I read with great interest the newly published study in SOARD (Surgery for Obesity and Related Disorders) by Frenkel et al. The authors attempt to elucidate the effect of sleeve gastrectomy on extra-esophageal reflux disease also known as silent reflux. Silent reflux or laryngo-pharyngeal reflux, LPR, is a poorly understood disorder. It is thought that gastric enzymes like pepsinogen are deposited in small quantities over the sensitive mucosal surface of the laryngo-pharyngeal area leading to a myriad of symptoms like chronic cough, globus, dry mouth, hoarseness and sometimes chronic inflammatory airway disease.
The role of gastric sleeve surgery in de novo GERD development or exacerbation of existing GERD is controversial. In my opinion, the controversy emanates from the great variability in performing a gastric sleeve among bariatric surgeons. Bariatric doctors in Houston for instance, use a bougie size ranging from 32 to 42. Some weight loss doctors in Houston perform a concomitant hiatal hernia repair on almost every gastric sleeve case while others only repair those hernias bigger than 4 cm in axial displacement. A group of sleeve doctors in Houston perform a radical antrectomy while others completely preserve the antrum. Furthermore, the technique of gastric sleeve surgery has greatly evolved over the past few years further adding to variability in outcomes and making it almost impossible to conduct long-term clinical data analysis. In the face of such variability, it is very difficult to establish any solid association or causation between gastric sleeve surgery and GERD.
Frenkel and colleagues used an animal model to study the effect of sleeve surgery on silent reflux. While the obese rat model is not perfect for neither sleeve surgery nor silent reflux evaluation, the article demonstrates a beneficial effect of gastric sleeve surgery on lung pathology examinations. The authors show that gastric sleeve surgery is not associated with pulmonary epithelium damage.
Silent reflux or LPR is very difficult to study. It is poorly understood and commonly missed in many patients. At Houston Heartburn and Reflux Surgery center and Houston Weight Loss Surgery Center, we have treated several patients with LPR and morbid obesity by performing hiatal hernia repair and gastric sleeve surgery. Our outcomes were great. Cough as well as other GERD related symptoms have completely resolved following proper hiatal hernia repair and gastric sleeve surgery. A twisted or narrowed sleeve will most definitively exacerbate reflux disease. I use a 40 French bougie and pay special attention to the incisura angularis. I do not resect the antrum completely but I make sure the gastric fundus is completely mobilized and resected. Equally important is the complete hiatal hernia reduction and posterior crural repair with interrupted pledgeted sutures. I believe that such an approach allows for effective and durable GERD resolution for most patients suffering with both obesity and GERD.