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), morbidly obese 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 and isotopic emptying of the esophagus.

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 reflux esophagitis was present in 17%. 33% had abnormal esophageal manometry with a hypotensive lower esophageal sphincter as the most common finding. Twenty-four hour esophageal pH-metry was abnormal in 54% of the cases and 9% had abnormal esophageal emptying. There was no 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 abnormal esophageal pH test and 46% had lower esophageal sphincter hypotonia. Only 20% of the patients showed an abnormal endoscopic finding like a hiatal hernia or reflux esophagitis. Interestingly, both studies showed that GERD related symptoms in obese patients are associated with low positive and negative predictive values. Furthermore, ambulatory pH testing is positive for acid reflux in more than 50 % of patients presenting for bariatric surgery. At the same time, the incidence of a hiatal hernia is much lower indicating that in obese patients acid reflux occurs way before a hiatal hernia fully develops. Mechanisms like lower esophageal sphincter hypotonia and delayed esophageal emptying are among other factors that contribute to acid reflux in this patient population. Consequently, one may safely assume that concomitant hiatal dissection and crural approximation during weight loss surgery may not be warranted. Gastric bypass surgery diverts most of the stomach away from the esophagus and hence reliably eliminates acid reflux. Gastric sleeve surgery increases gastric emptying, eliminates the postprandial acid pocket formation, and strengthens the lower esophageal sphincter according to a recent study. Therefore, gastric sleeve surgery similar to gastric bypass reliably controls acid reflux. The caveat is proper gastric sleeve resection. The incisura should be kept widely open, the antral pump should be preserved to promote gastric emptying and the gastric fundus should be completely resected. A gastric sleeve constructed in this fashion is in my experience a reliable anti-reflux procedure. Previous studies have shown that gastric sleeve surgery induces de novo acid reflux and worsens pre-existing GERD. In a recent prospective study, Moreno et al. disputed this idea and showed that gastric sleeve surgery is a reliable anti-reflux procedure.

GERD has become an epidemic similar to obesity. Both diseases are inter-related and further studies are needed to understand the relationship between obesity and acid reflux. Treatment of acid reflux in obese patients heavily relies on weight reduction. Bariatric surgery including both gastric bypass and gastric sleeve surgeries is an effective alternative to the traditional Nissen fundoplication for treatment of GERD.