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.”
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 are indicated to stop GERD.
In general, LINX surgery for acid reflux is associated with limited success rate. In the case of acid reflux following sleeve gastrectomy, LINX device placement has not been studied. LINX device cannot be placed without hiatal hernia repair. In most cases, hiatal hernia repair by itself is enough to control acid reflux after sleeve gastrectomy. If a gastric sleeve functional obstruction is present, LINX placement may be contraindicated for several reasons that are beyond the scope of this blog.
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.