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Why Does Acid Reflux Occur After a Gastric Sleeve? And What We Can Do

Older man grabbing chest suffering from heartburn

Dr. Tsuda’s Five Key Points

  1. New or worsened GERD is possible after a gastric sleeve
  2. There is no way to predict who will experience this concern after surgery
  3. Fixing a hiatal hernia is one of the most effective ways to reduce the risk of post-sleeve GERD
  4. We have various surgical and non-surgical options for living with dealing with   postoperative GERD
  5. Patients with poorly controlled or uncontrolled GERD before bariatric surgery may be best served by a gastric bypass

If you think about the stomach in its pre-surgical form, you quickly understand how it can be considered a pressurized pouch with valves at both ends – the lower esophageal sphincter separating the esophagus from the stomach and the stomal valve separating the stomach from the small intestine. These valves ensure that food and drink enter the stomach appropriately and stay within the stomach for a defined period to maximize digestion. Without these valves or something that approximates them, the stomach could not do its job correctly. In the gastric sleeve, when we cut away anywhere from 75 to 90% of the stomach (without removing and rebuilding either valve), you can imagine that the remaining pouch becomes a relatively higher-pressure tube. There shouldn’t be an issue if both valves are intact and working correctly. However, if one of the valves is dysfunctional, usually the lower esophageal sphincter, the pressure within the stomach will push gastric juices through, causing reflux.

As an aside, it’s essential also to consider the fact that most patients with obesity have a hiatal hernia, and many have a weakened lower esophageal sphincter dysfunction – LES dysfunction. These patients are more susceptible to GERD both before and after gastric sleeve surgery.

How Do We Go about Minimizing the Potential for GERD?

In the early days of the gastric sleeve, we realized that approximately 20% of patients were experiencing some new or worsened GERD after their sleeve procedure. Of course, this was a significant problem, not only for the sake of the patient’s comfort but also because the constant refluxing of stomach juices can eventually cause pre-cancerous lesions on the esophageal walls.

However, we quickly learned that correcting a hiatal hernia, which many of our bariatric patients have, reduces the likelihood of GERD after a sleeve by half or even more. As such, we can confidently say that only 5-7% of patients experience new or worsened GERD after their sleeve. Many of these cases improve or resolve without further intervention.

Knowing that GERD is a possibility after surgery, patient selection becomes much more critical. We can effectively minimize the occurrence of GERD by choosing a suitable surgery for each patient (and we have many to choose from). For example, a surgical procedure like gastric bypass can be beneficial for those most prone to reflux or for those patients who had poorly controlled or uncontrolled reflux before surgery.

Addressing Reflux Later

Since we cannot predict which patients will experience new or worsened GERD in their postop life, we have developed practical techniques to minimize its occurrence after surgery. From lifestyle changes and medications to endoscopic and even surgical corrective options, there are a wide variety of possible interventions for anyone dealing with postoperative reflux. Most importantly, you should have a candid conversation with Dr. Tsuda about any GERD issues you may be having so that you can address them most safely and efficiently.