The Dumbbell Gastric Sleeve: A Recipe for Heartburn

The Dumbbell Gastric Sleeve: A Recipe for Heartburn

A 45-year-old female patient presented herself to my weight loss surgery clinic with severe heartburn and food regurgitation of two-year duration. She underwent sleeve gastrectomy 7 years ago by a bariatric surgeon in Houston who is no longer in practice. Patient did well initially and lost around 100 pounds. However, over the past 4 years she started experiencing acid reflux symptoms. Her acid reflux was initially managed with medications and lifestyle changes. However, over the past two years GERD symptoms have gotten worse and difficult to control even with high dose proton pump inhibitors. Patient reports excellent restriction and good appetite control. She still maintains her 100-pound weight loss.

Upper endoscopy, performed in Houston by a general gastroenterologist with limited experience in bariatric surgery, showed moderate gastritis and distal esophagitis. No description of hiatal hernia, sleeve shape, gastric fundus size, incisura diameter mentioned. I performed an UGI that showed a dumbbell shape gastric sleeve with significant narrowing at the level of the incisura angularis and gastric body. Gastric fundus was dilated and appeared like a perfect circle with air fluid level on the X-ray pictures. Contrast emptying from stomach into duodenum appeared to be accelerated but there was contrast pooling in the gastric fundus. I repeated the upper endoscopy to confirm upper GI findings and demonstrate significant laxity at the diaphragmatic opening. There was also narrowing and twisting at the level of the incisura angularis creating a functional obstruction.

Aggressive gastric sleeve resection over a small bougie size results in a narrowed incisura angularis. A narrowed incisura angularis leads to functional gastric sleeve obstruction; as a result, gastric fundus, cardia and hiatal opening dilate over time. This slowly leads to hiatal hernia formation and a dumbbell looking gastric sleeve. A dilated gastric fundus in the setting of a hiatal hernia results in severe heartburn and food regurgitation. Treatment requires surgical correction of hiatal hernia and conversion of gastric sleeve to gastric bypass. Gastric bypass alleviates the functional obstruction at the level of the incisura. In certain cases, adhesion formation around the incisura angularis form and narrow this area. Scar tissue resection at this level alleviates the obstruction. The associated hiatal hernia still needs to be repaired to control acid reflux symptoms. The dilated gastric fundus is either resected or plicated around the distal esophagus.

Sleeve Gastrectomy in Patients with Previous Nissen fundoplication

Sleeve Gastrectomy in Patients with Previous Nissen fundoplication

I read with great interest the case series published this month in Surgery for Obesity and Related Diseases, SOARD, by Yerdel et al. “Sleeve Gastrectomy in patients with previous antireflux surgery. Preliminary results of the “no-touch to posterior wrap” technique. The authors converted 14 Nissen fundoplication patients with morbid obesity to sleeve gastrectomy. Mean follow up time was around 2 years after conversion surgery. Conversion surgery preserved the posterior and right lateral aspect of the wrap. Continue reading “Sleeve Gastrectomy in Patients with Previous Nissen fundoplication”

Does Gastric Sleeve Surgery Cause Barrett’s Esophagus?

Felsenreich et al. recently published in the journal of Obesity Surgery a very interesting study on gastric sleeve surgery long-term outcomes. The study is titled: “Update: 10 years of sleeve gastrectomy-the first 103 patients” and includes all patients who had gastric sleeve surgery prior to 2006 at participating bariatric centers in Austria. Continue reading “Does Gastric Sleeve Surgery Cause Barrett’s Esophagus?”

Nissen-Sleeve operation, is it an option?

Nissen-Sleeve operation, is it an option?

David Nocca, MD, head of Bariatric Surgery department at the University of Montpellier in France is currently conducting an international bariatric workshop about a new weight loss procedure: Nissen-Sleeve operation. The French team have already published a pilot study in SOARD in 2016 demonstrating Nissen-sleeve surgery feasibility and safety in 25 patients. The authors advocate that this approach eliminates acid reflux following gastric sleeve surgery with comparable weight loss outcomes to the traditional sleeve gastrectomy. A secondary advantage of Nissen-sleeve surgery is a decrease in the risk of staple line leak at the angle of His. The authors further advocate that the risk of remnant gastric fundus ischemia in Nissen-sleeve surgery is low given the rich blood supply of the stomach. Continue reading “Nissen-Sleeve operation, is it an option?”

Case of the week: Gastric Sleeve Surgery Following Nissen Fundoplication

The patient is a 54-year-old female with morbid obesity presenting for weight loss surgery evaluation. She is particularly interested in gastric sleeve surgery. The patient underwent hiatal hernia repair and Nissen fundoplication 14 years ago for severe GERD. She reports excellent acid reflux symptom control but recently she has been experiencing heartburn, bloating, excessive belching. An upper endoscopy showed a Hill grade 3 hiatal hernia with 5 to 6 cm diaphragmatic opening and 8 cm axial displacement. The Nissen fundoplication appeared intact and has herniated along the rest of the upper stomach into the chest. Continue reading “Case of the week: Gastric Sleeve Surgery Following Nissen Fundoplication”

Question of the week: Sleeve surgery after Fundoplication surgery

Question of the Week:


I am a 54-year young woman. I am 5’6″ and 244 lbs. I had fundoplication surgery approximately 18 years ago in Cincinnati, Ohio.

I would like to have the sleeve surgery and I’m told that I can’t have it due to the fundoplication surgery. This is such devastating news for me.

I have osteoarthritis, low thyroid, asthma. I’m taking metformin 500 mg/2 x daily along with a Trulicity injection 1x weekly for weight loss.

I am a flight attendant and I can feel the stress on my body from my weight. I would give anything to not have the joint pain that I do. I do not want to become a diabetic. I also want to feel better about myself.

I would appreciate any help that can be provided to me.


Dear Patti,

Fundoplication surgery is not a contraindication for weight loss surgery in the form of gastric bypass or sleeve gastrectomy. Weight gain with age is common and while fundoplication surgery is an excellent solution for GERD it does not protect against obesity. Typically, we perform a wrap take down prior to sleeve gastrectomy or gastric bypass surgery. In certain cases, the wrap is adherent to surrounding tissue and it is difficult to safely dissect it. In such cases, gastric bypass can be performed with excellent weight loss outcomes while preserving the wrap. The gastric pouch is simply created below the fundoplication. In the case of Sleeve gastrectomy, stomach resection can be performed up to the level of the fundoplication. However, we don’t have any long-term data in terms of weight loss outcomes with such an approach. Complete gastric fundus resection is crucial when it comes to proper sleeve resection. Whether a wrapped fundus is equivalent to a resected gastric fundus in terms of weight loss remains to be determined. Few months ago, a French group of surgeons reported on their experience with the N-Sleeve. The study was published in SOARD (Surgery of Obesity and related Disorders). N-Sleeve is a Nissen fundoplication added to sleeve gastrectomy procedure offered to patients with severe GERD. The authors reported short-term weight loss results comparable to a traditional gastric sleeve surgery. Additional studies are needed to confirm these findings. I personally think that a wrapped gastric fundus like a resected fundus is functionally inactive. Gastric fundus invagination, a novel weight loss procedure I have developed, functions along the same line of thought. An invaginated gastric fundus is incapable of stretching and dilating to accommodate a meal. In an obese mouse model, Ghrelin did not increase following gastric fundus invagination in response to weight loss indicating an inactive fundus. Should these results be confirmed, gastric fundus invagination is a less invasive approach to weight loss than sleeve gastrectomy. Sleeve gastrectomy mechanism of action remains to be determined. Until we do so, we can only rely on outcome studies and statistics to determine whether a wrapped fundus is equivalent to a resected fundus in the setting of gastric sleeve surgery.

Do You Suffer from Acid Reflux Following Sleeve Gastrectomy?

It has become a routine to publish at least one article on the effect of sleeve gastrectomy on GERD in the monthly SOARD publication of the American Society of Bariatric and Metabolic Surgery, ASMBS. Acid reflux is threatening to undermine the very low long-term complication rate of gastric sleeve surgery. “Gastroesophageal reflux disease and Barrett’s esophagus after laparoscopic sleeve gastrectomy: a possible, underestimated long-term complication” is a new study by Nicola Basso el al from Rome, Italy. The authors show a significant increase in esophagitis, Barrett’s esophagus and upward migration of the Z line in 110 patients following sleeve gastrectomy performed between 2007 and 2010. Interestingly, they have noticed that most reflux is bilious in nature and describe it in their article as “biliary-like reflux”. The authors report that 14% of the patients underwent a concomitant hiatal hernia repair. They performed what they describe as a “radical fundectomy”. Gastric sleeve resection started at 6 cm from the pylorus and was performed over a 48 F bougie. The staple line was reinforced with a running suture. The gastric remnant measured 60-80 ml, however, the authors do not mention how they measured the gastric sleeve volume.

The most striking finding in this study is the very high incidence of post sleeve gastrectomy GERD related symptoms. All sleeve patients had esophagitis on repeat post-operative EGD and 75% developed Z line migration which in certain cases may represent de-novo hiatal hernia formation. These are the highest reported numbers in the literature and by far, they do not reflect my experience with gastric sleeve surgery. Indeed, when properly performed sleeve gastrectomy resolves pre-existing acid reflux and it prevents the development of de-novo GERD. Hence, is Nicola Basso and colleagues doing something wrong?
The most common cause of post-sleeve gastrectomy GERD is functional narrowing of the incisura angularis. Is it possible that the authors have inadvertently narrowed the incisura angularis? Over sewing the staple line can cause a functional stricture especially when the staple line is too close to the bougie. Adding a “radical fundectomy” and resecting most of the antrum results in a narrow rigid tube that is a recipe for acid and bile reflux. Indeed, when the stomach is mutilated in this a fashion to achieve a “60 to 80 ml” pouch, the tube-like sleeve and the esophagus becomes one continuous cavity that is subject to the negative intra-thoracic pressure. With every breath, the negative intrathoracic pressure is directly transmitted to the sleeve lumen promoting bile reflux into the gastric lumen. Bile and acid accumulate in the proximal stomach above the narrowed incisura. Bile and acid then reflux into the esophagus resulting in severe esophagitis and favoring the development of Barrett’s esophagus. With time, the Z line migrates into the chest favoring the development of a hiatal hernia and the migration of the sleeve into the chest leading to worsening GERD.

When gastric sleeve surgery mutilates the stomach, GERD is an inevitable consequence. I have advocated for a long time, antrum preservation, and a wide incisura angularis (at least 2.5 cm or 75 F). Unfortunately, most bariatric surgeons across the world are driven by the concept of mechanical restriction. Mechanical restriction by itself does not result in durable weight loss. Excessive restriction in the case of sleeve gastrectomy results in GERD. By the same token, inadequate gastric sleeve resection that leaves too much gastric tissue results in poor weight loss. Sleeve resection must be tailored to the stomach shape and must follow basic principles to achieve the most optimal result. Gastric sleeve surgery like any other surgery remains an art with a scientific basis. Mastering the art of sleeve gastrectomy while understanding basic physiology and anatomy can save many patients from unwanted complications.

Hiatal Hernia Repair During Sleeve Gastrectomy Is Safe and Feasible

“Concomitant hiatal hernia repair with laparoscopic sleeve gastrectomy is safe: analysis of the ACS-NSQIP database” by Safadi et al is a retrospective review 32581 patients who underwent sleeve gastrectomy between 2010 and 2014. This database is part of NSQIP, the American College of Surgeons National Surgical Quality Improvement Program. 14.4% of those patients underwent a concomitant hiatal hernia repair. There was no difference in the 30-day mortality and morbidity rates between those who underwent a gastric sleeve procedure with hiatal hernia repair and those who only had a sleeve gastrectomy.

Hiatal hernia repair, when performed by expert acid reflux and weight loss surgeons is safe. It may be more technically challenging in the morbidly obese patient especially in the presence of an enlarged liver due to steatohepatitis. Bariatric surgeons, however, continue to debate the need to repair hiatal hernias during gastric sleeve surgery. Should all hiatal hernias be addressed irrespective of size? Does sleeve gastrectomy improve, worsens or causes GERD postoperatively irrespective of hiatal hernia repair?

It is our experience at Houston Weight Loss Surgery Center, that a well performed gastric sleeve procedure is associated with improvement of existing GERD. The components of a well performed sleeve gastrectomy are:
1- Any size hiatal hernia must be repaired
2- Gastric fundus must be completely resected
3- Incisura angularis must not be narrowed
4- Sleeve lumen must be straight and free of any kinking or narrowing

Indeed, sleeve gastrectomy that follows these guidelines is as good as Nissen fundoplication in curing and preventing GERD. The most commonly accepted explanation for GERD is related to increased transient lower esophageal sphincter relaxation, TLESR, events. Gastric fundus greatly affects the frequency of TLESR events. Resecting the gastric fundus and wrapping it around the distal esophagus may have the same effect on reducing TLESR and improving GERD.

Additional studies are needed to prove the long-term effect of sleeve gastrectomy on GERD. However, it remains a fact that preventing both mechanical and functional gastric sleeve lumen narrowing while completely resecting the gastric fundus are crucial steps in alleviating GERD related symptoms. Concomitant repair of a hiatal hernia furthers reinforces the anti-reflux barrier. It prevents the herniation of the gastric sleeve into the chest which exposes the intra-gastric and non-compliant lumen to negative intrathoracic pressure. This in turns transforms the sleeve lumen into a suction pump causing bile and acid reflux into the esophagus. From this perspective, we advocate the safe and concomitant hiatal hernia repair with sleeve gastrectomy.

Bariatric Surgery and Esophageal Adenocarcinoma

Esophageal adenocarcinoma is the fastest rising cancer in the US. Obesity, and GERD are well known risk factors for esophageal adenocarcinoma development. Weight loss surgery like sleeve gastrectomy and Roux-en-Y gastric bypass are effective solutions for both obesity and GERD. Therefore, obese patients undergoing gastric sleeve or gastric bypass surgery are expected to have lower incidence of esophageal adenocarcinoma. A recent population based cohort study published in SOARD (Surgery for Obesity and Related Diseases) shows the opposite. The article is titled “Esophageal adenocarcinoma after obesity surgery in a population-based cohort study”. John Maret-Ouda et al analyzed 34437 patients who underwent weight loss surgery between 1980 and 2012 in Sweden. 8 cases of esophageal adenocarcinoma occurred after weight loss surgery compared to 53 detected esophageal adenocarcinoma cases in 123695 obese individuals who did not undergo any obesity surgery. Using Cox regression, the authors demonstrated no difference in esophageal adenocarcinoma risk between obese patients who had weight loss surgery and those who did not.

The study is quite unique since esophageal adenocarcinoma is not well studied following bariatric surgery. However, this study has two major limitations that undermine its relevance and importance. The first limitation is related to the small number of esophageal adenocarcinoma cases resulting in limited statistical power. The second limitation is related to the fact that most esophageal adenocarcinoma cases occurred in Lap band and vertical banded gastroplasty patients. Both procedures are known to increase the risk of GERD. Nissen fundoplication surgery has been shown to cause Barrett esophagus regression. Both gastric bypass and sleeve gastrectomy are excellent anti-reflux procedures and should theoretically offer the same protective effect against Barrett’s esophagus and esophageal adenocarcinoma. In fact, obese patients with GERD or Barrett’s esophagus are best treated with an effective weight loss procedure like sleeve gastrectomy and Roux-en-Y gastric bypass. Gastric banding in the form of lap band and VBG are no longer offered due to poor weight loss results. Furthermore, lap band surgery alters the esophago-gastric motility in favor of acid reflux development. Therefore, lap band surgery may potentially increase the risk of esophageal adenocarcinoma.