I read with great interest the articles “Esophageal abnormalities in morbidly obese adult patients” and “Frequency of Abnormal Esophageal Acid Exposure In Patients Eligible For Bariatric Surgery”. Both studies were published in SOARD (Surgery for Obesity and Related Disorders). The authors conducted a thorough study on 224 (first study) and 88 (second study), overweight patients preparing for weight loss surgery. All patients were examined and a detailed acid reflux related symptom evaluation was performed. In addition, each patient received a complete objective esophageal evaluation including:

• Upper endoscopy
• Esophageal manometry
• Ambulatory esophageal pH monitoring.

The results of the first study showed that heartburn (51%) and regurgitation (29%) were the most common acid reflux disease related symptoms. Hiatal hernia was found in 12%, and inflammation of esophagus lining was present in 17%. 33% had abnormal esophageal manometry with a low pressure lower esophageal sphincter as the most common finding. Twenty-four hour esophageal acid level monitoring was abnormal in 54% of the cases.

The authors did not find a correlation between the degree of obesity and the severity of GERD related symptoms or esophageal function test results.

Similarly, the second study showed that 65% of patients had an elevated esophageal acid exposure and 46% had weak lower esophageal sphincter pressure. Only 20% of the patients showed an abnormal endoscopic finding like a hiatal hernia.

The authors also show that GERD symptoms in overweight patients do not predict severity of disease. In other words, you can can have severe symptoms and mild reflux and mild symptoms. Or, you can have mild symptoms and severe acid reflux disease.

Furthermore, esophageal acid exposure was elevated in more than 50 % of patients presenting for bariatric surgery in both studies. At the same time, the incidence of a hiatal hernia detected on upper endoscopy is much lower. This is due to:

1. Acid reflux can occur in obese patients before a hiatal hernia develops.
2. Hiatal hernia can be missed on upper endoscopy because fat accumulation obliterates the hiatal opening.
   • Consequently, a bariatric surgeon may falsely assume that a concomitant hiatal hernia repair during gastric sleeve surgery is not warranted.

At Houston Weight Loss Surgery Center, almost every gastric sleeve surgery we perform is associated with a concomitant hiatal hernia repair. Obesity and GERD are inter-related diseases. Fixing one while ignoring the latter, leads to worsening or new onset acid reflux after sleeve gastrectomy. A good hiatal hernia repair along with a properly performed and well contoured gastric sleeve surgery reliable eliminates and prevents acid reflux development.