**3.3 Surgery**

Antireflux surgery is an alternative for long-term treatment of GERD patients with severe reflux esophagitis (LA grade C or D), large hiatal hernias, and/or persistent distressing GERD symptoms [36]. Laparoscopic antireflux surgery (Nissen fundoplication, Toupet fundoplication) has been viewed as an alternative to lifelong PPI treatment in GERD [18]. The efficacy and safety of this procedure in patient with obesity, however is still controversial [46, 47]. Therefore bariatric surgery (Roux-en-Y gastric bypass) is being more considered recently as a procedure of choice for GERD in patient with morbid obesity [18]. Bariatric surgery was able to achieve substantial weight reduction and lower abdominal-thoracic pressure gradient [18]. Many studies have shown consistent improvement in both reflux symptoms and mucosal complication of GERD following a bariatric procedure in obese patients [18]. Nonetheless, it must be highlighted that all patients, require a lifelong and multidisciplinary follow up care after bariatric surgery [18].

Laparoscopic sleeve gastrectomy (LSG) is another approach of bariatric procedure that has gained more attention, owing to less technical complexity as compare to laparoscopic Roux-en-Y gastric bypass (LRYGB), it showed lower incidence of postoperative complication, and leads to substantial weight loss [48]. The impact of LSG on GERD, however is still inconsistent in regards to the control of pre-existing reflux, development of *de novo* GERD after procedure, and several studies suggested that LSG is a refluxogenic procedure [49–51]. Another study showed that the main technical issues that determine the occurrence of postoperative GERD are relative narrowing of the sleeve and hiatal hernia [52]. Ultimately, the baseline severity of reflux symptoms and mucosal injury is the key determinants of patient's feasibility to surgery [51]. Erosive esophagitis is considered as a relative contraindication to the surgery by the joint statement of ASMBS, SAGES, and ASGE [53]. Recently, the available management options for GERD after LSG include pharmacotherapy with PPI or repair with laparoscopic Roux-en-Y gastric bypass [52]. These available options should be openly discussed with the patients [51].
