Bariatric and metabolic surgery remains the most effective and durable treatment for obesity, and laparoscopic sleeve gastrectomy (LSG) achieves excellent weight loss outcomes with a minimal side effect profile. Despite its popularity, there is significant variability in the development of de novo postoperative gastroesophageal reflux disease, and variations in staple placement during sleeve creation may be contributory [10]. Single-fire staplers may reduce variability in postoperative anatomy, and thereby reduce the incidence of postoperative GERD [11]. This single-surgeon study with 1-year follow-up included 257 patients and compared robotic-assisted sleeve gastrectomy creation with multiple fires of an articulating linear stapler to a single-fire of a non-articulating linear stapler. Our results suggests that single-fire stapler use is highly associated with absence of postoperative reflux (OR [95% CI]: 8.4 [2.8–32.5]).

Overall, the two groups were well balanced, and there was no significant difference in the average age, gender distribution, reported ethnicities, or preoperative co-morbidities. Interestingly, the patients in the single-fire group had a significantly higher average preoperative BMI and continued to have a small but significantly higher 1-year postoperative BMI. Even though high BMI is associated with reflux [12], the proportion of patients with 1-year postoperative reflux was considerably lower in the single-fire group. Importantly, there was no difference in 1-year total weight loss percent. All patients were followed for 1 year, suggesting that these results are not transient changes in the immediate postoperative period. As this was a single-surgeon study, there were also no significant differences in intraoperative practices between the two groups which were contemporaneous. Importantly, there was no difference in the proportion of patients with preoperative hiatal hernias, and it is the standard practice of this surgeon to repair all hiatal hernias that are discovered incidentally during surgery. All surgeries were done using a robotic platform, which allows for better evaluation of the impact of a single-fire stapler. No postoperative leaks, reoperations, or surgical site infections were reported in either group.

Our primary outcome was the presence or absence of postoperative reflux at 1 year after surgery. The proportion of patients who reported 1-year reflux was significantly lower in the single-fire group (multiple-fire: 26.4%, single-fire: 7.1%, p = 0.002), even though there was a higher but statistically non-significant proportion of patients in this group who reported preoperative reflux (multiple-fire: 26.4%, single-fire: 30.4%, p = 0.6). When we further analyzed patterns of change in reflux status, we found that a lower proportion of patients in the single-fire stapler group developed de novo reflux (multiple-fire: 10.9%, single-fire: 1.8%), and a higher proportion reported resolution of their reflux after surgery (multiple-fire: 10.9%, single-fire: 25%). One possible explanation for these findings is that using a single-fire stapler results in less kinking along the sleeve staple line, which prevents inadvertent narrowing. Interestingly, patients in the single-fire group did have a small but significantly shorter length of stay (2.0 ± 0.03 days) compared to patients in the multiple-fire group (2.2 ± 0.04, p = 0.04). While many factors influence length of stay, including postoperative complications, poor pain control, or social barriers to discharge, in our experience, a common cause for delayed discharge is intolerance of oral intake [13]. We hypothesize that patients may also have less postoperative nausea with single-fire stapler use, as it creates a uniform gastric sleeve with less hour-glassing and fewer angulations (colloquially referred to as ‘zigzags’ or ‘dog-ears’). The mechanisms underlying decreased 1-year reflux may also contribute to improved early oral intake, but future studies focused on assessing postoperative nausea after single-fire stapler will be required to better characterize these findings.

Our study does have some inherent limitations, including reliance on self-reported reflux symptoms corroborated with PPI use as a surrogate marker for GERD. This is an indirect measurement of GERD, and some studies have suggested that patients may continue PPI therapy even in the absence of clinical reflux due to concerns about symptom recurrence [14]. Empiric trials of proton pump inhibitor (PPI) therapy are often used to simultaneously diagnose and treat GERD, however, 35% of patients with no objective evidence of GERD report symptomatic relief from PPI therapy [15]. It is the opinion of these authors that surveying patients on the presence of GERD symptoms with concurrent anti-reflux medication use is a practical method for standardizing the assessment of improvements in GERD, as quantitative tests are expensive, invasive, and impractical to serially obtain, especially in asymptomatic patients.

It must be noted that a Roux-en-Y gastric bypass is the preferred operation in patients with concomitant reflux. During preoperative counseling, it is our practice to explain that gastric bypass tends to offer better reflux control compared to sleeve gastrectomy. However, many patients are averse to gastric bypass due to its associated complications and elect to undergo a sleeve gastrectomy despite the risks of de novo or worsening reflux. Our finding of a significant decrease in the rate of reported reflux in the single-fire group provides a compelling argument for the use of single-fire staplers in this patient population and suggests the need for future studies involving formal postoperative testing for GERD resolution, including endoscopy or combined pH-impedance monitoring to measure acid exposure time and analyze reflux-symptom association profiles.