Gastroesophageal reflux disease (GERD) is frequently associated with obesity. The onset or worsening of GERD after sleeve gastrectomy (SG) remains a matter of debate in metabolic and bariatric surgery (MBS). Concomitant hiatal hernia repair (HHR) is increasingly performed, and SG combined with fundoplication has emerged as a potential bariatric option, although current evidence is conflicting and the learning curve can lead to a considerable rate of reinterventions. Transoral Incisionless Fundoplication (TIF) is a minimally invasive endoscopic approach that reconstructs the gastroesophageal valve and provides a 270° fundoplication. To date, only one case report has described TIF performed simultaneously with SG without HHR, demonstrating the basic feasibility of this combined strategy.

AIMS. To evaluate the feasibility of concomitant TIF with laparoscopic HHR and SG (C-TIF + SG) and to assess the postoperative evolution of GERD symptoms in obese patients with confirmed preoperative GERD.

Four obese patients with typical GERD symptoms were prospectively enrolled. Symptom severity and frequency were assessed using the GERD-HRQL questionnaire. All patients underwent preoperative endoscopy, 24-hour pH-impedance monitoring, and high-resolution manometry (HRM). GERD was diagnosed following the Lyon Classification 2.0 criteria. Under general anesthesia, five laparoscopic trocars were placed, followed by posterior cruroplasty after dissection of the diaphragmatic crura and abdominalization of the distal esophagus. The EsophyX® device was then inserted transorally, retroflexed, and used to create a 270° gastroesophageal valve under laparoscopic control. The procedure was performed jointly by two experienced endoscopists. A standard laparoscopic sleeve gastrectomy followed. Clinical follow-up was scheduled at 1, 3, 6, and 12 months.

The mean preoperative BMI was 35.4 kg/m² (SD ± 3.99). All patients were taking daily standard-dose PPIs. The mean preoperative GERD-HRQL score was 40.5 (SD ± 11). Hiatal hernia was present in all patients (mean size 2.1 ± 0.6 cm), along with Grade A esophagitis (Los Angeles Classification). pH-monitoring confirmed pathological reflux, while HRM demonstrated hiatal hernia with an IRP <15 mmHg.Mean follow-up was 10.5 months (range 8–13). Total body weight loss at 6 months was 25.3%. GERD symptoms significantly improved at last follow-up (p < 0.01), with a mean postoperative GERD-HRQL score of 2.25. All patients discontinued PPI therapy within one month. Follow-up endoscopy at 6 months showed no recurrence of hiatal hernia or esophagitis. No complications were observed.

In this preliminary experience, C-TIF with concomitant SG appears safe, technically feasible, and associated with favorable mid-term outcomes in terms of both weight loss and GERD symptom resolution. Larger studies with longer follow-up are needed to validate the combined approach for the simultaneous management of obesity and GERD.