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The mechanisms underlying post-sleeve GORD are multifactorial and include: Reduced lower oesophageal sphincter (LOS) pressure due to removal of the gastric fundus, which normally acts as a pressure buffer Increased intragastric pressure within the narrow sleeve, promoting reflux of acidic contents into the oesophagus Altered gastric emptying and motility changes that can delay clearance of acid from the oesophagus Hiatus hernia , which may be unmasked or worsened by the surgical procedure Sleeve stenosis , which can contribute to reflux and should be considered if symptoms are refractory For patients who develop de novo GORD or experience a significant worsening of pre-existing reflux after sleeve gastrectomy, long-term PPI therapy may be necessary