About 20-30% of patients might experience these symptoms after Sleeve Gastrectomy and for 5-10% symptoms are really bothersome to the point that surgery might be needed to control GERD. Often this is associated with weight regain due to maladaptive eating behavior since patients are trying to buffer the acid with foods.
If conservative measures like acid reducing medications, avoidance of deep fried foods, acidic juices, soft drinks, certain fruits and caffeine do not work, patients should consider surgical treatment – Sleeve conversion to Gastric Bypass frequently with Hiatal hernia repair.
After my gastric sleeve surgery in 2015, my acid reflux worsened. In 2022, a CT scan revealed complications: a hernia, stomach migration, and ulcers from severe acid reflux. A bypass revision was recommended. Dr. Hamdallah deemed my case one of his most challenging. My acid reflux is now managed and my health metrics have greatly improved. Saint Agnes and Dr. Hamdallah’s bariatric team rescued me from suffering and misery. I’ve reclaimed my life. Heartfelt thanks to Dr. Hamdallah and the Saint Agnes team!
There are a number of potential causes for development of significant GERD after a Sleeve surgery:
- Performing primary Sleeve Gastrectomy on patients with significant GERD, large Hiatal hernia, bile reflux
- Sleeve herniation into the chest later on after surgery with development of large Hiatal hernia
- Abnormal movement of the esophagus, a dysmotility that is exacerbated after surgery
- Incompetent valve mechanism of the esophago-gastric junction
- Sleeve stricture or narrowing by the scar tissue with angulation or twisting of the Sleeve
- So called “retained fundus” or excessive portion of stomach in the proximal part of Sleeve gastric tube
- Bile reflux
- Pressure gradient between narrowed stomach and esophagus with incompetent valve mechanism
All three surgeons were named
Top Docs 2022 in peer review
by “Baltimore Magazine”
Dr. Hamdallah
Dr. Swift
Dr. Catriona Swift is trained in laparoscopic, robotic, and endoscopic techniques and offers duodenal switch, gastric bypass, sleeve gastrectomy, revisional bariatric surgery, endoscopic weight loss procedures, and surgical treatment of GERD, hiatal hernia, and achalasia.
Surgical considerations
Before any surgery a substantially higher proportion of obese patients experience GERD compared to non-obese patients. Gastric Bypass with/without simultaneous repair of Hiatal hernia is considered the best surgical option for morbidly obese patients with GERD.
When choosing Sleeve as an initial bariatric procedure, some surgeons were expecting for the GERD to get better with time after surgery and weight loss. The issue is that obese patients have abdominal “hypertension” or increased pressure inside the abdomen squeezing gastric contents into the esophagus. The popularity of Sleeve surgery among some surgeons was also driven by simplicity and expected absence of negative side effects.
With experience and acquisition of long-term follow up results, bariatric surgeons realized that we need to be careful when establishing indications for procedures and look for signs of GERD before surgery. As such Gastric Bypass is a better option for patients with significant reflux before surgery.
When Sleeve is converted to Gastric Bypass, surgeons are reducing the acid producing part of the stomach by 2/3 by creating a small bowel shunt or bypass. Reduced amount of acid and prevention of bile reflux into esophagus relieves the symptoms of heartburn and regurgitation. Also, repair of hiatal hernia (protrusion of the stomach into the chest that disrupts the valve mechanism of the junction) further facilitates symptom resolution by partially/completely restoring normal one-way valve mechanism of the esophago-gastric junction.
It has become apparent now that converting Sleeve Gastrectomy to Gastric Bypass is the only available meaningful option for patients with severe, troublesome GERD. A majority of patients (80-95%) notice nearly immediate resolution of reflux when conversion to Gastric Bypass is done simultaneously with Hiatal hernia repair. Even for those with persistent heartburn, symptoms are mild and easily controllable with acid suppressing medications.
