from 19 to 2 %). It is also associated with significant reduction of antisecretory medication use from between 40 and 60 % preoperatively to 10 % postprocedure and a concurrent improvement in quality-of-life measures [31]. Perry and colleagues reported similar findings in 57 patients with a mean BMI of 47 who underwent gastric bypass with 18 month follow-up. Specifically all patients reported improvement or no symptoms of GERD, there was a mean weight loss of 40 kg, and quality-of-life scores (SF-36) were above national norms for physical and mental components [32]. Another study enrolled 12 morbidly obese patients with six undergoing laparoscopic complete fundoplication (mean BMI 40 kg/m²) and six undergoing laparoscopic gastric bypass (mean BMI 55 kg/m²). Postoperative symptom scores and 24-h pH scores were normal in both groups after surgery. While outcomes focused on GERD physiology were similar between the two operations, gastric bypass carried the additional benefit of comorbidity resolution [33].

Gastric bypass is also comparable to laparoscopic fundoplication in its safety profile. Varela and colleagues analyzed the University Health System Consortium database for patients who underwent laparoscopic fundoplication or laparoscopic gastric bypass from 2004 to 2007 (n = 27,264). Gastric bypass was associated with significantly lower overall in-hospital complications and comparable mean length of stay, observed mortality, risk-adjusted mortality, and hospital cost as compared with laparoscopic fundoplication [34].

In addition to the level of safety observed with gastric bypass in the treatment of GERD and comorbid conditions due to obesity, impressive prescription medication use and costs are also reduced. Nguyen et al. followed 77 morbidly obese patients for one year following gastric bypass. The mean excess body weight loss was 67+/−14 % one year after surgery. The mean number of prescription medications per patient was reduced from 2.4 preoperatively to 0.2 one year after surgery. The mean monthly medication cost decreased from $196 preoperatively to $54 one month after surgery, representing a 72 % cost savings. One month postoperatively, medication cost saving for GERD was 81 %; for diabetes it was 69 %; for dyslipidemia it was 53 %; and for hypertension it was 43 %. The mean monthly medication cost savings for the first year after surgery was $168 with a yearly savings of $2,016 per patient [35]. Gastric bypass has also been associated with a 40 % decrease in all-cause mortality, a 56 % decrease in mortality from coronary artery disease, 60 % decrease in mortality from cancer, and a 92 % decrease in mortality from diabetes as compared with age, sex, and BMI-matched control subjects in large population studies [36].

The additional benefit of bariatric procedures, particularly gastric bypass in the treatment of GERD and concomitant illnesses in the morbidly obese population has led some surgeons to avoid offering fundoplication in higher BMI patients. In a recent survey of foregut surgeons with expertise in bariatrics the majority of respondents felt that laparoscopic Roux-en-Y gastric bypass was the best option (91 %), distantly followed by laparoscopic sleeve gastrectomy (6 %). Many reported having morbidly obese patients with a primary surgical indication of GERD who were denied a bariatric procedure by a third-party payer (57 %), and some (35 %) of those surgeons would choose to do nothing rather than proceed with fundoplication alone, which they felt was suboptimal as it did not address all of the obesity related comorbidities. The majority of respondents felt that bariatric surgery should be recognized as a standard surgical option for treating GERD in the obese (96 %). Currently however, third-party payers in the US often decline to provide benefits for a bariatric procedure for this indication [37].

Evidence that gastric bypass not only resolves GERD symptoms as an index procedure but also does so when employed following failed fundoplication in obese patients was demonstrated in a study by Stefanidis et al. in which 25 patients with class I obesity who suffered recurrent GERD following fundoplication were converted to Roux-en-Y gastric bypass with resultant substantial improvement in quality-of-life scores and gastrointestinal symptoms rating scale scores after a mean of 14 months following conversion [38].

The concerns echoed above regarding long-term durability of fundoplication when exposed to increased intra-abdominal pressures in the obese population are magnified when these patients who suffer from GERD have an associated hiatal or paraesophageal hernia. While treating this particularly challenging patient population foregut surgeons have reported the combination of hiatal and paraesophageal hernia repair with gastric bypass or sleeve gastrectomy with minimal recurrence of GERD or hernia symptoms [39–42].

The laparoscopic adjustable gastric band is performed less and less worldwide due to efficacy questions and need for surgical reinterventions. It acts as a purely restrictive bariatric operation (Fig. 16.2). Its sole advantage is based on the minimally disruptive nature of the procedure. An adjustable silicone band is placed immediately distal to the gastroesophageal junction followed by imbrication of the gastric fundus over the band, to create an approximately 15 cm³ proximal gastric pouch. A subcutaneous port is accessed percutaneously with a Huber needle to adjust band volume (0–12 mL) and control the degree of gastric restriction. There are conflicting reports to as to the improvements of GERD symptoms following adjustable gastric band placement. Some reports suggest a 90 % resolution or improvement in GERD symptoms, [43]. while others note that GERD is the most common complication requiring reoperation (4.7 %) after band placement [44]. The band may be particularly inducive of GERD if it slips distally or the proximal gastric pouch dilates. While this might be corrected by laparoscopically unbuckling the band and replacing it in the correct anatomical position, it seems like a bad idea to do such a revision for GERD. More recently, Brancatisano and colleagues followed 838 patients and showed moderate weight loss (54 % EBWL) but a fairly mediocre 66 % improvement in GERD symptoms. No objective testing was reported [45].

Another concern regarding the band for GERD surgeons is the occurrence of band-related esophageal dysmotility. Several animal and human studies report severe esophageal dysmotility secondary to gastric banding. O’Rourke and colleagues placed nonadjustable bands around the proximal stomach of opossums and followed them for 14 weeks. There was a 36 % decrease in both baseline mean resting LES pressure and in the distal esophageal peristaltic pressure in banded animals. Motility disorders developed during the study in more than one-third of the banded animals [46]. This problem has been reported in up to 70 % of patients, with 25 % of patients presenting with esophageal dilation [47]. Overall it is clear that the LAGB is a very poor choice for treating the obese patient seeking GERD treatment [48].

The laparoscopic sleeve gastrectomy is the most recent bariatric procedure to gain acceptance by third-party payers. It consists of a stapled resection of the greater curve of the stomach initiated 2–6 cm proximal to the pylorus and proceeding cephalad to the angle of His. It is commonly performed over a 32–40 French bougie, placed along the lesser curvature resulting in gastric volumes of 50–80 cm³ (Fig. 16.3). The lesser curvature is less compliant than the resected greater curvature resulting in a fairly stable restrictive endolumenal environment. This degree of gastric resection probably results in a reduction in gastric acid production, but also reduces the production of the hunger-inducing hormone Ghrelin (produced by the resected greater curvature gastric tissue) resulting in increased satiety. This metabolic component adds to the restrictive component of the procedure to cause significant weight loss which is typically less than that seen with gastric bypass and more than that seen with adjustable gastric band. GERD resolution after sleeve gastrectomy is very variable and in general suboptimal. Any benefit is probably related to the weight loss that results post procedure. Due to the resected parietal cell rich fundus and greater curvature during sleeve gastrectomy, acid secretion within the tubularized stomach should be decreased, however biliopancreatic juices are not diverted.

Sleeve gastrectomy has been implicated with both the amelioration as well as the development of GERD. A few studies have shown improved GERD symptoms [49, 50]. Most studies however showed the same or worse incidence of GERD symptoms [51, 52]. One of the few studies performing objective pH testing after surgery showed an increase in upright pH exposure (5–12.6 %) and supine exposure (1.4–11 %). This study also showed a deterioration of the LES pressures post sleeve (18.3 mm/Hg to 11) [52].

A recent meta-analysis of 15 studies reporting postoperative GERD symptoms after sleeve gastrectomy found increased incidence of GERD in four studies and reduced GERD in seven studies [53]. Overall, the evidence points to sleeve resection as being a poor treatment option for the GERD patient and should probably be considered contraindicated for this indication.

To assess the impact of each of the bariatric procedures discussed so far on GERD, The Bariatric Outcomes Longitudinal Database (a prospective database of patients who undergo bariatric surgery by a participant in the American Society of Metabolic and Bariatric Surgery Center of Excellence program) recently assessed the results from 22,870 morbidly obese patients with GERD who were undergoing adjustable gastric banding, sleeve gastrectomy, and gastric bypass. The mean BMI was 46.3 kg/m². All three operations resulted in improved GERD symptom scores 6 months following surgery. GERD symptom score reduction was most pronounced in gastric bypass patients (56.5 %; 7,955 of 14,078) followed by adjustable gastric banding (46 %; 3,773 of 8,207) and sleeve gastrectomy patients (41 %; 240 of 585) [54]. Overall, this seems to indicate a rather poor effect of bariatric surgery on GERD making it clear that more well constructed studies based on objective test endpoints are needed.

Innovative methods of GERD treatment in the obese patient are now being pursued via both laparoscopic and endoscopic approaches. Greater curvature gastric plication is being investigated as a potential alternative to sleeve gastrectomy for weight loss but would not be expected to be any better a treatment for GERD than standard sleeve resection [55].

A different technological approach to the treatment of GERD utilizes a magnetic bracelet made of titanium beads and magnetic core placed laparoscopically around the gastroesophageal junction to augment the antireflux function of the LES has received U.S. Food and Drug Administration approval [56, 57]. In non-obese patients there was a significant reduction in the mean esophageal acid exposure time with pH normalization achieved in 80 % of the patients 3 years following insertion. At >4 years there was a significant improvement in quality-of-life measures for GERD in all the patients with complete cessation in the use of PPIs in 80 % of the patients. Transient postoperative dysphagia was common but typically resolved by 12 weeks following surgery [58]. The use of this device in the obese population has not been completely evaluated. It may have a role in palliation of post bypass or sleeve induced GERD but this has not yet been defined or published (Fig. 16.4).

While gastric bypass is often associated with amelioration or resolution of GERD in the morbidly obese patient, there are certainly circumstances where GERD persists, is induced, or recurs. In mild to moderate cases, such refractory GERD can be managed by life style adjustments and/or medication. Fundoplication via mobilization of the remnant stomach and radiofrequency treatment of the LES have been described with some success [59, 60]. In more severe cases, revisional surgery may be required. GERD persistence or development following adjustable gastric banding can be related to technical issues secondary to band slippage or proximal pouch dilation or induced esophageal dysmotility. Slippage can be corrected laparoscopically as mentioned earlier. If this is not adequate, or if the underlying problem is esophageal dysfunction masquerading as GERD, then removing the band and conversion to gastric bypass is appropriate. Ardestani et al. followed 19 patients requiring conversion of adjustable gastric band to gastric bypass due to inadequate weight loss or band erosion. Perioperative complications were acceptable with 2 of 19 (10.5 %) having surgical site infections without major intracorporeal complications [60].