After 5 months of strict Keto I'm feeling good, have lost all but 7 lbs of regain and restored my overall health. However, at the appointment with my surgeon last fall, he told me if the GERD still persists after weight loss, my only option is revision to RNY.

I'm feeling focused and still have another 4 months before I see him again, but I'm still taking a PPI twice a day. I've had an EGD which shows persistent reflux, however no Barrett's or significant scarring right now. I've had GERD almost my entire life due to the way I carry my weight, in fact I had an upper GI series as a baby from such severe reflux! I've been on a PPI for about 15 years and really want to get off of it related to the longterm risks with the drug class. I'm a nurse practitioner so I am very familiar with the research on the subject.

I guess this all boils down to the fact that I'm probably still looking at a revision. I'll do what I have to for my total health but really hoping that I can get another 15-20 lbs off before I see him and the GERD is resolved.

I suspect that you are headed toward revision, given your lifelong experience with this, but there are always things that should be tried before going for surgical solution. Given your history, I suspect that you have tried most of the various tricks and treatments for GERD, such as sleeping with head elevated, not eating X hours before bedtime, etc. There are some books out there by MDs who specialize in the problem that may give some more insight. One common thread seems to be that dietary fat may be contributory to the problem, so your keto efforts may be working against you if that is the case (OTH it may have little to do with it and is just a throwback to the days when low fat diets would fix anything, much as low carb diets are today's universal solution.) It may be worth a try to shift your dietary balance for a while and see if it has any effect on you, There are also some foods that supposedly help or hinder the functioning of the lower esophageal sphincter, and likewise some medications that target it, so those are things to explore.

Given your history, I assume that shifting meds may have been discussed - transitioning from PPI to H2 inhibitors such as Zantac or Pepcid - they are generally somewhat less effective but generally preferable from the long term use perspective. Given that you are still seeing reflux evidence in the EGD even on the PPI, it is unlikely to make a significant difference as symptomatic relief doesn't necessarily mean that the problem doesn't still exist and is doing damage, but it is something else worth considering.

Historical curiousity - back in the dark ages, vagotomies were performed, severing part of the vagus nerve to disable some of the protein pump ports as a chronic reflux treatment; this was obsoleted by the introduction of PPIs, but maybe it's time to reintroduce the "old school".

Good luck in working through this.....