Evaluation of a patient referring GERD after sleeve gastrectomy should start with a detailed history and physical examination; the presence or absence of GERD-related symptoms should be thoroughly documented as well as any prior treatments or therapy used to treat it. Obtaining preoperative and operative records is of paramount importance particularly in those patients who had their index procedure performed elsewhere. Any endoscopic findings and prior imaging available are important to determine what the best course of action would be. If the patient had preoperative and postoperative imaging such as UGI, it is useful to compare those with a recent study to look for anatomical problems that may have been not addressed at the time of the index operation or developed over time. After this information is obtained, we can classify the GERD after sleeve as:

1. De novo GERD
2. Preexisting GERD without improvement
3. Preexisting GERD with worsening/complication

Regardless of how we classify the GERD, an initial evaluation with imaging
studies such as UGI and EGD is recommended. Comparison with any prior films if available is of significant value. Based on the UGI, we can determine if the shape of the sleeve falls into one of the following categories: tubular, dilated bottom, dilated upper, or dumbbell-shaped sleeve; we will also be able to evaluate esophageal peristalsis in real time and if there is associated hiatal hernias. We believe UGI under fluoroscopy provides important physiologic and anatomic information that can help guide our management approach, and therefore we offer it to all patients. We follow the radiologic evaluation with endoscopy, and during endoscopy, we look for objective signs of reflux such as esophagitis, presence of bile in the stomach or esophagus, as well as missed or recurrent hiatal hernias. In patients with evidence of esophagitis or metaplasia, multiple biopsies are taken. During the endoscopy, subtle findings that suggest a kink or a stricture may be present. In the absence of objective signs of gastroesophageal reflux disease on both endoscopy and upper GI series, we pursue physiologic testing followed by highresolution manometry and pH monitoring. In those patients where clear reflux esophagitis is seen, this additional testing may not be necessary or may be performed in selected cases depending on what the surgical or endoscopic therapy would be.

While it is true that most sleeve-related GERD will be effectively treated with a conversion to Roux-en-Y gastric bypass, not every patient with GERD after reflux will require a bypass or would agree to have one. First key step in addressing the patient is to evaluate whether the patient was selected appropriately to have a sleeve and second is to determine the exact sleeve anatomy; are there anatomical factors that will make it more likely for this patient to experience reflux; is there dilated fundus? Is there a kink or stricture in the sleeve or is it an anatomically appropriate operation? We should pay important attention to the weight loss the patient has experienced with the sleeve. Patients who do not have adequate weight loss and have GERD symptoms should not undergo other therapies and should probably undergo a bypass; however it is our unpublished experience that patients with the association of poor weight loss after sleeve and difficult to treat GERD will correct their GERD after conversion, but their weight loss results are still marginal even with a well-constructed bypass.

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