Eighty percent (80%) of obese patients have acid reflux disease. Weight loss is associated with improvement and sometimes resolution of GERD related symptoms. The most effective weight loss solution, in 2018, remains weight loss surgery. Gastric sleeve surgery is the most commonly performed procedure in Houston, TX. Sleeve gastrectomy is safe, effective and minimally invasive. There is, however, a concern regarding the effect of gastric sleeve surgery on GERD. Several published studies have shown an increased incidence of de novo as well as worsening pre-existing acid reflux symptoms following sleeve gastrectomy. The interpretation of these studies is, however, quite challenging. The diagnosis and severity of acid reflux is evaluated using GERD symptom analysis and use of proton pump inhibitors. Very few studies use objective measures of GERD evaluation like upper endoscopy with biopsies and pH monitoring before and after surgeries to study sleeve gastrectomy effect on GERD. Furthermore, sleeve gastrectomy technique is not yet standardized. Gastric sleeve size and shape varies from surgeon to surgeon and sleeve size and shape plays an important role in GERD pathophysiology. At Houston Heartburn and reflux Center, we have found that a properly performed sleeve gastrectomy is an excellent anti-reflux procedure for the obese patient. A properly performed sleeve gastrectomy follow three basic principles:
1. Preserve the incisura angularis to prevent reflux
2. Resect the gastric fundus to promote weight loss
3. Preserve the antrum to maintain gastric emptying
Unfortunately, the blind use of a small diameter bougie mutilates the stomach and results in functional and sometimes anatomical narrowing at the incisura angularis. The incisura angularis is an important anatomic landmark that separates gastric antrum from gastric fundus. Gastric content movement across the incisura angularis between fundus and antrum is highly coordinated. The Magenstrasse gastric emptying pathway, among others, depends on such coordination. Narrowing stomach angularis and resecting the gastric antrum impair gastric emptying pathways are likely to cause GERD.
Studies are much needed in this field to confirm these theories. Our outcomes, however, at Houston Heartburn and reflux Center, clearly indicate that a contoured sleeve that follows the above mentioned privciples, is equivalent to a Nissen fundoplication in terms of GERD symptom control. Concomitant hiatal hernia repair is crucial as most obese patients have a sliding hiatal hernia. The resected stomach has low wall compliance and can easily transmit the negative intra-thoracic pressure inside its lumen. This results in the creation of a pressure gradient that favors cephalad gastric content movement. A proper hiatal hernia repair moves the gastro-esophageal junction into the abdominal cavity and shields the sleeve lumen from the negative intra-thoracic pressure.
In summary, if you have acid reflux disease and suffer from morbid obesity a PROPERLY performed gastric sleeve and hiatal hernia surgery may be an excellent solution for you.