The annual meeting for SAGES (Society of Gastrointestinal and Endoscopic Surgeons) was in Houston this year. I have attended most of the bariatric sessions and I have pleasantly surprised. Most weight loss surgery lectures were well presented and quite relevant to my practice at Houston Weight Loss Surgery Center. The dominant theme this year was related to GERD management in obese patients. The effect of sleeve gastrectomy on pre-existing and de novo GERD was particularly debated on more than one occasion. Is GERD a contraindication for sleeve gastrectomy? Does sleeve gastrectomy result in de novo GERD? Two questions that remain unanswered.
According to one presenter, obese patients with symptomatic GERD should only be offered gastric bypass surgery and never sleeve gastrectomy. According to this presenter, around 20% of sleeve gastrectomy patients will develop de novo GERD. Couple of years ago, I used to believe in these assumptions. Recently, however, I have realized that sleeve gastrectomy effect on GERD is much more complicated than these assumptions and deserves deeper study and thorough analysis.
Gastric anatomy and physiology including gastric emptying and its effect on GERD, obesity and gastroparesis remain poorly understood. When weight loss surgeons started performing sleeve gastrectomy several years ago, the debate concentrated on bougie size. How tight can the sleeve be made to achieve the best weight loss? The assumption that the smaller the volume the better weight loss has dominated bariatric surgery for many years. With this guiding principle in mind, sleeve gastrectomy has evolved over a short period of time into a mutilating procedure. Around 90% of the stomach was resected including the gastric antrum to achieve the smallest possible volume. The delicate and complex gastric anatomy was completely overlooked and the stomach was straightened into a narrow and stiff tube along a small size bougie. The incisura angularis was completely obliterated resulting in most cases in a functional obstruction. The result was a high-pressure system that favored GERD development or worsened pre-existing GERD especially in the presence of a hiatal hernia.
The art of gastric sleeve surgery requires antrum and incisura angularis preservation, aggressive gastric fundus resection and proper hiatal hernia repair. Following these steps, maximizes weight loss and minimizes GERD. Our results at Houston Weight Loss Surgery Center and Houston Heartburn and reflux Center clearly indicate that gastric sleeve surgery is as good as Nissen fundoplication for acid reflux control. Indeed, we recommend hiatal hernia repair and sleeve gastrectomy for obese patients presenting with GERD as an effective cure for acid reflux. There is no need to perform a gastric bypass on a GERD patient with a BMI of 32 and no other obesity related co-morbidities. The key to gastric sleeve success and patient satisfaction is proper sleeve gastrectomy surgery technique.