Reflux of stomach contents into esophagus exacerbated by increased intraabdominal pressure from obesity; surgical interventions modify anatomy to reduce reflux
Target Population
Patients aged 20-93 years with GERD refractory to medical management and moderate obesity (BMI < 40 kg/m2)
Care Setting
Surgical department in tertiary care hospital with laparoscopic or robotic surgery capabilities
Key Highlights
Fundoplication enhances the lower esophageal sphincter barrier by wrapping the stomach around the esophagus to reduce reflux.
Roux-en-Y Gastric Bypass (RYGB) provides sustained weight loss, alters gastric anatomy to reduce acid and bile reflux, and lowers intragastric pressure.
No clear international guidelines exist for surgical choice in moderate obesity due to lack of high-quality comparative trials.
Guideline-Based Recommendations
Diagnosis
Confirm GERD diagnosis with endoscopy, pH monitoring, and manometry.
Assess obesity class and comorbidities to guide surgical decision-making.
Use validated questionnaires (RSI, BQL, QOLRAD) to evaluate reflux symptoms and quality of life preoperatively.
Management
Consider Fundoplication for GERD refractory to medical therapy, especially in patients without significant obesity-related comorbidities.
Consider RYGB for patients with moderate obesity and GERD, particularly when weight loss and metabolic improvements are desired.
Perform hiatal hernia repair concurrently with Fundoplication when indicated.
Prefer laparoscopic or robotic surgical approaches for both procedures.
Monitoring & Follow-up
Postoperative follow-up at 3 and 12 months to assess reflux symptom regression, weight/BMI changes, and comorbidity improvement.
Use Clavien-Dindo classification and Comprehensive Complication Index to monitor surgical complications.
Repeat RSI, BQL, and QOLRAD questionnaires at least one year postoperatively to evaluate outcomes.
Risks
Potential perioperative complications vary by procedure; RYGB may have lower in-hospital morbidity in severe obesity but data in moderate obesity are limited.
Surgical risks include anesthesia duration, blood loss, and postoperative complications classified by Clavien-Dindo.
Lack of high-quality evidence necessitates individualized risk-benefit assessment.
Patient & Prescribing Data
Patients with GERD and moderate obesity (BMI < 40 kg/m2) undergoing surgical treatment
RYGB may offer superior reflux control and metabolic benefits compared to Fundoplication, but choice depends on symptom severity, comorbidities, and patient preference; both procedures require careful perioperative management.
Clinical Best Practices
Perform thorough preoperative assessment including objective reflux testing and quality of life questionnaires.
Use propensity score matching in studies to compare surgical outcomes controlling for age, BMI, and gender.
Tailor surgical approach to individual patient characteristics and comorbidities.
Ensure standardized postoperative protocols and follow-up to monitor symptom control and complications.
Incorporate multidisciplinary teams including bariatric and reflux specialists for optimal management.
