Background

GERD after LSG is due to turbulent flow resulting from uneven sleeve diameter. Uneven sleeve diameter is due to incomplete fundal resection, stricture, sleeve rotation from division of lateral attachments and “zig-zag” staple line formation from use of 60mm staple loads (SL) in a curved line. The validated GERD-Health Related Quality of Life (GERD-HRQL) instrument (0-45: none-severe GERD) was used preoperatively, 6/12 months and annually thereafter. Postoperative score at last follow-up was used. GERD was defined as GERD-HRQL ≥10. LSG techniques included 38Fr bougie and 60mm SL (A), A plus gastropexy (B) and no bougie, 45mm SL and gastropexy (C). 122 LSG and 749 LRYGB patients with a mean follow-up of 12.8 (6-72) and 23.7 (6-120) months were included. Hiatal hernia repair (HHR), or gastropexy was performed in 13/122 and 100/122 LSG patients. GERD-HRQL score difference (GERDscdiff) from baseline improved with HHR (12.5±12.7 vs. 5.0±11.6, p=.0048) and gastropexy (-2.1±11.3 vs. 7.8±11.1, p=.0011). Technique C had the best GERDscdiff (A: -2.1±11.3, B: 6.2±9.0, C: 7.9±11.2, p=.0011). There was a significant reduction of GERD postoperatively (41/122 (A: 3/22, B: 2/7, C: 36/93), vs. 11/122 (A: 4/22, B: 1/7, C: 6/93, p<.0001). Postoperative de-novo GERD reduced from technique A to C (A: 4/22, B: 1/7, C: 2/93, p=.0088). LSG and LRYGB had similar GERD-HRQL scores preoperatively (8.7±10.6 vs. 7.7±10.3), and postoperatively (2.9±5.8 vs. 5.4±10.1). Postoperative GERD is not an inherent issue of LSG but technique-related. Gastropexy, avoidance of bougie and use of 45mm SL may achieve postoperative GERD scores comparable to LRYGB.