Surgery for Obesity and Related Diseases ] (2013) 00–00

Original article
Improvement in gastroesophageal reflux disease symptoms after various
bariatric procedures: review of the Bariatric Outcomes Longitudinal Database
Pradeep K. Pallati, M.D.c, Abhijit Shaligram, M.D.a, Valerie K. Shostrom, M.S.b,
Dmitry Oleynikov, M.D., F.A.C.S.a, Corrigan L McBride, M.D., F.A.C.S.a,
Matthew R. Goede, M.D.a,*
a
Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska
b
Department of Biostatistics, University of Nebraska Medical Center, Omaha, Nebraska
c
Department of Surgery, Creighton University Medical Center, Omaha, Nebraska
Received May 14, 2013; accepted July 23, 2013

Abstract Background: The prevalence of gastroesophageal reflux disease (GERD) in the morbidly obese
population is as high as 45%. The objective of this study was to compare the efficacy of various
bariatric procedures in the improvement of GERD.
Methods: The Bariatric Outcomes Longitudinal Database is a prospective database of patients who
undergo bariatric surgery by a participant in the American Society of Metabolic and Bariatric
Surgery Center of Excellence program. GERD is graded on a 6-point scale, from 0 (no history of
GERD) to 5 (prior surgery for GERD). Patients with GERD severe enough to require medications
(grades 2, 3, and 4) from June 2007 to December 2009 are identified; the resolution of GERD is
noted based on 6-month follow-up.
Results: Of a total of 116,136 patients, 36,938 patients had evidence of GERD preoperatively.
After excluding patients undergoing concomitant hiatal hernia repair or fundoplication, there were
22,870 patients with 6-month follow-up. Mean age was 47.6 11.1 years, with an 82% female
population. Mean BMI was 46.3 8.0 kg/m2. Mean preoperative GERD score for patients with
Roux-en-Y gastric bypass (RYGB) was 2.80 .56, and mean postoperative score was 1.33 1.41
(P o .0001). Similarly, adjustable gastric banding (AGB, 2.77 .57 to 1.63 1.37, P o .0001)
and sleeve gastrectomy (SG, 2.82 .57 to 1.85 1.40, P o .0001) had significant improvement
in GERD score. GERD score improvement was best in RYGB patients (56.5%; 7955 of 14,078)
followed by AGB (46%; 3773 of 8207) and SG patients (41%; 240 of 585).
Conclusion: All common bariatric procedures improve GERD. Roux-en-Y gastric bypass is
superior to adjustable gastric banding and sleeve gastrectomy in improving GERD. Also, the greater
the loss in excess weight, the greater the improvement in GERD score. (Surg Obes Relat Dis
2013;]:00-00.) r 2013 Published by Elsevier Inc. on behalf of American Society for Metabolic and
Bariatric Surgery.
Keywords: Gastroesophageal reflux disease (GERD); Bariatric Outcomes Longitudinal Database (BOLD); Roux-en-Y
gastric bypass; Adjustable gastric banding; Sleeve gastrectomy

The prevalence of obesity has been increasing at an

Presented as a poster of distinction at the 29th American Society of
Metabolic and Bariatric Surgery Meeting, San Diego, California,
June 2012.
*
Correspondence: Matthew Goede, M.D., Department of Surgery,
University of Nebraska Medical Center, 983280 Nebraska Medical Center,
Omaha, NE 68198-3280.
E-mail: mgoede@unmc.edu
alarming rate during the past decades in the United States,
as shown by the recent reports from Centers for Disease
Control and Prevention [1]. According to this report, in
2009–2010, 35.7% of U.S. adults are obese. Obesity, defined
as body mass index (BMI) Z30 kg/m2, increases the risk of
cardiovascular disease, hypertension, dyslipidemia, and type

1550-7289/13/$ – see front matter r 2013 Published by Elsevier Inc. on behalf of American Society for Metabolic and Bariatric Surgery.
http://dx.doi.org/10.1016/j.soard.2013.07.018
2 P.K. Pallati et al. / Surgery for Obesity and Related Diseases ] (2013) 00–00
2 diabetes, among others, and decreases the life expectancy
significantly [2]. In addition, obesity increases the risk of
gastroesophageal reflux (GERD), with increased prevalence
of Barrett’s esophagus and esophageal cancer. The preva-
lence of GERD in the general population has been shown to
be in the range of 8% to 26%. In obese individuals, this is
considerably higher than in the nonobese population [3].
The treatment of GERD involves dietary and lifestyle
intervention along with pharmacotherapy and antireflux
procedures. As noted in a review article, dietary and lifestyle
intervention may improve GERD in obese patients; how-
ever, the most favorable effect is likely to be found after
bariatric surgery [4]. The fundoplication for treatment of
GERD has been associated with increasing failures in the
severely obese patients, although results are conflicting, and
it has been suggested that bariatric surgery rather than
fundoplication should be strongly considered in these
patients [5]. Several studies have focused specifically on
the improvement of GERD after various bariatric procedures
[6–9]. Roux-en-Y gastric bypass (RYGB) has been associ-
ated with the most improvement in GERD symptoms, but
adjustable gastric banding and sleeve gastrectomy have also
shown some improvement; the results are conflicting [8,9].
The reports so far involve only small cohort of patients in an
individual center study or a review of the current literature.
Bariatric Outcomes Longitudinal database (BOLD) is a
nationwide database that collects information on various
procedures, outcomes, and other parameters as entered by
American Society for Metabolic and Bariatric Surgery
Centers of Excellence (BSCOE) participants. The present
study reviews the outcome of GERD with various proce-
dures in the BOLD database.
Methods
Database
BOLD is a proprietary, Internet-based software product
developed by the Surgical Review Corporation (SRC) to
collect prospective data for all bariatric surgery patients treated
by American Society for Metabolic and Bariatric Surgery
BSCOE participants for the purpose of assessing outcomes
and quality of care. Data entry started in June 2007, and all
BSCOE participants have been required to enter patient data
into BOLD since January 2008. The participants enter
preoperative, intraoperative, and postoperative data on all
research-consented patients, as well as long-term follow-up
information for a minimum of 5 years. Recently, SRC has
transferred administration of the BSCOE program to the
American Society for Metabolic and Bariatric Surgery; how-
ever, the data was obtained before transfer of the database.
Data acquisition
A formal BOLD Data Access Request along with a
BOLD Data Dissemination Request was submitted to the
SRC. An Institutional Review Board approval was also
obtained from our institution to conduct the research. The
data were presented to us in a Microsoft Access format with
a unique identification for the individual patient. Several
variables were identified, but the data were approved for
research on effect of various procedures on GERD only.
Study data
All patients operated on between June 2007 and Decem-
ber 2009, with at least 6 months of follow-up are identified.
All the variables entered into the BOLD database have been
previously reported in the literature [10]. The data used in
this study included age, sex, race, BMI, excess weight and
GERD co-morbidity. GERD is identified as a co-morbidity,
and it is graded as shown in Table 1. Because grade 5
includes patients who meet criteria for both antireflux
surgery and prior surgery for GERD, these patients were
excluded. The study population included patients with
GERD severe enough to require medications (grades 2, 3,
and 4). Patients undergoing concomitant hiatal hernia repair
or fundoplication at the time of the bariatric surgery were
excluded from the results.
Statistics
PC SAS version 9.2 (SAS Institute, Cary, USA) was used
for all summaries and analyses. Gender and race are
summarized using frequencies and percentages. Descriptive
statistics, including the mean and standard deviation are
used to describe age and BMI. The difference in GERD
score at 6 months is calculated by subtracting the pre-
GERD score for each subject. This difference is classified as
improvement (a decrease in GERD score), no improvement
(no change in GERD score), or worsening (an increase in
GERD score).
Percentage of excess weight loss (%EWL) was catego-
rized as 4 levels. The first level was no change or a gain in
excess weight. The remaining 3 levels were based on the
tertiles for %EWL. These levels were low change in %EWL
Table 1
Symptom grading based on medication use
Grade Symptoms Number of patients
(Total number ¼ 116,136)
0 No symptoms of GERD 62,881
1 Intermittent or variable symptoms, 15,908
no medication
2 Intermittent medication 10,969
3 H2 blockers or low dose PPI 23,241
4 High dose PPI 2729
5 Meet criteria for antireflux surgery, 408
or prior surgery for GERD
GERD ¼ gastroesophageal reflux disease; H2 ¼ histamine 2; PPI ¼
proton pump inhibitor.
 Gastroesophageal Reflux After Bariatric Surgery / Surgery for Obesity and Related Diseases ] (2013) 00–00 3
(change between 0% and 34%), moderate change in %EWL
(change between 35% and 54%), and high change in
%EWL (change 454%). A general linear model was used
to compare the difference in GERD values among %EWL
categories. Pairwise comparisons were made when the
overall P value was o.05. The Tukey adjustment was used
for multiple comparisons.
A χ2 test was used to compare the change in GERD score
among the surgery types and %EWL categories. Because
both χ2 tests were statistically significant, a multivariate
logistic regression model with terms for %EWL category,
surgery type, and the interaction of these 2 terms was fit.
The interaction was not significant and was then removed
from the model leaving the fixed effect terms for %EWL
category and surgery type. The statistical level of signifi-
cance was set at .05 for all comparisons. Fig. 1. Change in gastroesophageal reflux disease composite score based
on procedure type.

Results by RYGB (2%) and AGB (1.2%). The remainder of the

A total of 116,136 patients underwent bariatric surgery
from June 2007 to December 2009. Of these, 36,938
patients had preoperative evidence of GERD severe enough
to require medications. After excluding patients undergoing
concomitant hiatal hernia repair or fundoplication, there
were 31,642 patients. Of these, 22,870 (72.3%) patients had
a 6-month follow-up recording the outcome of GERD.
Demographic characteristics of these patients are shown
in Table 2. Predominantly more patients had RYGB
(61.6%) than adjustable gastric banding (AGB, 35.9%)
and sleeve gastrectomy (SG, 2.5%). There were signifi-
cantly more men in the SG group compared with AGB and
RYGB (P o .05). Mean age of the patients was
47.6 11.1 years and involves predominantly Caucasians
(83.7%). Weight loss was significantly greater in RYGB
patients, followed by SG and AGB.
GERD score improvement was significantly highest in
RYGB patients (56.5%), followed by AGB (46%) and SG
patients (41%) (P o .05). Worsening of GERD was seen in
a small number of patients, mostly in SG (4.6%), followed
patients had no change in their GERD status.
The change in the composite score is shown in Fig. 1.
Pairwise comparisons showed that RYBG is better than
both AGB and SG (P o .0001) and that AGB is better than
SG in improving GERD (P ¼ .02).
The change in the composite score based on %EWL is
shown in Fig. 2. All levels showed significant improvement
in GERD composite score. Tukey adjusted pairwise compar-
ison showed that there were statistically significant differ-
ences in all of the %EWL category comparisons except for
low %EWL versus no change/gain in %EWL. The greater
the %EWL, the greater the improvement in GERD score.
Table 3 presents the results of multivariate logistic
regression for improvement in GERD score. When surgery
type is held constant, the odds of GERD improvement
increase with greater change in %EWL compared with no
change/gain in %EWL. And when %EWL category is held
constant, the odds of GERD improvement are much greater
for RYGB compared with the other 2 surgery types.
We also reviewed the effect of surgery type on patients
who had GERD score of 0 or 1 preoperatively. Of 69,542

Table 2
Demographic data
Variable RYGB N ¼ 14,078 AGB N ¼ 8207 SG N ¼ 585 Total N ¼ 22,870 P value

Gender .1162
Male 17.9% 17.8% 21.2% 18%
Female 82.1% 82.2% 78.8% 82%
Age, years (mean SD) 47.5 10.9 47.7 11.5 48.0 11.0 47.6 11.1 .1189
Preoperative BMI (mean SD) 47.1 8.18 44.8 7.17 48.5 10.3 46.3 7.98 o.0001
Postoperative BMI (mean SD) 33.2 6.58 38.6 6.48 36.1 8.19 35.2 7.07 o.0001
Race
Caucasian 83.9% 83.4% 83.4% 83.7% .5214
Black 7.5% 8.7% 8.2% 8% .0109
Hispanic 4.8% 4% 4.8% 4.5% .0088
Other race 4.2% 4.5% 3.6% 4.3% .3826

AGB ¼ adjustable gastric banding; RYGB ¼ Roux-en-Y gastric bypass; SD ¼ standard deviation; SG ¼ sleeve gastrectomy.
4 P.K. Pallati et al. / Surgery for Obesity and Related Diseases ] (2013) 00–00
Fig. 2. Change in gastroesophageal reflux disease composite score based on percentage of excess weight loss (%EWL).
patients, only 48,101 (69.2%) patients had 6 month follow-
up score. Worsening of GERD was significantly more in
SG (9.2%) followed by RYGB (4.6%) and AGB (2.7%). The
remainder of the patients had no change or had
improvement in their GERD status.
Discussion
Roux-en-Y gastric bypass has been shown to be asso-
ciated with significant improvement in GERD, which is
corroborated by our study. AGB is also associated with
improvement in GERD in 46.5% patients. Although this is
significantly less than RYGB, it does represent improve-
ment in up to half the patients undergoing AGB. Similarly,
sleeve gastrectomy (SG) is associated with 41.7% improve-
ment in GERD. This represents a fairly good number of
patients overall.
AGB has been implicated with both improvement and
worsening of GERD in the literature [9,11–13]. Dixon et al.
[11] and Woodman et al. [12] reported significant improve-
ment in GERD of up to 91% in a small number of patients.
On the contrary, Ovrebø et al. [13] reported markedly
increasing gastroesophageal reflux after AGB. De Jong
et al. [9] performed a systematic review of the available
Table 3
Odds of gastroesophageal reflux disease improvement at Z6 months
Effect level Reference level
%EWL category
Low %EWL No change/gain
Moderate %EWL No change/gain
High %EWL No change/gain
Surgery type
AGB RYGB
SG RYGB
%EWL ¼ percentage of excess weight loss; AGB ¼ adjustable gastric banding; RYGB ¼ Roux-en-Y gastric bypass; SG ¼ sleeve gastrectomy.
literature and found that “AGB has antireflux properties
resulting in resolution or improvement of reflux symptoms,
normalized pH monitoring results, and a decrease of
esophagitis on short term. However, worsening or newly
developed reflux symptoms and esophagitis are found in a
subset of patients during longer follow-up.” The present
study was a 6-month follow-up that showed improvement
in GERD in 46.5% patients, worsening in only 1.3%, and
no change in the remainder of the patients. In patients with
minimal or no symptoms before the surgery, only 2.7%
developed worsening GERD.
SG has been implicated with worsening and new onset
GERD in previously nonreflux patients. Howard et al. [14]
reported an 82% worsening of GERD symptoms after SG.
Tai et al. [15] also noted a significant increase in the
prevalence of GERD symptoms (12.1% versus 47%) and
erosive esophagitis (16.7% versus 66.7%) after SG in 66
patients with 1 year follow-up. However, Daes et al. [16]
reported that with careful attention to surgical technique
along with concomitant hiatal hernia repair, incidence of
GERD decreased from 49.2% to 1.5% at 6–12 months
postoperatively. Also, Soricelli et al. [17] noted GERD
remission in 73.3% of the patients who had preoperative
GERD when combined hiatal hernia repair was performed.
Odds ratio 95% confidence interval Odds ratio P value
1.107 (0.865, 1.416) .4206
1.364 (1.063, 1.749) .0146
1.579 (1.228, 2.030) .0004
0.809 (0.749, .874) o.0001
0.567 (0.479, .671) o.0001
 Gastroesophageal Reflux After Bariatric Surgery / Surgery for Obesity and Related Diseases ] (2013) 00–00
“De novo” GERD symptoms developed in 22.9% of the
patients undergoing SG alone compared with 0% of patients
undergoing SG plus hiatal hernia repair. Finally, a recent
review of literature on the effect of SG on GERD by Karmali
et al. [8] in 2011 noted that of a total of 11 studies that had
both preoperative and postoperative data, 4 studies reported
an increase in GERD after SG and 7 studies found reduced
GERD prevalence after SG. Similarly, the present study
found GERD score improvement in 41% of patients with
preexisting GERD. Worsening of GERD was seen in
4.6%, and “de novo” GERD was seen in 9.2% of the
patients, which was significantly higher than other groups.
RYGB has been the procedure of choice for patients with
GERD. In the present study, it was shown to result in
improvement of GERD in 56.5% of patients. This is in
concordance with the available literature, which shows
similar results. Murr et al. [7] noted 94% improvement in
typical reflux symptoms after gastric bypass for morbid
obesity by 9 months with 4% showing worsening symp-
toms. Schauer et al. [18] noted similar significant decrease
in GERD-related symptoms, including heartburn (from 87%
to 22%, P o.001), in their series after gastric bypass.
RYGB combines a low-pressure small gastric pouch that
enters directly into the jejunum. It reduces exposure to acid
and prevents bile reflux, thus resulting in maximum
improvement in GERD. Prachand et al. [19] compared the
resolution of co-morbidities between patients undergoing
either RYGB or duodenal switch (DS). Although DS
offered better weight loss, greater risk of remission of
diabetes, greater improvement in hypertension, and much
better control of hyperlipidemia, RYGB was more effective
for GERD.
The %EWL categories noted in this study take into
account the tertiles based on the %EWL noted. We
observed that, of the patients losing weight, one third
lose o35%, one third lose 455%, and the remainder lose
between 35%–55%. Surprisingly, the group with no change
or gain in weight within 6 months after surgery also noted
significant improvement in postoperative GERD scoring.
On further review, we noted that all the patients with
improvement were in the AGB or RYGB group only. We
hypothesize that AGB and RYGB inherently decrease
GERD as a result of the decrease in amount of gastric
juice present in the proximal pouch. We also noted that, if
you have significantly higher %EWL with whatever the
surgery type, you have significantly greater improvement in
GERD. This is expected from the loss of high intra-
abdominal pressure resulting in decreased pressure gra-
dients between stomach and esophagus.
This study is based on the largest registry of bariatric
surgery patients available today with good follow-up.
However, there are a few limitations. This is a retrospective
database research that is based on the quality of database,
which is subject to continuous quality improvement within
BOLD. GERD, as documented in the BOLD, only identifies
5
the disease based on the use of acid suppressive medica-
tions and does not have any objective data, such as 24-hour
pH monitoring, to confirm gastroesophageal reflux. The
variation in the number of procedures is inherent to the data,
especially the low number of sleeve gastrectomies noted.
Also, these procedures are performed with minor modifica-
tions across the nation with no standardized technique
across various institutions. As with sleeve gastrectomy,
there has been variation in the distance from pylorus, size of
the sleeve, and hiatal dissection, all of which could affect
the GERD itself. We did remove the procedures involving
hiatal hernia repair to remove the bias, however this
limitation needs to be noted.
Conclusions
All common bariatric procedures improve GERD. Roux-
en-Y gastric bypass is superior to adjustable gastric banding
and sleeve gastrectomy in improving GERD. Improvement
in GERD is also a function of weight loss, because patients
with higher weight loss experience significantly higher
improvement in GERD.
Disclosures
The authors have no commercial associations that might
be a conflict of interest in relation to this article.
References
[1] Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity in
the United States, 2009–2010. NCHS data brief, no 82. Hyattsville,
MD: National Center for Health Statistics; 2012.
[2] Peeters A, Barendregt JJ, Willekens F, Mackenbach JP, Al Mamun A,
Bonneux L. NEDCOM, the Netherlands Epidemiology and Demog-
raphy Compression of Morbidity Research Group. Obesity in adult-
hood and its consequences for life expectancy: a life-table analysis.
Ann Intern Med 2003;138:24–32.
[3] Ogden CL, Yanovski SZ, Carroll MD, Flegal KM. The epidemiology
of obesity. Gastroenterology 2007;132:2087–102.
[4] De Groot NL, Burgerhart JS, Van De Meeberg PC, de Vries DR,
Smout AJ, Siersema PD. Systematic review: the effects of conserva-
tive and surgical treatment for obesity on gastro-oesophageal reflux
disease. Aliment Pharmacol Ther 2009;30:1091–102.
[5] Prachand VN, Alverdy JC. Gastroesophageal reflux disease and
severe obesity: Fundoplication or bariatric surgery? World J Gastro-
enterol 2010;16:3757–61.
[6] Klaus A, Gruber I, Wetscher G, et al. Prevalent esophageal body
motility disorders underlie aggravation of GERD symptoms in
morbidly obese patients following adjustable gastric banding. Arch
Surg 2006;141:247–51.
[7] Nelson LG, Gonzalez R, Haines K, Gallagher SF, Murr MM. Ameli-
oration of gastroesophageal reflux symptoms following Roux-en-Y
gastric bypass for clinically significant obesity. Am Surg 2005;71:950–3.
[8] Chiu S, Birch DW, Shi X, Sharma AM, Karmali S. Effect of sleeve
gastrectomy on gastroesophageal reflux disease: a systematic review.
Surg Obes Relat Dis 2011;7:510–5.
[9] De Jong JR, Besselink MGH, van Ramshorst B, Gooszen HG, Smout AJ.
Effects of adjustable gastric banding on gastroesophageal reflux and
esophageal motility: a systematic review. Obes Rev 2010;11:297–305.
6 P.K. Pallati et al. / Surgery for Obesity and Related Diseases ] (2013) 00–00
[10] DeMaria EJ, Pate V, Warthen M, et al. Baseline data from American
Society for Metabolic and Bariatric Surgery-designated Bariatric
Surgery Centers of Excellence using Bariatric Outcomes Longitudinal
Database. Surg Obes Relat Dis 2010;6:347–55.
[11] Dixon JB, O’Brien PE. Gastroesophageal reflux in obesity: the effect
of lap band placement. Obes Surg 1999;9:527–31.
[12] Woodman G, Cywes R, Billy H, Montgomery K, Cornell C, Okerson
T, APEX Study Group. Effect of adjustable gastric banding on
changes in gastroesophageal reflux disease (GERD) and quality of
life. Curr Med Res Opin 2012;28:581–9.
[13] Ovrebø KK, Hatlebakk JG, Viste A, et al. Gastroesophageal reflux in
morbidly obese patients treated with gastric banding or vertical banded
gastroplasty. Ann Surg 1998;228:51–8.
[14] Howard DD, Caban AM, Cendan JC, Ben-David K. Gastroesopha- geal
reflux after sleeve gastrectomy in morbidly obese patients. Surg Obes
Relat Dis 2011;7:709–13.
[15] Tai CM, Huang CK, Lee YC, Chang CY, Lee CT, Lin JT. Increase in
gastroesophageal reflux disease symptoms and erosive esophagitis
1 year after laparoscopic sleeve gastrectomy among obese adults.
Surg Endosc 2013;27:1260–6.
[16] Daes J, Jimenez ME, Said N, Daza JC, Dennis R. Laparoscopic
sleeve gastrectomy: symptoms of gastroesophageal reflux can be
reduced by changes in surgical technique. Obes Surg 2012;22:
1874–9.
[17] Soricelli E, Iossa A, Casella G, Abbatini F, Calì B, Basso N. Sleeve
gastrectomy and crural repair in obese patients with gastroesophageal
reflux disease and/or hiatal hernia. Surg Obes Relat Dis. Epub 2012
Jun 19.
[18] Frezza EE, Ikramuddin S, Gourash W, et al. Symptomatic improve-
ment in gastroesophageal reflux disease (GERD) following laparo-
scopic Roux-en-Y gastric bypass. Surg Endosc 2002;16:1027–31.
[19] Prachand VN, Ward M, Alverdy JC. Duodenal switch provides
superior resolution of metabolic comorbidities independent of weight
loss in the super-obese (BMI Z50 kg/m2) compared with gastric
bypass. J Gastrointest Surg 2010;14:211–20.