Question from Tonya in Clear Lake:

“A bariatric surgeon told me I might be a candidate for RYGB, but it depends on my transit times for the smart pill. If I have gastroparesis with delayed gastric and large intestinal transit but normal small intestine am I a good candidate for gastric bypass surgery?”

Dear Tonya,

For patients with severe gastroparesis, I prefer a modified sleeve gastrectomy over gastric bypass to improve gastric emptying and effectively resolve gastroparesis related symptoms. One study has shown that sleeve gastrectomy improves both gastric and small intestine emptying. Therefore, I predict that a modified sleeve gastrectomy improves intestinal motility too. I am not sure about the effect of gastric surgery on colon emptying. I am also not sure about the clinical significance of small bowel transit time in the setting of gastroparesis.

For patients with delayed gastric emptying but normal small intestine motility, will gastric bypass surgery be equally effective to modified sleeve gastrectomy in alleviating gastroparesis related symptoms? This is a very interesting question and I am not sure if we have an answer for. Gastroparesis is a heterogeneous disorder with many different subtypes. There may be a role for gastric bypass surgery in some gastroparesis patients with “normal” small bowel motility, but I am not aware of studies to support such an approach. In my own personal and limited experience, I have had great success with the modified sleeve gastrectomy for treatment of severe refractory gastroparesis.

Question from Tonya in Clear Lake:

“A bariatric surgeon told me I might be a candidate for RYGB, but it depends on my transit times for the smart pill. If I have gastroparesis with delayed gastric and large intestinal transit but normal small intestine am I a good candidate for gastric bypass surgery?”

Dear Tonya,

For patients with severe gastroparesis, I prefer a modified sleeve gastrectomy over gastric bypass to improve gastric emptying and effectively resolve gastroparesis related symptoms. One study has shown that sleeve gastrectomy improves both gastric and small intestine emptying. Therefore, I predict that a modified sleeve gastrectomy improves intestinal motility too. I am not sure about the effect of gastric surgery on colon emptying. I am also not sure about the clinical significance of small bowel transit time in the setting of gastroparesis.

For patients with delayed gastric emptying but normal small intestine motility, will gastric bypass surgery be equally effective to modified sleeve gastrectomy in alleviating gastroparesis related symptoms? This is a very interesting question and I am not sure if we have an answer for. Gastroparesis is a heterogeneous disorder with many different subtypes. Unlike longitudinal gastrectomy or modified sleeve gastrectomy, gastric bypass or resection does not address the underlying pathophysiology of gastroparesis. For this reason, most gastroparesis patients do not respond well to either gastric bypass or gastric resection.

To summarize, in my own personal and limited experience, modified sleeve gastrectomy is the best treatment for severe refractory gastroparesis independent of small bowel transit time. There may be a role for gastric bypass surgery in gastroparesis patients with “normal” small bowel motility, but I am not aware of studies to support such an approach.

Kate from Houston sent us this question: “Do you guys offer testing for hiatal hernias? I’ve been considering gastric sleeve surgery, but I have severe heartburn and food regurgitation. Was thinking if I do have a hiatal hernia, might as well do both surgeries at once”.

Dear Kate,

Hiatal hernia testing and repair is an integral part of gastric sleeve surgery. Hiatal hernia is a defect in the opening in the breathing muscle through which the stomach herniates into the chest. Hiatal hernia repair restores normal anatomy by reducing the stomach back into the chest and closing the hernia defect. Keeping part of the stomach in the chest especially after sleeve gastrectomy results in severe acid reflux. Gastric sleeve has low compliance and readily responds to negative chest pressure. Negative pressure transmitted into gastric lumen results in a plunger like effect: acid and bile are aspirated into the upper part of the sleeve and distal esophagus where there is negative pressure. The effect is reproduced with the smallest hiatal hernias necessitating repair of any size hiatal hernia during sleeve gastrectomy. Since acid reflux and hiatal hernias are prevalent in the obese patient population careful testing for hiatal hernias prior to gastric sleeve surgery is routinely performed at Houston Weight Loss Surgery Center. Testing is performed using upper endoscopy. Additional tests like ambulatory pH testing and esophageal manometry are added if needed. Using this approach, we have prevented new onset acid reflux after sleeve gastrectomy and cured pre-existing acid reflux with proper hiatal hernia repair and gastric sleeve surgery.

“Determining the health benefits of sleeve gastrectomy in patients with body mass index, BMI less than 35” is a new article published in Surgery for Obesity and Related Diseases journal. The authors compare the outcomes of sleeve gastrectomy in 1073 patients with low BMI to 44511 patients with BMI more than 35 (mean BMI 46.7).

Statistical analysis shows comparable rates of hypertension, diabetes and hyperlipidemia medication discontinuation. Low-BMI patients were more likely to achieve a healthy BMI (less than 25). The authors conclude that despite being older and with higher rates of metabolic disease, low-BMI sleeve gastrectomy patients benefited from bariatric surgery. Furthermore, low-BMI sleeve gastrectomy patients were more likely to achieve a healthy weight. Therefore, abolishing the BMI threshold for sleeve gastrectomy should be considered.

I wholeheartedly agree with these conclusions. Sleeve gastrectomy is currently one of the safest general surgeries we perform with very high success rate. Why wait to lose weight? Bariatric surgery is currently the most effective treatment for type 2 diabetes. Denying low-BMI patients with metabolic disease a safe and effective procedure like sleeve gastrectomy is not reasonable. BMI is a statistical tool established more than 50 years ago by insurance companies to predict mortality in a population. BMI, however, is not a personalized measure of one’s health. A diabetic low-BMI patient is at higher risk for cardio-vascular disease then a non-diabetic high-BMI patient. Eliminating diabetes at a lower BMI and younger age should be the norm rather than the exception. Sleeve gastrectomy is a powerful tool to safely control and cure metabolic disease. It is time to update our guidelines.

We have previously discussed the pathophysiology associated with bile reflux from duodenum into gastric sleeve lumen ending into distal esophagus in the setting of hiatal hernia. At Houston Weight loss Surgery Center, we have made the observation of increased incidence of bile gastritis in gastric sleeve patients with hiatal hernia and distal esophagitis. Continue reading “Duodeno-gastric Bile Reflux after Sleeve Gastrectomy” →

Gastric sleeve surgery is a restrictive bariatric procedure. Stomach volume is greatly reduced resulting in small meal consumption. Weight loss, however, is not related to stomach volume reduction. Gastric sleeve induced weight loss is a physiologic result of altered gastrointestinal neuro-hormonal signals secondary to increased Continue reading “Is Your Gastric Sleeve Dilated?” →

I have recently evaluated a patient for severe heartburn and food regurgitation following gastric sleeve surgery performed in 2013 in Houston. The patient was happy with weight loss results. She had excellent restriction but suffered from severe GERD related symptoms poorly controlled with high dose proton pump inhibitors. Continue reading “Single Incision Gastric Sleeve Surgery” →

I read with great interest the study published in Surgery for Obesity and Related Diseases by DeMaria et al. It is a retrospective review of 96 gastric bypass patients who underwent conversion of to distal gastric bypass between 2010 and 2016. The Roux or alimentary limb is cut at the jejuno-jejunostomy and transposed distally leaving a common channel between 150 to 200 cm in length. Continue reading “Gastric Bypass and Sleeve Gastrectomy Revision Surgery” →