Sleeve Gastrectomy and Gastro-Oesophageal Reflux Disease

Gastro-oesophageal reflux disease (GORD) occurs when stomach acid or content flow back into the oesophgus. This acid irritates the lining of the oesophagus and causes heartburn and regurgitation.

GORD and Obesity

GORD occurs in about 20% of the general population.  Obesity is a known risk factor for GORD, hiatus hernia, ulceration in oesophagus and cancer of the oesophagus. Approximately 60-80% of patients undergoing weight-loss surgery have symptoms of acid reflux and about 15% will have a hiatus hernia. This is because obesity causes a chronic increase in the intra-abdominal pressure and this induces reflux (back-flow) of stomach content through the weakened lower oesophageal valve. The increased abdominal pressure also leads to delayed emptying of the stomach into the intestine and pushes the stomach through the oesophageal opening in the diaphragm resutling in a hiatus hernia. Thus increasing the chance for acid reflux into the oesophagus. 

GORD after Sleeve Gastrectomy

In the first few weeks after sleeve gastrectomy nearly all patients experience symptoms of acid reflux. The stomach tube is very small and very stiff while it heals. If you drink fast or take a big gulp you will find that there is no room for the fluid in the stomach and some fluid will come back into the oesophagus. This will get better with time as the staple line heals, the stomach adapts and becomes softer and more pliable. We recommend our patients take the Nexium (stops acid production by the stomach) for 3 months after surgery. After 3 months the majority of patients will have no or minimal symptoms of reflux however, around 10-20% of sleeve patients will continue to have symptoms of GORD 12 months or more after the surgery. In my opinion acid reflux is the major long term drawback of the sleeve gastrectomy.

The Effect of Sleeve Gastrectomy on the Anti-Reflux Mechanism

Sleeve gastrectomy has a complex effect on the anti-reflux mechanism. Some of these effects promote acid reflux while other effects reduces acid reflux.

Factors That Increase GORD After Sleeve Gastrectomy

1. Reduction in the pressure of the lower oesphgeal sphincter (the valve gets weaker)
2. Reduced capacity of the stomach tube (sleeve can take only 150 mL)
3. Reduced compliance of the stomach tube (the sleeve is less distensible)
4. Increased pressure inside the sleeve
5. Removing too much of the stomach (too tight sleeve)
6. Kinking in the sleeve tube
7. Dilatation of the top part of stomach tube
8. Not repairing a hiatus hernia

Factors That Reduce GORD After Sleeve Gastrectomy

1. Rapid emptying of the stomach into the intestine
2. Decreased intra-abdominal pressure as a result of weight loss
3. Increased compliance of the stomach tube after 2 years (the sleeve becomes more distensible)
4. Less acid production by the very small stomach tube
5. Removal of the fundus (top part of the stomach)
6. Repairing a hiatus hernia (if one existed) at the time of sleeve gastrectomy

This complex effect on the anti-reflux mechanism may explain why some patients with acid reflux before surgery have no more reflux after the sleeve gastrectomy while other patients experience a significant acid reflux as a complication of their sleeve gastrectomy. In addition, oesophageal sensitivity to acid varies from one individual to another and acid in the oesophagus is not always associated with heartburn. 

What Can Be Done During Sleeve Gastrectomy to Reduce the Chance of GORD?

It is not possible to totally eliminate the risk of acid reflux following a sleeve gastrectomy, however, certain steps during the operation can reduce the risk.

1. Proactive search for and repair of any hiatus hernia
2. Avoid narrowing the sleeve at the corner of the stomach (incisura angularis)
3. Freeing up the back side of the stomach fully before stapling
4. Creating a uniform sleeve with no kinks or twists
5. Removing the fundus fully ( top part of the stomach)
6. Avoid creating a conical shaped sleeve (more chance of reflux)

How to Manage Symptoms of Acid Reflux After Sleeve Gastrectomy?

Diet Modification

1. Avoid drink liquid 30 minutes before and after eating.
2. No liquid with meals
3. Do not eat or drink 2 hours before going to bed
4. Have your evening meal earlier
5. Avoid food that promotes acid reflux: coffee, tea, fizzy drinks, citrus fruits, tomato, chocolate, mint, alcohol, spicy food, onion and garlic.
6. Eat slowly and learn to put down the fork in between bites

Life Style Modification

1. Avoid wearing tight clothes or a tight belt. The pressure will force more stomach acid into the oesophagus.
2. Raise the head of your bed by 4-6 inches by putting blocks under the legs at the head side. This way gravity will help keep stomach content down. Please note that raising your head with only pillows will not help.
3. Stop smoking. Smoking increases acid production by the stomach and this increases worsens acid reflux.
4. Start regular exercise if you have not done so already. Exercise will help you lose more weight and this further reduces the pressure on the stomach.

Medications

Antacids such as Mylana, Gaviscon or QuickEase will help occasional or breakthrough symptoms

H2 Blockers such as Zantac can be bought over the counter and more effective than anatcids

Proton Pump Inhibitors (PPIs) such as Nexium, Pariet or Somac are the most effective medical treatment for acid reflux. These are best taken 30 minutes before evening meal and the must be taken regularly. Do not take them only when needed but rather take them for at least couple of weeks or better constantly. Taking them on and off results in too much acid produced in between the doses and this results in a severe attack of heartburn.

Surgical or Endoscopic  Interventions

Some patients have certain anatomical problems that promote acid reflux after sleeve gastrectomy such as

1. Dilated fundus (top part of the stomach)
2. Kink in the sleeve at the incisura (angle of the stomach)
3. Narrowed segment of sleeve
4. Twisted or corck screw sleeve tube
5. Narrowing in the pylorus

These conditions can be surgically corrected depending on the severity of the condition, ability to eat and the weight loss result. Often a balloon dilatation during gastroscopy can be useful.

Rarely, reflux can be particularly severe and hard to manage. In these situations a gastric bypass may be necessary to help control acid reflux.

Recently there has been interest in new procedures for acid reflux after sleeve gastrectomy such as the LINK device (a ring on mangetic beads surgically place around the lower end of the oesophgus) and endoscopic proedures for acid reflux such as the Stretta device but these are still under investigations.