Pamela from Cypress sent us this question: “I had a sleeve gastrectomy in 2015 and have had horrible heartburn/reflux since. I recently had a surgical consult for a hiatal hernia and was told that a repair wasn’t possible with a sleeve. He recommended to research the LINX™ or revision to a Roux-en-Y. I’m not excited about either of these options. Would it be possible to get more information about fixing a hiatal hernia with a sleeve? The heartburn is very painful and it’s a daily occurrence, I’ve become insanely frustrated and I’m not sure what my next step should be! I’m located in Cypress, but I’m having trouble finding a good solution in my area. Thank you so much for any info/advice you could provide.”
Dear Pamela,
Hiatal hernia repair after sleeve gastrectomy is feasible and indicated to alleviate heartburn and acid reflux. Gastric sleeve has low wall compliance. Consequently, when the gastric sleeve herniates into the chest, negative intra-thoracic pressure is easily transmitted inside sleeve lumen. Negative pressure exacerbates not only acid but also bile reflux back into esophagus. This results in “horrible” heartburn and reflux as you explain.
Hiatal hernia repair after sleeve gastrectomy restores normal anatomy and reverses the effect of negative chest pressure on gastric sleeve lumen. This results in immediate acid reflux resolution. Gastric sleeve surgery, like Nissen Fundoplication, improves gastric emptying and moves the postprandial acid bubble away from distal esophagus. Therefore, in the absence of functional sleeve lumen obstruction, hiatal hernia repair by itself is enough to stop acid reflux in the setting of sleeve gastrectomy. Obviously, if gastric sleeve lumen is narrowed, conversion to gastric bypass along with hiatal hernia repair is needed to stop GERD.
A recent study was published in Obesity Surgery journal to evaluate the efficacy and safety of LINX™ surgery following sleeve gastrectomy. A total of 30 patients were enrolled in the study. Patient underwent upper endoscopy and contrast studies prior to LINX™ surgery. At one year after LINX™ implantation 6 out of 27 patients showed normalization of esophagus acid exposure. However, 80% of patients reported improvement in acid reflux symptoms and decrease in proton pump inhibitor. Of note, 90% of patients underwent a concomitant hiatal hernia repair. In a subsequent study published in Diseases of the Esophagus, the same author recommends carefully selecting sleeve gastrectomy patients with GERD for LINX™ surgery by using esophageal manometry to measure lower esophagus sphincter pressure and motility as well as contrast studies and upper endoscopy to evaluate gastric sleeve morphology. If gastric sleeve morphology is abnormal or if esophagus diameter is more than 3 cm, sleeve to gastric bypass conversion is recommended. Abnormal gastric sleeve morphology in this paper is defined as narrowed sleeve lumen at the incisura angularis, dilated or retained gastric fundus, tubular sleeve shape with most of the antrum resected. If sleeve morphology is normal and lower esophageal sphincter pressure is low in the setting of normal esophageal motility then magnetic sphincter augmentation is indicated to help control acid reflux. If sleeve morphology and lower esophageal sphincter pressure are normal and there is no hiatal hernia the author recommends Stretta. Follow up studies on GERD patients treated according to this algorithm are currently not available.
In conclusion, if you suffer from acid reflux after sleeve gastrectomy, get evaluated by an experienced acid reflux specialist. A properly performed hiatal hernia repair is enough to control heartburn and acid reflux in most cases. If gastric sleeve functional obstruction is present, LINX™ placement is not recommended and conversion to gastric bypass is indicated. If lower esophagus sphincter pressure is low but esophagus motility is normal, and sleeve morphology is normal, magnetic sphincter augmentation, in addition to hiatal hernia repair, may help you. At his point, Houston Heartburn and Reflux Center does not offer magnetic sphincter augmentation surgery.