About 30% of patients experience worsening or de novo gastroesophageal reflux disease (GERD) after sleeve gastrectomy (SG). The majority of the patients’ symptoms can be managed with medical treatment. Approximately 6–8% of patients require conversion surgery to Roux-en-Y gastric bypass (RYGB). It is important to perform a thorough workup including upper endoscopy, barium upper GI series, manometry, 24-h pH monitoring, and a complete course of medical treatment before considering conversion of SG to RYGB. The oral boards questions will pertain to worsening heartburn, dysphagia, or regurgitation after SG. Patients can be managed medically initially. However, some patients may require conversion to RYGB if there is no improvement in symptoms with medical therapy. Be sure to rule out Barrett’s esophagus and esophageal cancer, which will modify the workup and surveillance approach for the patients.