Bile gastritis after Sleeve Gastrectomy

Jenny from Humble sent us this question: “Had sleeve done in 2014. After EGD done 1/2020 it showed I had lots of bile in my stomach. Have bile reflux, take 40mg Omeprazole DR twice a day. Still have burning in throat, chest, esophagus. Also having hiccups and belching after eating. Cut out all caffeine, sodas, acidic fruits, and tomatoes. Still no difference. Also fried foods. Just hurting when I eat anything. EGD also showed esophagitis. 65 and getting tired of all of this daily. Will go to Dr. 5/21. Just asking for more advice or what I can do. Thanks JD”.

Dear Jenny,

Bile gastritis and bile reflux after sleeve gastrectomy is indicative of hiatal hernia. Hiatal hernia is a defect in the diaphragm hiatus. The diaphragm or breathing muscle has an opening in its center. The esophagus or food pipe goes through this opening to join the stomach in the abdominal cavity. The opening is wide enough to allow for the esophagus to go through. If the opening is large a hiatal hernia forms and the stomach herniates through the hiatal hernia into the chest.

Obesity is a major risk factor for hiatal hernia formation. Most overweight individuals have a hiatal hernia. Therefore, most obese patients undergoing sleeve gastrectomy must have a concomitant hiatal hernia repair. If hiatal hernia is not repaired, gastric sleeve herniates into the negative pressure area of the chest. This results in bile reflux from the duodenum into the stomach lumen and eventually ending in the esophagus.

Bile reflux may be worse than acid reflux in terms of damage to esophagus lining, severe burning symptoms and esophageal cancer development. Most importantly, bile reflux does not respond to proton pump inhibitors like Omeprazole and Nexium. I strongly recommend you consult with the best acid reflux and weight loss surgery specialist in your area to get evaluated and treated. Hiatal hernia repair is quite effective at stop bile reflux especially if gastric sleeve lumen is not narrowed or twisted.

Lap Band and Esophageal Damage

Lap Band and Esophageal Damage

Emily from Pasadena sent us this question: “Had lap band removed in Nov 2019. Having esophagus trouble.  Food and drink sticking.  Food still there in the morning, wheezing and coughing at night. Constant heartburn etc…”

Dear Emily,

Lap band for weight loss causes significant damage to esophagus especially when over-restricted. Many bariatric surgeons fell in the trap of over-restriction in hopeless attempts at promoting weight loss. The end result of lap band over-restriction was damage to esophagus, and dissatisfied bariatric patients. Lap band damages esophageal motility resulting in a condition called pseudo-achalasia. Pseudo-achalasia patients have a dilated esophagus secondary to chronic partial obstruction created by lap band. Heartburn, difficulty swallowing, food regurgitation, cough and wheezing (especially at night) are some of the symptoms associated with band over-restriction and pseudo-achalasia. Aspiration pneumonia is a serious side effect of lap band over-restriction.

The first step in lap band over-restriction management is fluid removal. The earlier fluid is removed the less is esophageal damage. Patients who present after years of over-restriction require lap band removal. Most patients will slowly improve, and acid reflux symptoms resolve. Some may develop irreversible esophageal function loss resulting in persistent symptoms of acid and food regurgitation. In this case, first line of treatment consists of diverting gastric content from esophagus by performing a Roux-en-Y gastric bypass. Gastric bypass is quite an effective solution for acid reflux. Dysphagia, however, may not resolve. In these rare cases and especially in the setting of recurrent aspiration episodes esophageal resection is necessary. Fortunately, Lap Band is rarely performed these days in Houston. Our understanding of weight loss surgery mechanism of action has greatly evolved. We no longer think that mechanical restriction leads to weight loss. Rather, we know that bariatric surgery modifies a number of neuro-hormonal signals that alter satiety and metabolism leading to long-term weight loss.

Gastric bypass, Gastroparesis, Sleeve Gastrectomy

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.

Gastric bypass, Gastroparesis, Sleeve Gastrectomy

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.

Should You Check for Hiatal Hernia before Sleeve Gastrectomy?

Should You Check for Hiatal Hernia before Sleeve Gastrectomy?

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.

Sleeve Gastrectomy for BMI less than 35: Is it Worth it?

Sleeve Gastrectomy for BMI less than 35: Is it Worth it?

“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.

Gastric Bypass, Gastroparesis Houston

Gastric bypass, Gastroparesis, Sleeve Gastrectomy

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,

My experience is limited to gastroparesis and delayed gastric emptying. For patients with severe gastroparesis, I prefer a modified sleeve gastrectomy over gastric bypass to improve gastric emptying and effectively resolve gastroparesis related symptoms. Sleeve gastrectomy improves both gastric and intestinal 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. 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 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.

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.

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.