Gastroesophageal Reflux Disease as an Indication of Revisional Bariatric Surgery—Indication and Results—a Systematic Review and Metanalysis

Best practice approach for redo-surgeries after sleeve gastrectomy, an expert's modified Delphi consensus

“…The experts agreed with a significant consensus of 97.7% that conversion to RYGB is the only acceptable surgical treatment option in symptomatic GERD. This statement is congruent with the current literature since in a systematic review and meta-analysis by Chiappetta et al evidence underlines that RYGB is an efficient surgical treatment option for GERD and that conversion in RYGB was the most performed redo-surgery (73.2%) in GERD in the literature [17]. Parmar et al just published in 2017 that conversion of SG to RYGB is mainly effective for GERD symptoms, but not for further weight loss [19].…”

“…Therefore, esophageal pH monitoring, impedance reflux monitoring, and esophageal manometry may be indicated in symptomatic patients, which have a negative EGD, but not as a standard diagnostic procedure in patients with positive EGD. Since conversion to RYGB is the most performed redo-surgery after SG in patients with GERD [17], the diagnostic tools can be considered in a special cohort of patients, to exclude hiatal hernias, hypotensive lower esophageal sphincter, and severe esophageal motility disorders beyond GERD.…”

“…Finally, the experts agreed with a second-round consensus of 73.9% that minimum time to revision/conversion after SG for GERD should be 12 months. In a recently published meta-analysis in total, 915 patients (SG = 764 patients, 83.5%) underwent redo-surgery due to GERD, and the interval between primary surgery and redo-surgery was 31.23 + / − 16.32 months (1 to 67 months) [17]. This important range from 1 to 67 months underlines the heterogeneity of the patients, indicating that depending on the severity and response to conservative treatment, indication for redo-surgery in patients with severe GERD after SG might be given at different timeline.…”

“…The consensus group of experts agreed with 84.7% consensus that the BPL should be increased in RYGB and OAGB when they are used in revisional cases. Many systematic reviews have shown that longer BPL gives better results in revisional cases and also in patients with higher BMI [17,49]. Similarly, the experts overwhelmingly agreed that the alimentary limb should be at least 75 cm if the conversion to RYGB is for GERD.…”

“…In cases of stricture or rotation of the sleeve, a conversion to bypass proximal to the stricture/rotation was considered the best option [50]. There is sufficient evidence to support this as the conversion is technically safe and gives good long-term results [17,19]. Majority of the experts disagreed that fundoplication is an acceptable option in the presence of a dilated fundus and GERD as this procedure is still novel and life-threatening complications like wrap necrosis that have been reported with this [51].…”