Difficulty Swallowing after Gastric Sleeve Surgery

Difficulty Swallowing after Gastric Sleeve Surgery

Cynthia from Humble Sent us this question:

“I had Gastric Sleeve & Hiatal Hernia surgery in Nov 2017.  Lots of problems afterwards with food not staying down.  Food still gets stuck in a pouch/bubble & taking Dexilant/Aciphex for acid reflux.  It’s recommended that I get the Gastric Bypass surgery to correct the problem… is that a good suggestion?  Thank you!”

Dear Cynthia,

Food not going through gastric sleeve lumen is highly suggestive of gastric sleeve stricture. Gastric sleeve stricture is a narrowing in gastric sleeve lumen that leads to food regurgitation, nausea, vomiting and pain. Gastric sleeve proximal to stricture tends to dilate with time creating a pouch where food accumulates. Gastric sleeve surgery is performed using mechanical stapler. The stomach is resected and stapled over a bougie placed inside stomach lumen. If bougie size is too small a stricture may form. Some bariatric surgeons in Houston oversaw the staple line to prevent bleeding or leaks. This may narrow the lumen. Other causes of gastric sleeve stricture include adhesion formation around stomach or twisting of gastric sleeve.

Upper endoscopy and contrast study are recommended to elucidate the problem. Sometimes, balloon dilation using endoscopy or scar tissue resection is enough to resolve the problem. If the stricture is long and/or severe, conversion of gastric sleeve to gastric bypass is the only way to alleviate obstruction.

Whatever the cause, your symptoms are not normal after sleeve gastrectomy and you don’t need to suffer. Please consult with a competent bariatric surgeon to help you fix the problem and improve your quality of life.

Is Barrett’s Esophagus a Contraindication for Sleeve Gastrectomy?

Is Barrett’s Esophagus a Contraindication for Sleeve Gastrectomy?

Laura from Houston Sent us this question:

“Hello. I have a BMI of 32.6 and high blood pressure, which has landed me in the ER twice this year. Additionally, I was diagnosed with Barrett’s esophagus over a decade ago and have been treated with PPIs and monitored regularly. Although I do not meet the criteria for weight loss surgery for insurance, I am interested in off label (self-pay) for the sake of my health. I have tried many times to lose weight without success. The gastric bypass has been recommended to me in lieu of the sleeve, but that seems quite extreme for my BMI. I am very interested in your thoughts on this, given your knowledge of reflux and bariatric surgery. Both of my grandmothers died of strokes early in life, and I am very concerned about my health as I near 50. I appreciate your thoughts and have greatly appreciated your blog and research as well. Thank you!”

Dear Laura,

I greatly enjoyed your question. Thank you for sharing with us your health concerns and a medical problem with no clear guidelines to address it. First, allow me to mention that BMI criteria for weight loss surgery are outdated. Our weight loss surgery complication rate is very low. For someone, with BMI between 30 and 35 and two comorbidities (uncontrolled hypertension and Barrett’s esophagus) who is struggling to lose weight and failing to achieve durable and significant weight loss, weight loss surgery is indicated.

Second, I agree with you that gastric bypass, while effective and safe, is slightly more aggressive than gastric bypass especially for someone with a lower BMI. Gastric sleeve surgery is an equally effective weight loss procedure but less invasive than gastric bypass. Gastric sleeve surgery is not associated with long-term complications like marginal ulceration and internal hernias.

A number of published studies have shown increased acid reflux after gastric sleeve surgery. A meta-analysis of 46 studies including 10718 sleeve gastrectomy patients was recently published in the Annals of Surgery journal. The study shows a 19% increase in post-sleeve gastrectomy GERD and 23% new onset acid reflux. Long-term prevalence of esophagitis was 28% and Barrett esophagus was 8%. 4% of all patients required conversion to gastric bypass for severe reflux.

At Houston Heartburn and Reflux Center, my sleeve gastrectomy outcomes have been different. I have found that a properly performed sleeve gastrectomy in conjunction with a properly performed hiatal hernia repair lead to acid reflux resolution. Gastric sleeve lumen must be uniform with no narrowing or twisting. Herniated stomach and distal esophagus must be reduced into the abdominal cavity and initial normal anatomy restored. Gastric antrum must be preserved to promote gastric emptying. All my sleeve gastrectomy patients, with proven acid reflux, have reported complete acid reflux symptom resolution immediately following sleeve gastrectomy and prior to any significant weight loss. Most published studies that shown increased acid reflux after sleeve gastrectomy do not comment on the presence or absence of hiatal hernia, gastric sleeve lumen narrowing… If we control for these variables will post-operative acid reflux symptoms and incidence decrease?

Furthermore, patients who underwent sleeve gastrectomy somewhere else and presented to Houston Heartburn and Reflux Center for evaluation of acid reflux have invariably been found to have hiatal hernias. Those patients with no narrowing of gastric sleeve lumen, underwent hiatal hernia repair resulting in complete acid reflux symptom resolution. Consequently, over the past 5 years, I have come to the conclusion that a properly performed sleeve gastrectomy/hiatal hernia repair is an effective anti-reflux procedure. Does the same apply to Barrett’s mucosa? Unfortunately, I don’t have any data or personal experience with patients with Barrett’s esophagus undergoing sleeve gastrectomy at Houston Heartburn and Reflux Center. One would assume that Barrett’s esophagus is likely to improve or stabilize after sleeve gastrectomy if acid reflux is cured, but studies are needed to confirm such an assumption. Furthermore, if Barrett esophagus progresses to cancer and resection is needed, the remaining stomach is used as a conduit to replace the resected esophagus. Sleeve gastrectomy eliminates this option should the patient need esophageal cancer resection. I should mention that we currently have effective noninvasive and endoscopic treatment options for Barrett’s esophagus that ablate Barrett’s mucosa before it progresses to cancer. Consequently, if you have Barrett’s esophagus, you are most likely to continue periodic surveillance. Your chances of progressing to esophageal cancer are low.

Recently, a group of surgeons from France developed a procedure called the N-sleeve. The procedure is a hybrid of Nissen fundoplication and sleeve gastrectomy. A Nissen fundoplication is first constructed then a sleeve gastrectomy is added below the wrap. The published study shows good early weight loss results and excellent acid reflux control. Additional studies are needed to corroborate these findings.

Back to your question, what is the best weight loss procedure in your case? Would I offer sleeve gastrectomy to a patient with Barrett’s esophagus? I don’t think there is a clear answer or guideline. The general consensus is to offer gastric bypass for patients with Barrett’s esophagus. I don’t agree with the general consensus and I think Barrett’s esophagus is likely to improve and/or not progress to cancer following sleeve gastrectomy. This is my personal opinion. Should acid reflux worsen after sleeve gastrectomy (I have not yet seen this with my own patients), gastric sleeve to bypass conversion can be easily performed.

Endoscopic Sleeve Gastroplasty Under Fire

Endoscopic Sleeve Gastroplasty Under Fire

“Without data, you are just another person with an opinion”, concluded R. Cohen MD his attack and critique of the novel weight loss procedure, endoscopic sleeve gastroplasty also known as Endosleeve. Cohen et al conducted a systemic review regarding the efficacy and safety of endoscopic sleeve gastroplasty. The authors found no supporting scientific evidence to recommend the use of endoscopic sleeve gastroplasty for treatment of obesity in clinical practice. Continue reading “Endoscopic Sleeve Gastroplasty Under Fire”

Is Sleeve Gastrectomy the Best Gastroplasty for Weight Loss?

Over the past 50 years a number of gastroplasties have been developed to treat obesity. From the first horizontal gastroplasty to the latest endoscopic sleeve gastrectomy, bariatric surgeons in Houston and all over the world attempted to reduce stomach volume in hopes of restricting food intake and promoting weight loss. Continue reading “Is Sleeve Gastrectomy the Best Gastroplasty for Weight Loss?”

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?”

Demystifying the Role of Weight Loss Surgery

There is widespread belief that weight loss surgery is a last resort treatment for patients who are struggling to lose weight. Indeed, most primary care physicians, endocrinologists and cardiologists do not refer an obese patient for gastric sleeve or Roux-en-Y gastric bypass surgery until it is too late. Endocrinologists resort to escalating doses of long acting insulin in hopeless attempts to control blood sugar. Cardiologists spend countless hours chasing high cholesterol and blood pressure. Pulmonologists work tirelessly adjusting CPAP machines to improve breathing and control sleep apnea… The result is disease progression with more weight gain, shortened survival, and poor quality of life.

Weight loss surgery is currently the only effective, reliable and durable treatment for obesity and associated diseases like type 2 diabetes. Furthermore, weight loss surgery is safe with less than 1% mortality and morbidity rates. Accordingly, gastric sleeve and gastric bypass procedures must be considered early in the disease process. Young patients have many productive years ahead of them. The earlier we intervene in a chronic disease, the more effective the treatment can be and the longer it can last. Studies have clearly shown that the longer the duration of type 2 diabetes, the less likely is the resolution rate following laparoscopic sleeve gastrectomy. So why wait? Intervene now to relieve your body from the toll of obesity. Stop the Yo-Yo dieting for good and throw away all the supplements you are taking to lose weight. Reverse the damage obesity has incurred on your health and gain back your life.

If you suffer from excess weight and other obesity related diseases call the experts at Houston Weight Loss Surgery Center for a complimentary consultation.

Reference:

Surg Obes Relat Dis. 2011 Nov-Dec;7(6):697-702.
Ten-year duration of type 2 diabetes as prognostic factor for remission after sleeve gastrectomy.
Casella G1, Abbatini F, Calì B, Capoccia D, Leonetti F, Basso N.