Today we will keep talking about acid reflux.
One of the special cases where we can find more acid reflux is with the gastric sleeve. The gastric sleeve surgery is a high-pressure surgery. When we staple and cut the stomach and we do a proper gastric sleeve, we remove part of the fundus, so, the higher sphincter and the ligaments that create that anti-acid reflux are basically a little bit wider.
It’s normal that around 18% of cases with gastric sleeve have acid reflux. This is one of the highest concerns in patients after undergoing gastric sleeve. You can probably have acid reflux after the surgery. There are some cases where the patients didn’t have acid reflux before the surgery and do so after, and there are other cases where patients had a lot of reflux and just with the gastric sleeve and the weight loss improve their acid reflux.
With the gastric sleeve, one of the main concerns is that during the first three months we leave all of our patients with proton pump inhibitors. The PPI’s will help reduce acid reflux because of the staple line; however, if after that you still have some acid reflux we will need to review if after losing weight your hiatal region began to become loose and has led to acid reflux again.
Even if we find a hernia during the surgery and then repair it, sometimes that repair becomes quite loose because you lose weight, which will allow the stomach to move around the hiatus. In that case, what we can do is repair that hernia again, but there is a risk that that repair will become loose again. The other option is to do an endoscopy.
If in the endoscopy we find that most of the heartburn sensation is coming from the lower part of the esophagus to the upper part, or if you have ulcers, or if you have esophagitis or if you have any of the Barrett’s symptoms, we can take a biopsy and send it to pathology. In this case, the next step is to either do a barium swallow and review if your stomach is emptying out properly or we may have to do a gastric bypass.
There are some patients that don’t want a gastric bypass because they are comfortable with their gastric sleeve: “I lost all the weight that I wanted and I’m keeping my weight down”. In this case, the gastric bypass isn’t a surgery to lose more weight. We can do a very small gastric bypass with low malabsorption and we can staple and cut your pouch and do the anastomosis to help the acid reflux drift down and go away. In this case, surgery will be basically anti-reflux surgery.
We cannot do a normal fundoplication like the Nissen surgery for acid reflux because there is no more fundus after we’ve stapled and cut that stomach, therefore what we do in this case is remove that part of the stomach and reattach the intestine and refix it if you have a hiatal hernia.