Acid Reflux and Gastric Sleeve

What is Gastric Sleeve?

Bariatric procedures are a proven treatment for morbid obesity and its related diseases. Sleeve gastrectomy, which is the first stage of Duodenal Switch, is now one of the most effective and popular bariatric surgeries used worldwide on its own. Performed laparoscopically, 80% of the stomach is removed to restrict food intake and decrease hunger hormones. Patient’s set-point is changed after surgery, their appetite is reduced, their metabolism goes up, and starts burning fat.

Gastric sleeve surgery (VSG) is relatively a safe procedure and does not result in a significant nutritional deficiency. This procedure also helps improve comorbidities such as type II diabetes, hypertension, osteoarthritis, etc. After VSG surgery, patients tend to have more energy to tackle their day, easier mobility without all that extra weight, and a newfound confidence in themselves. It’s like hitting the reset button on your health, giving you a fresh start to live your best life.

Heartburn, Acid Reflux and GERD

Heartburn, Acid reflux, and GERD terms are used interchangeably; although closely related they do not necessarily mean the same thing.

Heartburn

Heartburn is a mild to severe pain in the chest caused by the acid irritating delicate lining of the esophagus (food pipe) — the tube that connects the throat and stomach. Heartburn is common and is sometimes mistaken for heart attack pain. Heartburn usually occurs after eating and it gets worse when bending over or lying down.

Lifestyle changes, like losing excess weight, eating smaller meals, and avoiding alcohol, nicotine, and fried or fatty foods can help reduce heartburn.

Acid Reflux

According to studies, about 9% of people report having new or worsening acid reflux after surgery. If the circular muscle that joins the esophagus and stomach, Lower Esophageal Sphincter (LES), does not close properly,  the stomach content flows backward into the esophagus. This is known as Acid reflux. Acid reflux can cause heartburn and other symptoms, such as a sour taste in the mouth and a bitter taste in the back of the throat.

Occasional acid reflux can be treated with over-the-counter medication, antacids such as Tums, H-2-receptor blockers such as Tagamet HB or Pepcid AC, Proton pump inhibitors such as Prilosec OTC (Omeprazole).

GERD

Acid reflux may progress to a more severe form of reflux, called Gastroesophageal Reflux Disease (GERD). One of the conditions associated with obesity is heartburn or GERD. Heartburn is caused by acid reflux from the stomach into the esophagus due to an incompetent Lower Esophageal Sphincter. GERD causes burning sensation and pain in the chest area similar to a heart attack. Individuals with this problem have regurgitation of food, feel a sour taste in the mouth, nausea, vomiting, difficulty swallowing, coughing, wheezing, and chest pain. It has been shown that this condition has a higher occurrence in patients with higher BMI. GERD may be treated with surgery or other procedures, such as Nissen Fundoplication.

Nissen Fundoplication procedure, where stomach fundus is sewn in position all around the lower esophagus, is used to treat reflux. For the gastric sleeve procedure to be possible, a fundoplication must be dismantled before the sleeve is created.

Before undergoing weight loss surgery, patients must evaluate pre-existing GERD or related risk factors. This assessment may involve endoscopic evaluation, esophageal manometry, or pH monitoring to determine the presence and severity of reflux.

Hiatal Hernia

Hernia – When an internal body part protrudes into an area where it doesn’t belong.

Hiatus – Is an opening in the muscular wall separating the chest cavity from the abdomen, called the diaphragm.

Hiatal hernia (hiatus hernia) occurs when the upper part of the stomach called the fundus bulges up through the hiatus into the chest. Patients with GERD may also have a hiatal hernia. The pressure in the abdomen caused by obesity can cause a hiatal hernia – pressure pushes the stomach through the diaphragm. The formation of hiatal hernia also causes Lower Esophageal Sphincter incompetence and gastroesophageal reflux.

There are two types of hiatal hernias:

• Sliding Hernia
• Para-Esophageal Hernia (PEH) or Fixed Hiatal Hernia (next to the esophagus)

Sliding Hernia is more common. It happens when part of your stomach and the junction between your esophagus and stomach slide up into your chest through a hole called the esophageal hiatus. This movement can go back and forth, usually because of changes in your body position or tummy pressure. Sliding hernias often team up with GERD, giving you heartburn, regurgitation, and trouble swallowing.

Para-Esophageal Hernia (PEH) is a bit different and involves part of your stomach, sneaking up next to your esophagus in your chest. The junction between your esophagus and stomach stays where it should be. This type of hernia is sometimes called a fixed hiatal hernia. While it might not dish out GERD symptoms as often as the sliding type, it’s got its own set of problems. It can lead to serious stuff like gastric volvulus, where your stomach twists and blocks blood flow. Signs of a para-esophageal hernia include chest pain, swallowing issues, and feeling stuffed after just a little nibble.

Causes of Heartburn/GERD

• Certain Food – Acidic/Spicy/Fatty Foods
• Overweight/Obesity
• Smoking
• Pregnancy
• Stress and Anxiety
• Medicines – Painkillers (like Aspirin and Ibuprofen)
• Hiatal Hernia
• Weak LES (Lower Esophageal Sphincter) Muscle

To manage acid reflux symptoms following gastric sleeve surgery, lifestyle modifications play a crucial role in complementing medical therapy. Maintaining a healthy weight through diet and exercise, avoiding tobacco use, and practicing stress reduction techniques can help alleviate reflux symptoms postoperatively. Additionally, elevating the head of the bed during sleep can reduce nighttime reflux episodes through gravity. By incorporating these lifestyle changes, individuals can effectively manage acid reflux symptoms.

Gastric Sleeve and GERD

After gastric sleeve surgery, the intra-abdominal pressure and acid production are reduced. On the other hand, the stomach size is reduced and the pressure within the stomach increases. This may cause reflux of acidic content of stomach into the esophagus. Gastric sleeve may worsen GERD symptoms or develop GERD in some patients.

It is reported that gastric sleeve induces GERD in 9% of patients. The surgeon’s technique and experience may affect the LES tone and outcome. Studies show that if the patient has a competent Lower Esophageal Sphincter, GERD is oftentimes improved after gastric sleeve.

Reflux problem after gastric sleeve can be treated with:

– Proton pump inhibitors like omeprazole, lansoprazole, and pantoprazole reduce the acid secretion of the stomach
– Prokinetic drugs like levosulpiride which increase the competency of the LES
– Eat small, more frequent meals
– Avoid food triggers

These medications help to control acid reflux by decreasing the acidity of gastric contents and promoting esophageal healing. If the heartburn problem persists and is severe a gastric sleeve revision to RNY bypass is necessary. Implementing a structured protocol following gastric sleeve surgery allows healthcare providers to identify and manage GERD symptoms. Regular follow-up visits, symptom assessment questionnaires, and objective testing are recommended.

Alternative Bariatric Options

In cases where conservative measures fail to adequately control acid reflux or when symptoms are severe and refractory to medical therapy, surgical revision procedures may be considered. Conversion to a Roux-en-Y gastric bypass (RYGB) or other bariatric procedures that divert gastric contents away from the esophagus may be warranted. Laparoscopic Roux-en-Y gastric bypass patients show less of a problem with GERD. Gastric sleeve may not be a good option for patients with GERD and individuals with risk of developing heartburn problems may have to opt for other forms of bariatric surgery. Duodenal Switch is very similar to gastric sleeve in relation to GERD and patients experiencing heartburn. Ultimately, deciding on the right surgery depends on a person’s situation and needs. It’s all about finding the best fit to improve quality of life and manage GERD effectively.

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