GERD after Sleeve Gastrectomy
Question of the week from Goldy: I am 4 months out of Gastric Sleeve surgery. While the weight loss results are wonderful, I’m constantly struggling with acid reflux. It affects every aspect of my daily life and is quite terrible. Omeprazole helped, but my doctor took me off it due to the long-term side effects. H2 blockers and antacids have not been helpful at all. The symptoms are becoming more unbearable each day. What would you advise I do?
Thank you for your interest in Houston Heartburn and Reflux Center. Your question is quite relevant. Acid reflux following gastric sleeve surgery is debilitating and poorly responsive to medications like Omeprazole. Post sleeve gastrectomy acid reflux occurs for two reasons:
1- A concomitant hiatal hernia was not repaired during sleeve gastrectomy
2- Gastric sleeve lumen was narrowed at the incisura angularis, the junction between upper two thirds and lower one third of the stomach
A properly performed gastric sleeve surgery and hiatal hernia repair are an excellent solution for GERD. Unfortunately, most bariatric surgeons elect to skip hiatal hernia repair with sleeve gastrectomy. As a result, the upper part of the sleeve is in the chest exposed to negative intra-thoracic pressure. This results in severe acid and bile reflux poorly responsive to medical treatment. The majority of patients have associated bile gastritis that further exacerbates symptoms of epigastric pain, bloating and nausea.
A number of bariatric surgeons continue to use very small calibrating bougie size especially at the level of the incisura angularis. A narrowed gastric sleeve lumen at this location causes severe GERD. With time, persistent GERD results in the development of hiatal hernia further exacerbating acid reflux related symptoms.
What can you do?
GERD post sleeve gastrectomy can be fixed. If a hiatal hernia is present, laparoscopic hiatal hernia repair can be performed. If narrowing of the incisura is found, then conversion of sleeve to gastric bypass is indicated. In both cases, GERD symptom resolution occurs immediately following surgery. Both surgeries are associated with low morbidity and mortality rates. I caution you against LINX device placement for management of post sleeve gastrectomy acid reflux. There is no role for LINX in this setting especially if the incisura angularis is narrowed. Furthermore, there are no studies to support LINX effectiveness post sleeve gastrectomy GERD.