REVIEW

CURRENT
OPINION Effects of bariatric surgery on the esophagus
Edoardo Savarino a, Elisa Marabotto b, and Vincenzo Savarino b

Purpose of review
Bariatric surgery is the best therapeutic approach to patients with morbid obesity, but there is mounting
evidence that it is associated with esophageal dysfunctions, including gastroesophageal reflux disease
(GERD) and motor disorders. In the present review, we summarize the existing information on the complex
link between bariatric surgery and esophageal disorders.
Recent findings
Although high-quality studies on these effects are lacking, because of evident methodological flaws and
retrospective nature, the review of published investigations show that pure restrictive procedures, such as
laparoscopic adjustable gastric banding (LAPG) and laparoscopic sleeve gastrectomy (LSG), are associated
with de novo development or worsening of GERD. Moreover, LAGB is the procedure with the greatest
frequency of esophageal motor disorders, including impairment of LES relaxation and ineffective
esophageal peristalsis associated with esophageal dilation. LSG seems to be less associated with
esophageal dysmotility, although evidence derived from studies with objective measurements of esophageal
dysfunction is limited. Finally, RYGB seems to be the best procedure for improvement of GERD symptoms
and preservation of esophageal function.
Summary
Overall, the restrictive-malabsorptive approach represented by RYGB must be preferred to pure restrictive
operations in order to avoid the negative consequences of bariatric surgery on esophageal functions.
Keywords
bariatric surgery, esophageal motility disorders, gastroesophageal reflux disease, obesity, reflux disease

INTRODUCTION pathophysiological alterations leading to GERD

Obesity is a worldwide epidemic in Western coun-
tries [1] and its prevalence, when defined as a BMI at
least 30 kg/m2, increased from 15 to 32.9% through-
out three decades among adults aged 20–74 years in
the USA [2]. In addition, a recent study [3] has also
shown that, over the past four decades, mean BMI
and obesity have increased in most regions and
countries of the world, even in children and ado-
lescents aged 5–19 years. The rise in children and
adolescents’ BMI has plateaued, albeit at high levels,
in many high-income countries, but has accelerated
in parts of Asia.
The association of obesity with several impor-
tant medical conditions, such as metabolic syn-
drome, acute myocardial infarction, hypertension,
sleep apnea, nonalcoholic fatty liver disease and
type II diabetes mellitus is well known [4]. There is
also increasing evidence that obesity is associated
with esophageal diseases, including gastroesopha-
geal reflux disease (GERD) and motor disorders [5].
As to the mechanisms linking obesity to GERD, in
particular, various studies have clearly docu-
mented that obese patients bear all the main
[6]. Abdominal fat seems to be the most important
pathogenetic factor, because it contributes to
increase intragastric pressure [7] and the gastro-
esophageal pressure gradient [8], to favor transient
lower esophageal sphincter (LES) relaxations [9]
and to induce the formation of hiatal hernias
[10]. An additional mechanism by which obesity
can cause GERD relies on the release of some
hormones, such as estrogens, or on the low serum
levels of potentially protective substances, such as
adiponectins [11].
a
Gastrointestinal Unit, Department of Surgery, Oncology and Gastroen-
terology, University of Padua, Padova and bGastrointestinal Unit, Depart-
ment of Internal Medicine and Medical Specialties, University of Genoa,
Genoa, Italy
Correspondence to Edoardo Savarino, Gastrointestinal Unit, Depart-
ment of Surgery, Oncology and Gastroenterology, University of Padua,
Via Giustiniani 2, 35128 Padova, Italy. Tel: +39 498217749;
fax: +39 010 3538956; e-mail: edoardo.savarino@unipd.it
Curr Opin Gastroenterol 2018, 34:243–248
DOI:10.1097/MOG.0000000000000439

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Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

Esophagus
KEY POINTS
 Bariatric surgery is an efficient method to successfully
achieve weight loss and improvements in morbidity and
mortality, but it has been associated with impairment of
esophageal function leading to GERD and esophageal
motility abnormalities.
 RYGB is the best approach to avoid the appearance of
GERD symptoms and to improve those cases with
preoperative reflux complains, whereas the pure
restrictive procedures, such as LAGB and LSG, often
are associated with worsening of GERD or de novo
GERD development in some patients.
 LAGB is the procedure with the greatest frequency of
esophageal motor disorders, including impairment of
LES relaxation and ineffective esophageal peristalsis
associated with esophageal dilation, whereas LSG
seems to be less associated with
esophageal dysmotility.
 RYGB seems to be the best procedure for patients with
known and unknown preoperative motor disorders
because of its absent or minimal effects on
esophageal motility.
 High-quality studies on the effects of the various
bariatric surgery procedures are lacking because of
evident methodological flaws and their predominant
retrospective nature, thus future high-quality
randomized controlled trials with longer follow-up
examinations are sorely needed.
Due to the relevant therapeutic limitations of
lifestyle modifications and available pharmacologi-
cal treatments in inducing weight loss, mainly in the
long term, bariatric surgery has become the most
effective therapy in reaching prolonged benefits in
terms of both weight reduction and improvement of
the above-mentioned comorbidities and overall
mortality [12] in morbidly obese patients with a
BMI greater than 35–40 kg/m2.
With the increasing use of bariatric operations,
however, there is mounting evidence that they may
affect esophageal function. In this review, we have
summarized the effects of bariatric surgery proce-
dures on the esophagus with a focus on their impact
on GERD and esophageal motor alterations and
related symptoms.
BARIATRIC SURGERY PROCEDURES
There are two main categories of bariatric opera-
tions: pure restrictive and restrictive-malabsorptive.
The former are represented by the laparoscopic
adjustable gastric banding (LAGB) and the laparo-
scopic sleeve gastrectomy (LSG), which are intended
to reduce the total amount of food the stomach can
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Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
hold and also to slow gastric emptying [13], and the
latter is the Roux-en-Y gastric by pass (RYGB), which
is the most frequently used restrictive-malabsorp-
tive procedure and serves both to limit the size of the
stomach and to favor selective malabsorption as an
additional weight loss-inducing benefit [14].
Laparoscopic adjustable gastric banding
This a restrictive weight loss operation that involves
the placement of a silicone ring around the proximal
part of the stomach. The band is connected to a
subcutaneous port, which allows injection of saline
to adjust the band tightness. Inflation leads to a
reduction in size of the gastric reservoir and limits
food capacity. In the early 1990s, the first reports of
LAGB were published, suggesting that was a well
tolerated and effective weight-loss operation.
Among both patients and surgeons, the popularity
of this technique grew rapidly, owing to short
operative times, low perioperative morbidity and
mortality, absence of need to re-route the gastroin-
testinal tract, reversibility of the operation and fewer
nutritional deficiencies. Over the next two decades,
LAGB became the most frequently used operation
for the management of morbid obesity and obesity-
related complications. However, as long-term out-
comes of this procedure were collected, its effective-
ness in terms of durability of weight loss and
resolution of comorbidities was questioned. Fur-
thermore, relevant long-term adverse events
and complications mainly related to the migration
of the device were reported, as described in the
following.
Laparoscopic sleeve gastrectomy
This is a restrictive weight loss operation that is
performed by removing the majority of the stomach
along a line within the angle of His and a point
along the greater curvature of the stomach, approx-
imately 3–6 cm from the pylorus. This results in
removing about the 80% of the body and the entire
fundus of the stomach, but the pylorus is preserved.
Obviously, the resection of the majority of the acid-
producing mucosa of the stomach leads to the fact
that the amount of acid in the gastric sleeve is
substantially diminished. Despite little or no mal-
absorptive component to this operation, it has been
associated with durable weight loss and control of
medical comorbidities.
Roux-en-Y gastric by pass
A gastric by-pass is performed by creating a small
gastric pouch and a Roux-en-Y gastro-jejunostomy
Volume 34  Number 4  July 2018

of variable length. In this way, the pouch prevents
overeating and the long Roux limb decreases calorie
absorption. Also this procedure is characterized by
very little acid production in the proximal gastric
pouch. It is associated with durable weight loss and
control of obesity-related comorbidities. For these
reasons, RYGB is one of the most commonly per-
formed bariatric operations.
EFFECTS OF BARIATRIC SURGERY ON
GASTROESOPHAGEAL REFLUX DISEASE
Laparoscopic adjustable gastric banding
Several long-term studies have shown that there is a
general increase in GERD following this surgical
approach in both patients with preoperative symp-
toms of GERD, which are aggravated, and in those
who were previously asymptomatic [15]. Interest-
ingly, however, patients with symptomatic GERD
often describe an initial improvement of their com-
plaints, but some months later (6 months on aver-
age) symptoms tend to return [16–17]. Moreover, it
has been shown that the type of symptoms tends to
change, because regurgitation predominates post-
operatively, whereas heartburn is prominent before
surgery [18]. On the other hand, in a retrospective
study by Dixon and O’Brien [19] evaluating 48
symptomatic GERD patients who consecutively
underwent LAGB, in 77% of the cases symptoms
vanished after 3 weeks of surgery. Furthermore, in
another prospective investigation assessing the
aggravation of GERD symptoms in 167 morbidly
obese patients following adjustable gastric banding
[20], 68% of them were symptom-free after the
operation.
The most severe form of esophageal dysfunction
that results after LAGB is pseudoachalasia, which is a
condition characterized by esophageal aperistalsis
associated with impaired distal esophageal LES
relaxation. It is reported in less than 2% of patients
undergoing band placement [21], but it is likely that
its incidence is underreported because of limited
manometric assessment of the phenomenon. It
has been hypothesized that the progressive filling
of the band overtime leads to stasis in the pouch and
the relative obstruction can cause regurgitation.
Overall, this procedure can favor esophageal dys-
function and other important complications, such
as slippage of the band and erosions [22,23].
Laparoscopic sleeve gastrectomy
The postoperative prevalence of GERD in patients
treated with this procedure is highly variable, per-
haps because of the use of questionnaires rather
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Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Effects of bariatric surgery on the esophagus Savarino et al.
than objective measurements of reflux [24]. Other
important methodological differences among the
various investigators (patient selection, GERD diag-
nosis, length of follow-up, exclusion criteria) also
may have affected their study results. Taking into
account the above limitations, there are studies
reporting a decreased prevalence of GERD [25–27]
and other showing an increased prevalence of the
disease [28–30]. However, it must be emphasized
that two investigations [31,32] using objective mea-
sures of GERD after LSG (esophageal pH-metry and
pH-impedance monitoring, respectively) found that
there is an increase in esophageal acid exposure and
also a major number of nonacid reflux episodes after
surgery, thus confirming that LSG can cause the
development of GERD. In fact, it is likely that the
sleeve leads to a disruption of the competency of the
esophagogastric junction and to an increased inci-
dence of hiatal hernia. Accordingly, two recent
studies combining LSG with hiatal hernia repair
[33,34] have shown a dramatic reduction in postop-
erative GERD over 12–18 months of follow-up.
Moreover, a recent multicenter study by Mion
&
et al. [35 ] evaluating, by means of high-resolution
impedance manometry, 53 patients who underwent
LSG, showed that the operation significantly modi-
fied esophagogastric motility, inducing a marked
increase of intragastric pressure (as potential mech-
anism of reflux occurrence), and a significant aug-
mentation of impedance-detected reflux episodes
associated with GER symptoms and esophageal
dysmotility.
Roux-en-Y gastric bypass
Gastric bypass has been shown to provide excellent
control of typical GERD symptoms. For example,
Schauer et al. [36] found that 96% of their patients
had improvement or total relief of symptoms and
none had aggravation of gastroesophageal reflux
occurrence, whereas Frezza et al. [37] observed a
marked reduction of heartburn, from 87% of
patients preoperatively to 23% postoperatively.
Moreover, the latter authors observed that atypical
symptom refractory to conventional medical ther-
apy also improved after RYGB. The protective effect
of RYGB on GERD was also objectively demon-
strated by means of traditional pH monitoring,
which showed that all pH-based parameters
improve significantly in both short-term and
long-term investigations [38,39].
The mechanisms by which RYGB mitigate distal
esophageal acid exposure and GERD symptoms
probably depend on the new anatomy formed by
surgery. First, the volume of the new gastric pouch is
small, averaging 30 ml [40], and this reduces the
www.co-gastroenterology.com 245
Esophagus
reservoir’s capacity to promote regurgitation. Sec-
ond, the cardia region of the stomach, where the
pouch is created, is relatively poor in density of acid-
producing parietal cells. Third, bile reflux is avoided
because of the Roux-en-Y biliary diversion.
It must be also emphasized that a recent varia-
tion of the RYGB, that is the omega-loop gastric
bypass, otherwise known as minigastric bypass or
the one anastomosis gastric bypass, was shown to
prevent the de-novo development of abnormal
&&
reflux or esophagitis [41 ]. However, data evaluat-
ing the effect of the omega-loop gastric by-pass on
esophageal function are still limited.
EFFECTS OF BARIATRIC SURGERY ON
ESOPHAGEAL MOTILITY DIORDERS
In addition to the pathophysiological alterations
leading to GERD with some of the major bariatric
surgery procedures, the development of frequent
abnormalities in esophageal motor function has
been well documented. These unintended conse-
quences can be very disabling for patients, because
the predominant symptom is persistent and often
progressive dysphagia.
Laparoscopic adjustable gastric banding
Traditional esophageal manometry and the modern
high-resolution manometry (HRM) have frequently
demonstrated various motor alterations, such as
ineffective esophageal motility or aperistalsis, and
incomplete LES relaxation in patients undergoing
LAGB [42,43]. We have already mentioned the pos-
sible development of pseudoachalasia, which is a
rare but severe complication [21] and can be man-
aged by band deflation or band removal. An alter-
native treatment option can be the conversion of a
LAGB to RYGB, which has been shown to favor a
considerable improvement of dysphagia as well as a
reduction of the intrabolus pressure 5 cm above the
LES [44]. The advantage of this approach consists in
improving esophageal dysmotility and providing a
concurrent procedure to manage obesity and its
related comorbidities.
Laparoscopic sleeve gastrectomy
An increase in ineffective peristalsis has been docu-
mented after LSG, resulting in stasis and postpran-
dial regurgitation [32]. Braghetto et al. [45] reported
a hypotensive LES in 73% (17/23) of their patients
(n ¼ 20 patients), perhaps because of the disruption
of gastric sling fibers during creation of the sleeve. In
contrast, Petersen et al. [46] found an overall
increase in postoperative LES pressure. Moreover,
246 www.co-gastroenterology.com
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
in a prospective study carried out using high-reso-
lution impedance manometry in 25 consecutive
patients who underwent LSG, Del Genio et al. [32]
found a normal LES pressure after surgery at a
median follow-up of 13 months. However, this latter
study also reported an increase in ineffective esoph-
ageal peristalsis, incomplete bolus transit and retro-
grade flow within the esophagus.
Overall, the medical literature regarding the
effects of sleeve gastrectomy on LES function is
inconsistent, but this seems to be highly dependent
on differences in the surgical technique of gastric
transection at the time of sleeve creation. However,
more objective data are necessary to understand
this association.
Roux-en-Y gastric by pass
The majority of functional studies do not show any
esophageal motor alteration after RYGB, although
some authors have reported several manometric
abnormalities including hypotonic LES [47,48], and
an increase in esophageal wave amplitude and esoph-
ageal wave duration in postoperative patients [48].
Regarding the appearance of dysphagia, two
studies have shown contradictory results [49,50].
At present, the limited evidence of any major esoph-
ageal motor disorders developing after RYGB is the
main reason why many surgeons recommend this
type of operation in patients with known esoph-
ageal dysmotility [51].
CONCLUSION
Bariatric surgery is an efficient method to success-
fully achieve weight loss and improvements in mor-
bidity and mortality, but it can impair esophageal
function leading to GERD and esophageal motility
abnormalities. This effect is variable depending on
the type of operation performed. Although high-
quality studies on the effects of the various bariatric
surgery procedures are lacking because of evident
methodological flaws and their predominant retro-
spective nature, this review dealing with the existing
published material in the field seems to permit the
following conclusions:
(1) RYGB is the best approach to avoid the appear-
ance of GERD symptoms and to improve those
cases with preoperative reflux complains,
because the pure restrictive procedures, such as
LAGB and LSG, are associated with worsening of
GERD or developing of de novo GERD in some
patients. A recent study comparing the three
techniques in a very large number of obese
patients (n ¼ 116136) showed that 56.5% of them
Volume 34  Number 4  July 2018

reported GERD improvement after RYGB against
46% after LAGB and 41% after LSG [52]. It must
be stressed, however, that the above operations
can be safer if hiatal hernia repair is performed
concomitantly, and several studies have shown a
significant decrease in GERD development as a
result of this combined approach.
(2) LAGB is the procedure with the major frequency
of esophageal motor disorders, which are
mainly represented by impairment of LES relax-
ation and ineffective esophageal peristalsis asso-
ciated with esophageal dilation. LSG seems to be
less associated with esophageal dysmotility,
although the evidence derived from studies
with objective measurements of esophageal dys-
functions is limited. Finally, RYGB seems to be
the best procedure for patients with known and
unknown preoperative motor disorders because
of its absent or minimal effects on esophageal
motility.
(3) Although mixed results have been obtained,
mounting evidence suggests that patients who
are considering bariatric surgery, with the pos-
sible exception of RYGB, might benefit from
preoperative manometry with or without reflux
testing as a means to determine which type of
bariatric operation represents the optimal
choice. However, future high-quality random-
ized controlled trials with longer follow-up
durations should be performed to help under-
stand the feasibility and benefits of preoperative
manometry in these patients.
Overall, the restrictive-malabsorptive approach
represented by RYGB must be preferred to pure
restrictive operations in order to avoid the negative
consequences of bariatric surgery on
esophageal functions.
Acknowledgements
None.
Authors’ contribution: E.S.: data analysis, writing of the
manuscript, approving final version; E.M.: writing of the
manuscript, approving final version; V.S.: writing of the
manuscript, approving final version. Guarantor of the
article: E.S.
Financial support and sponsorship
None.
Conflicts of interest
E.S. has received honoraria from Medtronic, Abbvie,
MSD, Takeda, Sofar, Malesci; V.S. has received hono-
raria from Abbvie, Takeda, Malesci. The remaining
author has no conflicts of interest.
0267-1379 Copyright ß 2018 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Effects of bariatric surgery on the esophagus Savarino et al.
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Volume 34  Number 4  July 2018