Obesity is a global epidemic whose prevalence is increasing. Obesity is a well-documented risk factor for many health conditions, including cardiovascular disease, type-2 diabetes mellitus, osteoarthritis, and some cancers. Moreover, gastroesophageal reflux disease (GERD) is a common condition in obese patients.
The pathophysiology of GERD in adults is thought to be multifactorial. It is caused by abnormal relaxation of the lower esophageal sphincter or a mix of inherited and functional factors arising from increased pressure from the stomach. The patients may typically present with atypical symptoms such as cough, sinusitis and pharyngitis, as well as typical symptoms like heartburn, acid or water regurgitation, dysphagia, and odynophagia.
Untreated GERD can result in reflux erosive esophagitis, ulceration, strictures, and Barrett's esophagus. 10% of Barrett's esophagus cases can progress to esophageal adenocarcinoma.
The research has shown that GERD responds different reactions to bariatric surgery, depending on which surgery is performed. Therefore, the evaluation of all patients in terms of GERD before the surgery is important in the preparation for bariatric surgery. Accordingly, preoperative upper gastrointestinal endoscopy is essential for all bariatric surgery patients.
In the patients who did not undergo simultaneous hiatal hernia repair with sleeve gastrectomy (gastric sleeve surgery), an increase in reflux symptoms is observed due to the reduction in the gastric emptying associated with the surgery, a decrease in lower esophageal sphincter pressure, the blunt in the His angle, herniation of a part of the newly formed stomach into the thoracic cavity, a decrease in gastric volume, and an increase of intragastric pressure that is secondary to the narrow stomach pouch. The role of the hiatal hernia repair in the sleeve gastrectomy is an important consideration for patients with reflux. It is observed that the reflux complaints regress at a rate of 94% in the patients who underwent hiatal hernia repair simultaneously with the sleeve gastrectomy surgery.
Gastric bypass is accepted as the most effective bariatric procedure for reflux. In the studies conducted, it has been determined that the clinical improvement and symptoms were not observed in terms of reflux in all patients who underwent gastric bypass surgery in long-term follow-up. Gastric bypass is our first preferred method, especially in patients with resistant reflux complaint. However, for other reflux patients, simultaneous hiatal hernia repair with sleeve gastrectomy will usually be sufficient.
