I read with great interest the commentary on evaluating the feasibility of phrenoesophagopexy during hiatal hernia repair in sleeve gastrectomy patients. The commentary was recently published in SOARD by Dr. Jose Ferrer from the Bariatric and Metabolic Surgery Center in Valencia, Spain. The author reports his concern about the development of GERD, severe reflux esophagitis, and Barrett’s esophagus following gastric sleeve surgery. Ferrer recommends hiatal hernia repair during gastric sleeve surgery. However, herniorrhaphy alone is not enough sometimes. Additional techniques have been developed such as phrenoesophagopexy, Hill gastropexy, Teres ligament pexy, and different forms of fundoplications to augment the anti-reflux barrier. Continue reading “Gastric Sleeve Surgery and GERD”
Question of the Week from Tina:
I’m planning on having VSG in the next three months. I had the Nissen funoplication 3 yrs ago for severe Gerd. My consult will be sometime next month. It seems that there is no contraindication for gastric sleeve after the nissen procedure, according to this article which is a relief to me. It seems nissen reversal prior to VGS would be a much riskier procedure. Will there be enough of the “hunger hormone” side of the stomach to surgically remove and can this side of stomach grow back? Or does it just stretch itself back out if one tends to over eat?
Excellent question Tina. Ghrelin or hunger hormone is mostly secreted by gastric fundus. Ghrelin blood level decreases following gastric sleeve surgery as the gastric fundus is resected. Decreased ghrelin levels contribute to hunger control, increased satiety and weight loss. We don’t have any study evaluating Ghrelin blood level following Nissen Sleeve surgery. I think that a plicated gastric fundus is metabolically equivalent to a resected fundus. Therefore, I expect Ghrelin level to decrease following Nissen Sleeve surgery. Nissen fundoplication is associated with weight loss and a recent study published in 2015 demonstrated decreased Ghrelin levels following fundoplication surgery. Gastric fundus invagination, a weight loss procedure I developed few years ago, prevents Ghrelin level increase with weight loss. I demonstrated this finding in an obese rat model. In humans, gastric fundus invagination has not been studied but I predict that Ghrelin levels will also decrease.
Ghrelin, however, is not the only hormone change responsible for weight loss. Many other signals are equally important like GLP-1 (Glucagon like peptide). GLP-1 decreases following Nissen fundoplication and is likely to decrease following Nissen Sleeve surgery. Increased gastric emptying is thought to contribute to GLP-1 increase and Nissen fundoplication is associated with increased gastric emptying. I have noticed on post-operative contrast studies that Nissen Sleeve procedure increases gastric contrast emptying.
Overall, I think that the plicated fundus is functionally equivalent to a resected fundus. When properly performed, fundus presrving gastric sleeve surgery, in obese patients with history of Nissen fundoplication, results in excellent weight loss results.
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”
Laparoscopic sleeve gastrectomy combined with Rossetti fundoplication (R-Sleeve) for treatment of morbid obesity and gastroesophageal reflux by Stefano Olmi is a new study published online in SOARD (Surgery for Obesity and Related Disorders). 40 patients suffering from morbid obesity and acid reflux confirmed by either upper endoscopy or ambulatory pH testing were retrospectively analyzed. All patients underwent sleeve gastrectomy that spared part of the gastric fundus. the remnant fundus was used to perform a 1.5 cm, two suture, floppy fundoplication. Interestingly, hiatal hernia repair was only performed for large defects. The authors describe an unusual technique of opening the space between the esophagus and left crus to reduce small hiatal hernias without any suture repair.
Patients underwent an upper endoscopy at 12 months after surgery. Patients with preoperative esophagitis showed improvement and those without mucosal inflammation showed no new onset esophagitis. Repeat ambulatory pH testing was not performed. All patients were off proton pump inhibitors and 95% of them acid reflux related symptom free. Excess weight loss percent at 12 months was around 62%.
At Houston Weight Loss Surgery Center, we perform a formal hiatal hernia repair for all obese patients with GERD presenting for sleeve gastrectomy. We have found that a properly performed sleeve gastrectomy with distal esophageal mobilization and posterior hiatal hernia repair result in excellent reflux control. In my opinion, a resected gastric fundus is equivalent to a plicated fundus around the esophagus (fundoplication) in terms of preventing reflux. The assumption that a fundoplication works by reinforcing the lower esophageal sphincter (LES) is naïve. Fundoplication mechanism of action is much more complicated than LES reinforcement. Indeed, repeat esophageal manometry does not show increased LES pressure and most GERD patients undergoing Nissen fundoplication surgery have normal LES pressure. Acid reflux disease is a multifactorial problem. Gastric fundus wall compliance, relaxation and motility affect transient lower esophageal relaxation events and reflux episodes. Fundoplication surgery alters these factors in favor of reflux control. Similarly, fundus resection in sleeve gastrectomy prevents reflux and promotes gastric emptying. There is no need to add a fundoplication to a properly performed sleeve gastrectomy and hiatal hernia repair.
Sleeve gastrectomy is a simple and straightforward surgery to perform. The stomach is mobilized along the greater curvature and cut longitudinally with a linear stapler. The purpose of surgery is to modify the interaction between ingested food and stomach to alter certain neuro-hormonal signals. Signals as Ghrelin, GLP-1 and PYY affect metabolism, appetite, satiety and ultimately result in weight loss. Many bariatric surgeons have difficulty accepting the fact that metabolic surgery is more about altering these neuro-hormonal signals than mechanically restricting the stomach. Consequently, when gastric sleeve surgery was first introduced several years ago, the debate about bougie size dominated our metabolic and bariatric surgery field. Whole sessions in Obesity Week and other bariatric surgery conferences were devoted to discussing the optimal sleeve lumen diameter. The assumption, of course, was that the smaller the bougie diameter the better is weight loss. This assumption was proven wrong. Many published studies have shown that the smaller the bougie size the higher is the leak rate with no improvement in percent excess weight loss.
Knowledge about sleeve gastrectomy mechanism of action, predictors of weight loss and optimal surgical technique is still not established. As John Naisbitt said: “We Are Drowning in Information but Starved for Knowledge”. We will continue to be bombarded by studies that will not advance our practice or improve our skills. This newly published article: “Is a retained fundus seen on postoperative upper gastrointestinal series after laparoscopic sleeve gastrectomy predictive of inferior weight loss?” is a perfect example. It is a single center, retrospective study that includes 149 sleeve gastrectomy patients. Patients were divided into 4 groups depending on the ratio of fundus to more distal sleeve lumen diameter, measured on postoperative upper gastrointestinal series (UGI). The authors found no difference in mean percent excess weight loss at one year following sleeve gastrectomy in all 4 groups. Of note, a single surgeon performed all 149 sleeve gastrectomies using a 34 French bougie. A 1 cm distance from GEJ was left at the angle of His.
I should mention that a postoperative UGI is not an accurate measure of sleeve lumen. The resected stomach is edematous, blood clots may be present along the staple line and sleeve lumen contrast filling is not homogeneous. Accepting this limitation, the study doesn’t show a difference in weight loss even when comparing the most optimally resected gastric fundus to the severely retained fundus. So how much gastric fundus should be resected to achieve the best weight loss? The answer to this question depends on the sleeve mechanism of action. If pure restriction is the dominant mechanism of action then the smaller the sleeve volume the better is weight loss. This however is not the case. Indeed, I preserve most of the antrum to prevent narrowing at the incisura angularis and to maintain the gastric pump that promotes gastric emptying. Most importantly, I preserve the antrum to maintain the Magenstrasse gastric emptying pathway. I believe that sleeve gastrectomy mechanism of action relies on restoring the Magenstrasse pathway of gastric emptying. This allows for rapid delivery of ingested food particles into the distal intestines stimulating the neuro-hormonal signals that result in weight loss. The Magenstrasse emptying pathway depends on antral wave contractions. Accordingly, mutilating the gastric antrum along a 34 French bougie is not necessarily associated with the best weight loss results. Discussing optimal gastric fundus resection in the setting of a resected antrum is not likely to yield any meaningful results. Preserving the antrum and optimally resecting the gastric fundus seem to be the best approach for sleeve gastrectomy. But what is optimal gastric fundus resection? The fundus can be completely resected flush at the GEJ. Part of the fundus may also be left unresected leaving a gastric bubble. At Houston Weight Loss Surgery center, we have found that aggressive gastric fundus resection is not associated with better long-term weight loss results. Rather, aggressive gastric fundus resection results in severe restriction and very limited gastric capacity. Patients typically reports uncomfortable restriction during the first 6 months of surgery without the benefit of increased weight loss. I have learned from observing such patients that mechanical restriction is not the dominant mechanism for weight loss. Excessive restriction following sleeve gastrectomy is not associated with better weight loss. I leave one cm of gastric tissue at the GEJ to prevent narrowing in that area and avoid patient discomfort. I resect most of the posterior gastric fundus by applying proper retraction during surgery. does leaving a larger unresected fundus lead to poor weight loss? The answer to this question maybe a yes but the cause is not poor restriction. Leaving a larger fundus may result in slower gastric emptying and poor Magenstrasse wave formation. Studies are needed to prove or disprove these observations. One thing for sure, we have had plenty of studies demonstrating that mechanical restriction by itself is not the underlying cause for weight loss. Yet, many still believe, like the authors of this article that “restriction is considered to be one of the most important mechanisms for weight loss in stapled procedures”.
The incisura angularis is the Achilles heel of sleeve gastrectomy. Preserving this natural gastric angulation is crucial to ensure proper weight loss while preserving basic gastric anatomy and function. Stapling too close to the incisura angularis results in sharp angulation in that area that causes functional obstruction. Functional obstruction of the gastric sleeve lumen increases the risk of postoperative staple line leak, decreases weight loss and precipitates acid reflux.
Chronic functional obstruction of gastric sleeve lumen results in increased intra-gastric pressure and proximal lumen dilation. The upper part of the sleeve enlarges with time leading to the creation of a neo-fundus. The upper part of the sleeve is more prone to dilation due to its thin and compliant wall. Furthermore, a small dog ear is typically left to decrease leak rate. This small residual gastric fundus has a larger diameter than the rest of the gastric sleeve lumen. The larger the lumen diameter, the higher is wall tension leading to more stretching and dilation. Indeed, the presence of a neo-fundus as the attached UGI picture depicts is an indirect sign of functional obstruction. Chronic obstruction also results in anterior and medial rotation of the gastric sleeve proximal to the incisura angularis resulting in the classic hairpin deformity and further accentuating the sharp angulation and obstruction.
Patients typically present with worsening acid reflux related symptoms poorly controlled with proton pump inhibitors. The combination of poor gastric motility, high gastric pressure and gastric fluid secretion accumulation in the neo-fundus results in severe reflux into the esophagus. The only effective solution in this case is to convert the gastric sleeve into a Roux-en-Y gastric bypass. The conversion is straightforward, effective and safe. Gastric bypass restores normal gastrointestinal motility. It immediately relieves all GERD related symptoms and promotes weight loss.
In summary, avoiding narrowing at the incisura angularis cannot be over-emphasized. Sleeve gastrectomy is a mutilating procedure but preserving basic gastric anatomy and function is mandatory to avoid complications. Gastric fundus invagination, a weight loss procedure that I have developed few years ago has the advantage of preserving gastric structure while modifying gastric emptying, and food interaction. Gastric fundus invagination or sleeve gastrotomy as Dr. Mason would like to call it has the potential of becoming the first line treatment for morbid obesity.
One of the most important surgical principles in gastric sleeve surgery is contouring the stapled stomach to prevent narrowing or twisting. To achieve this aim, I routinely place three 12 mm ports along the umbilical level to be able to staple from 3 different angles. Indeed, the first two firing of the linear staplers are always performed from the right lower quadrant port. Using this port, allows to stay away from the incisura angularis preventing narrowing at this critical location. The linear stapler is an articulating device. However, in many instances, even with sharp stapler angulation, firing from the midline port, risks narrowing the incisura angularis.
Single incision laparoscopic surgery, also known as SILS, limit the dissection and stapling along one single axis. Greater curvature mobilization in obese patients with large left hepatic lobe and thick omentum requires more than one working axis. Taking down the short gastric blood vessels without proper triangulation and adequate retraction by the assistant is quite cumbersome.
Despite these limitations, several studies have been published about single incision sleeve gastrectomy demonstrating safety and feasibility. A study published by Dagher el al. in 2016 in SOARD (Surgery for Obesity and related Diseases) journal evaluates 1000 consecutive single-port laparoscopic sleeve gastrectomy performed at one single hospital in Paris, France. The median BMI was 42.6 and only 7.8% of the patients required the addition of one extra port to complete the procedure. The staple line leak rate was 2.8% and the overall morbidity rate was 8.1%. incisional hernia from trocar insertion site was 3.7%. The authors conclude that gastric sleeve surgery can be routinely performed using SILS technique and the results are comparable to traditional mutli-port laparoscopic sleeve gastrectomy. It is hard to duplicate such results and very few bariatric surgeons in the US advocate the use of SILS for sleeve gastrectomy these days. Better cosmesis and decreased pain are desirable outcomes that we all seek. However, gastric sleeve surgery is primarily a contouring procedure that requires the use of more than one surgical axis. Limiting the gastric resection to one direction, along one single port, is not the optimal approach to creating the “perfect sleeve”. Therefore, in the absence of a modified stapling device that can be positioned along any desired axis of resection within the abdominal cavity, SILS remains a sub-optimal approach for sleeve gastrectomy.
Does gastric sleeve surgery increase intra-gastric pressure? The short answer to this question is unknown. There are no studies I am aware of that compare the gastric pressure before and after gastric sleeve surgery. Furthermore, intra-gastric pressure varies greatly throughout the day and depends on several factors like gastric wall compliance, gastric volume and content, pyloric contractions…
Gastric fundus is the most compliant part of the stomach and is resected during sleeve gastrectomy. Consequently, it is possible that gastric wall compliance decreases after sleeve gastrectomy leading to increased intra-gastric pressure. However, gastric emptying also increases following gastric sleeve surgery and therefore the integrated intra-gastric pressure may not significantly increase.
The assumption of increased intra-gastric pressure was introduced by several bariatric surgeons trying to explain sleeve gastrectomy staple line leak rate at the angle of Hiss area. It was assumed that gastric sleeve surgery leads to increased intra-gastric pressure. Increased luminal pressure not only results in leak development but also it delays and sometimes prevents healing. Such assumptions, however, have never been proven. Narrowing at the incisura angularis may cause increased intra-gastric pressure leading to increased staple line leak rate. However, a wide incisura angularis is unlikely to be associated with increased intra-gastric pressure. Therefore, a well performed sleeve gastrectomy is most likely associated with normal intra-gastric pressure, lower staple line leak rate, and lower incidence acid reflux. Indeed, a well performed gastric sleeve surgery may be associated with decreased intra-gastric pressure. Studies are needed to evaluate intra-gastric pressure before and after sleeve gastrectomy. New tools need to be developed to study gastric wall compliance, gastric volume and intra-gastric pressure. A silicon covered electronic chip attached to the gastric mucosa may deliver such information over several days like a pH Bravo capsule.
I had sleeve surgery about 2 years ago in Dallas. I’ve lost about 40 pounds and still eat pretty small amounts but can’t seem to lose more. I’m about 158 pounds now. I suffer from horrible GERD. Sometimes bile comes into my throat while I’m sleeping and I feel like I’m choking on acid. I’m 44 and take Dexilant, Nexium, Prevacid, alka seltzer, and tums daily. I’m worried about all this medication and my symptoms seem to be getting worse. Thank you
Your symptom description is highly suggestive of severe GERD post sleeve gastrectomy. A well performed sleeve gastrectomy is expected to resolve acid reflux rather than cause it. I suspect you have a missed hiatal hernia that can be easily corrected. An upper endoscopy as well as upper gastrointestinal contrast study are needed to study the anatomy of your stomach and esophagus. If the sleeve lumen is twisted, narrowed or dilated additional surgery may be needed to correct the problem.
Dexilant, Nexium, Prevacid and other antacid medications are not an effective solution in your case. Bile reflux is very common in missed hiatal hernia following gastric sleeve surgery because the sleeve lumen is rigid and non-compliant. As a result, the negative intra-thoracic pressure is easily transmitted into the sleeve lumen. This creates a suction effect that facilitates the retrograde flow of bile from the duodenum into the gastric lumen and esophagus. Almost every gastric sleeve patient I evaluate for post-operative GERD has evidence of bile gastritis. I have had great success alleviating both bile reflux and bile gastritis by properly repairing a missed or poorly dissected hiatal hernia in sleeve gastrectomy patients. If you had gastric sleeve surgery and currently suffer from acid reflux disease please give us a call. There is no need to suffer and ruin your weight loss journey.
This case was posted on the American College of Surgeons, bariatric portal, for discussion.
“A 60-year-old patient had a sleeve gastrectomy 4 months ago for morbid obesity. Patient had been doing well until 3 weeks ago when she began to have continuous belching. She noticeably gulps air and then immediately belches. This is almost every minute but is NOT present when asleep and nurses notice sometimes ceases when distracted.
CT scan and UGI contrast study were essentially normal. Air accumulation was noted in proximal sleeve. No gastric lumen stenosis noted. Contrast emptying from the stomach into the duodenum was within normal. Upper endoscopy was unremarkable and no hiatal hernia was noted.
Are these symptoms related to gastric sleeve surgery?
Is this a variety of frothing?
Is conversion to RNY indicated?”
Excessive belching and burping or eructation are common GERD symptoms. Patients who suffer from acid reflux disease tend to swallow air and saliva to neutralize acid reflux more than average. Swallowed air accumulates in the gastric fundus. Increased transient lower esophageal sphincter muscle relaxation because of esophago-gastric dysmotility results in air reflux.
Air reflux is diagnosed using pH impedance. pH impedance probe is positioned in the esophagus using esophageal manometry. It is the preferred diagnostic tool for GERD diagnosis following gastric sleeve surgery. Acid reflux may occur following sleeve gastrectomy if the gastric sleeve is poorly performed and/or a concomitant hiatal hernia is not repaired or inadequately repaired.
At Houston Weight Loss Surgery Center, we have had great success resolving GERD following sleeve gastrectomy. In 80% of the cases, we could salvage the sleeve and promote weight loss. In the remaining cases, gastric sleeve conversion to gastric bypass was needed due to significant gastric sleeve lumen narrowing.
The case presented above warrants full GERD workup including esophageal manometry and pH impedance. The gastro-esophageal junction must be carefully and closely examined for a hiatal hernia. Bile gastritis is commonly encountered in the case of a hiatal hernia and sleeve gastrectomy. the patient is considered behavioral only when the complete GERD work up is negative.