A gastric sleeve patient was referred to our weight loss surgery clinic for severe acid reflux, epigastric pain and food regurgitation. Her symptoms are worse at night: she wakes up from sleep choking and gasping for air several times a week. The patient has already been started on high dose proton pump inhibitors for several weeks prior to presentation to our office with minimal improvement. She has lost most of her excess weight over the past one year after her gastric sleeve surgery. Her GERD related symptoms, however, have gotten worse. Interestingly, the patient suffered no reflux related symptoms prior to her surgery.

An upper endoscopy was performed to evaluate her problem. It revealed a large hiatal hernia with around one third of the gastric sleeve herniated into the chest. Diffuse gastritis and a bile filled gastric sleeve lumen were noted. The incisura angularis was widely open with apparent twisting and there was no evidence of a retained gastric fundus. Multiple biopsies from the gastric mucosa were taken and showed moderate to severe inflammation with no evidence of h pylori infection. Given the amount of bile present, distal partial small bowel obstruction was suspected. Gastroparesis was also considered as a potential cause for bile stasis in the gastric lumen. Accordingly, a gastric emptying study and a CT scan of abdomen and pelvis were ordered and were both normal.

As a result, we offered the patient a hiatal hernia repair with possible conversion of gastric sleeve to Roux-en-Y gastric bypass as the most reliable solution for her problem. Her medical insurance, however, did not approve the gastric bypass and we limited our intervention to hiatal hernia repair only. Intraoperatively, the gastric sleeve was completely reduced from the chest. The hernia sac was dissected and the hiatal defect repaired with no tension. The abdomen was carefully explored and no further abnormalities were noted. The patient did very well and all her GERD related symptoms including food regurgitation and epigastric pain resolved.

Six months after surgery, our patient continued to be symptom free and decision was made to repeat the upper endoscopy to re-evaluate the gastric mucosa. There was no evidence of hiatal hernia or esophagitis. The gastric mucosa has completely healed with no residual inflammation or bile stasis.

So what was causing bile reflux into the gastric lumen? Gastric sleeve surgery improves gastro-intestinal motility. As a result, bile is less likely to reflux into the stomach even in the presence of a pyloromyotomy or pyloroplasty. The most likely explanation, in my opinion, is that the herniated gastric sleeve was acting like a suction pump drawing bile from the duodenum into the stomach. Indeed, the negative pressure in the chest was being effectively transmitted into the gastric sleeve lumen. Negative pressure within the gastric sleeve promoted bile reflux from the duodenum across the pylorus leading to bile induced gastritis. By repairing the hiatal hernia, re-establishing the intra-abdominal esophagus, the negative inspiratory pressure was no longer transmitted to the sleeve lumen hence preventing the suction effect. Interestingly, sleep apnea can cause or exacerbate acid reflux by a similar mechanism. Greater respiratory effort increases the pressure gradient across the lower esophageal sphincter and the diaphragm leading to retrograde flow of gastric content into the esophagus especially in the presence of a hiatal hernia.

Prior to gastric sleeve procedure, our patient antacid barrier has most likely reformed within the hernia sac hence preventing reflux. At Houston Heartburn and Reflux Center, we encounter many patients with asymptomatic large hiatal hernia. By performing a gastric sleeve, however, without addressing a concomitant large hiatal hernia, GERD will most likely develop. At Houston Weight Loss Surgery Center, we advocate proper hiatal hernia repair during gastric sleeve surgery. Obese patients with large hiatal hernias and a BMI more than 50 presenting for gastric sleeve surgery are either staged or placed on high protein low calorie liquid diet to reduce their liver size and weight allowing for a safer approach.