A tailored approach for reflux management after sleeve gastrectomy: dispelling the notion that all need conversion to a gastric bypass.

INTRODUCTION: Gastroesophageal reflux disease (GERD) after sleeve gastrectomy (SG) can be challenging to manage, with conversion to Roux-en-Y gastric bypass (RYGB) as a common surgical therapy. OBJECTIVES: To evaluate an algorithmic approach for identifying alternatives to SG conversion to RYGB for GERD. SETTING: This is a single-center, retrospective review of all consecutive patients with persistent GERD after SG between January 2015 and July 2021. METHODS: After lifestyle optimization, patients underwent esophagram, manometry, Bravo pH studies, and esophagogastroduodenoscopy. Thereafter, the algorithm was followed to determine intervention. Prospective data were collected in an institutional database with long-term follow-up comparisons. RESULTS: Sixty-four patients were managed (mean age 46 years; 92% female). Average time from index SG to surgical intervention was 4.04 years and mean follow-up was 5.8 years. Procedures included conversion to RYGB (n = 41), of which 26 had concomitant hiatal hernia repair (HHR), magnetic sphincter augmentation (n = 19), of which 12 had concomitant HHR, HHR alone (n = 3), and radiofrequency ablation (n = 1). Average body mass index was higher for those converted to RYGB (41.4 vs. 32.5). Average preoperative GERD-health-related quality of life (HRQL) improved from 38.9 to 9.3 at follow-up and high-dose/daily PPI use fell from 95% preoperative to 64% postoperative, with 28% off proton pump inhibitors at long-term follow-up. Outcomes did not differ by procedure type (P = .455 and .817, respectively). Four patients showed no GERD-HRQL improvement, with no association with procedure performed. (P = .455). CONCLUSIONS: Utilizing a rigorous protocol, 36% of patients with GERD after SG were spared conversion to RYGB with excellent long-term outcomes, as demonstrated by improved GERD-HRQL scores and reduced PPI use.