The patient is a 50 year-old female who underwent gastric sleeve surgery in Mexico approximately a year ago. Her comorbidities prior to surgery included hypertension and sleep apnea. She did not experience heartburn or food regurgitation prior to surgery. She underwent the procedure with no complications. Her operative report describes an uneventful gastric sleeve resection and anterior hiatal hernia repair consisting of anterior crural approximation with suture fixation of the gastric sleeve to the left crus. 12 days after surgery she started experiencing severe daily heartburn and food regurgitation. She was placed on proton pump inhibiters, Carafate and Zantac with very little symptom improvement. She underwent an upper endoscopy that showed a Hill grade 4 hiatal hernia with around 6 cm axial displacement and 4 to 5 cm diaphragmatic opening. The incisura angularis was widely open with no apparent narrowing. Continue reading “Case of the Week: Sleeve in the Setting of a Large Hiatal Hernia”
A fascinating new study analyzed 190,000 gastric sleeve cases performed between 2012 and 2014 at accredited bariatric surgery centers by MBSAQIP (Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program). The study was presented at the 2016 annual meeting of the American Surgical Association. 80% of the 1634 surgeons who performed these gastric sleeve surgeries used staple line reinforcement. A practice associated with decreased bleeding but a significantly higher leak rate according to this analysis. The study does not expand on the type of reinforcement used. Therefore, one cannot conclude if all types of reinforcement are associated with increased leak rate. This may be a major weakness associated with this high power study as over-suturing the staple line with or without imbrication may narrow the incisura angle and weaken the staples increasing the leak rate. Reinforcement material like Seamguard and bovine pericardium is conceptually and mechanistically different from suturing the staple line. Hence, it would be very interesting to break down the staple line leak cases into types of reinforcement to further understand this serious complication and better prevent it in the future. Continue reading “Staple line Reinforcement, Distance From Antrum and Bougie Size: A New Study From MBSAQIP”
Some patients from Houston elect to go to nearby Mexico for weight loss surgery for various reasons. Some have no medical insurance while others have very high deductibles. Affordable weight loss and cosmetic surgery packages are offered in several cities like Cancun and Tijuana. Patients can have a small vacation and come back to Houston with a gastric sleeve or tummy tuck.
Some are very lucky and receive quality surgery with fast recovery and no complications. Others, unfortunately, are hurt. Over the past one year, I have seen several gastric sleeve related complications particularly when performed in Mexico and mainly related to post operative acid reflux. Some have narrowing of the gastric lumen mainly at the level of the incisura angularis while others have a retained gastric fundus. A good number have a large hiatal hernia that is left unrepaired at the time of sleeve surgery. I am sure that many foreign bariatric surgeons are quite knowledgeable and skillful. Some, however, are unfortunately unqualified and Houstonians are falling victims.
Gastric sleeve surgery is one of the least challenging weight loss procedures to perform. Sometimes one may encounter a difficult case but overall the technique is simple and straightforward. The outcomes are easily reproduced when certain aspects of the surgery are taken into consideration. First, the gastric fundus must be completely mobilized and resected. Failure to do so results in poor weight loss and post-operative acid reflux. Second, the incisura angularis must not be narrowed. Failure to do so, results in vomiting, food regurgitation, severe acid reflux and possible staple line leak. Third, a large hiatal hernia must be repaired at the time of surgery. Obviously, a small indentation in the hiatus can be left alone. However, patients with a short intra-abdominal esophagus and GERD related symptoms upon presentation must be closely evaluated. A hiatal hernia in this setting ought to be fixed to prevent post-operative acid reflux. Finally, a corkscrew or twisted gastric sleeve can cause reflux. Every effort must be made to contour the staple line to prevent jagged edges that serve as reflux points.
The problem with de novo acid reflux following gastric sleeve surgery is not only limited to the immediate postoperative period. De novo reflux may surface years down the road. A study by Himpens et al. revealed a biphasic pattern in the symptoms of GERD during longer-term follow-up. In a subgroup of 30 patients followed-up for 6 years after LSG, GERD complaints were present in 23% of patients. Previously, this group of patients demonstrated a 22% GERD incidence at 1 year and then an incidence decrease to 3% at 3 years. The investigators commented that the development of a neofundus and a “relative mid-stomach stenosis” in gastric sleeve patients at long-term follow-up contributed to increased acid production and might explain the increased incidence of GERD. This is a fascinating theory that further supports our effort at keeping the incisura angularis as wide as possible while completely resecting the gastric fundus. Complete gastric fundus resection is key to gastric sleeve surgery. It allows for improved weight loss while preventing post-operative acid reflux. Neofundus formation may be inevitable with time but one thing for sure; complete gastric fundus resection will significantly limit the size and likelihood of neofundus development.
In a future blog I will discuss my take on gastric sleeve surgery as a mutilating procedure and what alternatives I came up with to replace the gastric sleeve.
Gastric sleeve surgery is currently the most commonly performed bariatric procedure in the US and the world. It is less invasive than gastric bypass and much more effective than lap band. When properly performed, gastric sleeve is safe and has minimal long-term complications. The most important step in gastric sleeve surgery is complete gastric fundus resection. Retained gastric fundus leads to poor weight loss results and most importantly to severe acid reflux. Complete take down of all short gastric vessels and full visualization of the left crus are key steps to mobilizing the posterior fundus.
For years, bariatric surgeons have debated the size of the bougie used to resect the stomach. A number of non-sense guidelines and recommendations were issued with little relevance to the underlying physiology of gastric sleeve and its metabolic effects. We now know that resecting the fundus is a key step in sleeve surgery irrespective of bougie size. Indeed, fundus resection is not only important for weight loss results but also to prevent postoperative acid reflux. Hiatal hernia repair dominated many discussions on acid reflux prevention following gastric sleeve surgery. The reality is that complete gastric fundus resection rather than hiatal hernia repair is the key to acid reflux control in the setting of sleeve gastrectomy.
“Association of radiographic morphology with early gastroesophageal reflux disease and satiety control after sleeve gastrectomy” by Moreno et al is a study published in the Journal of the American College of Surgeons in 2014. The study analyzes the gastric sleeve shape on routine post-operative gastrointestinal series. Those patients with retained fundus had lower satiety scores and higher severity of reflux symptoms. Along the same lines, Gagner el al published a series of 36 redo gastric sleeve surgeries in 2014 in Surgical Endoscopy journal. The indications for revision surgery were failure to loose weight, weight regain and intractable acid reflux. All patients had a large gastric fundus. The mean percentage of excess weight loss after sleeve revision was 58.5 % (±25.3) (p < 0.0004) for a mean follow-up of 20 months (range 6-56 months). Acid reflux related symptoms resolved in two patients after redo gastric sleeve.
Is gastric sleeve surgery the right choice for you? The answer is most likely yes granted that the gastric fundus is completely resected to give you the best weight loss possible and the least likelihood of developing acid reflux disease after surgery.
Hiatal hernias and acid reflux are common occurrences in obese patients. There is an almost linear correlation between BMI and GERD. Indeed, elevated intraabdominal pressure in overweight patients stresses the delicate phreno-esophageal membrane. Weakness in this membrane leads to effacement of the angle of His, laxity in the diaphragmatic crura, and migration of the intraabdominal esophagus into the chest. With time, a hiatal hernia develops, and acid reflux worsens. Most obese patients presenting for gastric sleeve surgery suffer from GERD. The question that frequently arises: what to do with the hiatal hernia if present?
A recent prospectively randomized study by Klein et al, published in SOARD journal, showed no difference in GERD symptoms at one year after sleeve gastrectomy. Morbidly obese patients scheduled for gastric sleeve surgery and found to have a hiatal hernia less than 4 cm in axial displacement were randomly divided into two groups. The first group underwent gastric sleeve surgery with hiatal hernia repair and the second group received a sleeve gastrectomy without hiatal hernia repair. Both groups were closely followed, and statistical analysis showed no significant difference in terms of GERD related symptom resolution or de novo symptom formation between both groups. In other words, according to this group of bariatric surgeons in Houston, there is no need to repair a hiatal hernia measuring less than 4 cm in axial displacement during gastric sleeve surgery.
At Houston Weight Loss Surgery Center, we have learned over the past few years that any size hiatal hernia must be repaired during gastric sleeve surgery to prevent post-operative GERD and bile gastritis. The main purpose of hiatal hernia repair is to restore normal anatomy consisting of at least 3 cm of intra-abdominal esophagus. This allows the lower esophageal sphincter to be exposed to the positive intra-abdominal pressure; this is particularly important in the case of gastric sleeve surgery. An unrepaired hiatal hernia leaves the upper part of gastric sleeve lumen exposed to the negative intra-thoracic pressure. The narrow gastric sleeve lumen has low wall compliance that easily transmits the negative intra-thoracic pressure into the gastric lumen. This results in a pressure gradient across the diaphragmatic opening favoring not only gastro-esophageal reflux but also duodeno-gastric reflux. Indeed, almost all sleeve gastrectomy patients with GERD and hiatal hernia have evidence of bile gastritis on upper endoscopy. Biliary acids also contribute to reflux esophagitis and Barrett’s esophagus development.
Gastric sleeve surgery and hiatal hernia repair go hand in hand to prevent de novo, persistent or worsening post-operative acid reflux. Meticulous surgical technique is key to achieve proper hiatal hernia repair and a well contoured gastric sleeve. When properly performed, bariatric patients experience a reflux free weight loss journey.
Gastroparesis or delayed gastric emptying occurs when the stomach is paralyzed and gastric emptying is impaired. As a result, patients report bloating, nausea, vomiting, and pain. The underlying pathophysiology of gastroparesis is poorly understood. The cause of gastroparesis is also unknown. When patients with diabetes develop gastroparesis, the condition is called diabetic gastroparesis. It appears that in diabetic patients enteric nerve damage results in gastric dysmotility. However, the relationship between diabetes and gastroparesis is far more complex than a simple neuropathy. Normally, rising blood sugar levels halt gastric emptying as a protective measure against further nutrient passage into the intestines and sugar absorption. In type 2 diabetic patients abnormal gastric emptying may be the cause of diabetes rather than the result. In fact, type 2 Diabetes may be looked at as a gastro-intestinal motility disorder resulting in insulin resistance. Dr. Mason, the father of bariatric surgery, is an avid proponent of this theory. The early resolution of type 2 Diabetes immediately following gastric bypass and sleeve surgery is partly secondary to faster delivery of food to the distal small bowel. Gastric sleeve increases gastric emptying allowing food particles to reach the distal bowel to stimulate more L cells leading to increased GLP-1 secretion. L cells are specialized cells that react to glucose in ingested food and secrete several hormones like GLP-1 that affect glucose metabolism. GLP-1 stimulates insulin secretion and blocks glucagon secretion hence improving post-prandial blood sugar levels.
Several studies have shown that gastric sleeve surgery increases gastric emptying. Few years ago, I used this concept to treat a severe case of diabetic gastroparesis in a 45-year-old male. I performed a longitudinal gastrectomy to mimic the effects of gastric sleeve and improve gastric emptying. I also added a duodeno-jejunostomy to promote duodenal emptying. The patient immediately improved and was tolerating regular diet few days after surgery. Interestingly, his diabetes resolved immediately after surgery. This observation shows again that type 2 Diabetes is primarily a gastro-intestinal motility disorder. I did not consider a gastric bypass in this particular patient because the stomach was massively dilated. Gastric remnant secretion would accumulate in the stomach causing symptoms. A recent study from the Cleveland Clinic showed that gastric bypass surgery is effective in morbidly obese gastroparesis patients and safer than subtotal gastrectomy. The series was small (7 patients) and the follow up was short. Two patients were converted to subtotal gastrectomy for persistent gastroparesis related symptoms following gastric bypass surgery. In my opinion, gastroparesis is a generalized motility disorder that affects the duodenum and sometimes the entire small bowel. Simply bypassing the stomach and proximal bowel may not resolve the symptoms especially in severe cases. A modified gastric sleeve or longitudinal gastrectomy is a more effective option that addresses the underlying problem. By resecting the gastric fundus and most of the greater curvature, stomach compliance decreases leading to improved gastric emptying. Furthermore, the malfunctioning gastric pacemaker that is located along the greater curvature is eliminated and potentially leading to increased motility. I recommend leaving the antrum intact as it represents the gastric pump and may help promote gastric emptying.
In summary, gastrointestinal motility affects many functions in the body and contributes to many diseases like acid reflux, diabetes and obesity. Gastric motility patterns are highly coordinated and still poorly understood. Lessons learned in gastric sleeve surgery may be applied to severe refractory gastroparesis cases. Future studies are needed to establish longitudinal gastrectomy as an effective treatment modality for gastroparesis.
GERD remains an intriguing disease with several important unanswered questions about its rising incidence, precipitating factors, underlying pathophysiology and relationship to the obesity epidemic. Today, around one-third of all Americans experience a GERD-related symptom at least once weekly.
Esophageal adenocarcinoma, a complication of GERD, is the fastest-rising cancer in the U.S. Abdominal girth and excess weight contribute to GERD. Several studies demonstrate a strong, almost linear association between BMI and GERD. Obesity may promote the development of GERD. If true, what would be the underlying mechanism?
The link between obesity and GERD seems to be related to increased intra-abdominal pressure secondary to abdominal fat accumulation. Intra-gastric pressure increases, promoting a backflow of gastric content into the esophagus. Several studies have shown that GERD patients’ increasing BMI is independently associated with increased intra-gastric pressure. While logical, these findings are a simplistic interpretation of a complex problem.
GERD is a result of a weak LES
GERD pathogenesis is centered on the gastroesophageal junction (GEJ). This complex and dynamic structure is comprised of the lower esophageal sphincter — the surrounding crural diaphragm — the angle of Hiss (angle where the intra-abdominal esophagus joins the stomach) — and the phrenoesophageal membrane (PEM). The diaphragmatic crura prevent strain-induced reflux events, while the angle of Hiss configuration prevents increased gastric pressure-induced reflux events. The PEM is composed of elastin intertwined with thick bundles of collagen. Elastin contributes to its elasticity and flexibility, while collagen confers strength. This delicate balance between flexibility and strength allows the remaining components of the GEJ to work in synchrony and with clocklike precision: relaxing, contracting and contorting to gastric pressure variations with upward esophageal movements to prevent reflux. Secondary to obesity, a persistent elevated intra-abdominal pressure may challenge the delicate PEM (the Achilles heel of the anti-reflux barrier). A weak and lax PEM causes anatomic changes in the structure of the GEJ that evolve into functional failure of multiple acid reflux defense mechanisms like low sphincter pressure, transient lower esophageal sphincter relaxation, prolonged acid clearance, and changes in the post-prandial acid pocket position. The end result is the development of an overt hiatal hernia: the only independent predictor for GERD.
Weight loss surgery options rather than acid suppression
Interestingly, increased gastric acid secretion is not a contributing factor in the GERD pathogenesis — quite a paradox in that acid suppression has been the mainstay of GERD therapy for the past 50 years. Particularly in the obese patient population, GERD treatment should mainly rely on weight loss rather than acid suppressive therapy. The most effective weight loss therapy for obese patients is bariatric surgery. Roux-en-Y gastric bypass surgery is an established anti-reflux procedure. It diverts the acid-producing stomach away from the esophagus. The literature remains ambivalent on the effect of sleeve gastrectomy in resolving acid reflux disease. Is gastric fundus resection during sleeve gastrectomy equivalent to gastric fundus plication during a Nissen fundoplication surgery? A recent prospective study by Morino et al. showed resolution of symptomatic GERD following sleeve gastrectomy in morbidly obese patients. Will the sleeve gastrectomy have a role in GERD treatment in obese patients?
Additional studies are needed to answer these questions. As GERD continues to rise, new screening, diagnostic and treatment paradigms will emerge.
The rising Gastric Sleeve is replacing older and ineffective procedures like adjustable gastric banding. Gastric sleeve surgery is a metabolic procedure that alters several hormones that control appetite, satiety and energy metabolism. The end result is significant and durable weight loss. At Houston Weight Loss Surgery Center, we offer the gastric sleeve surgery as a first line weight loss surgery option for almost 80% of our patients. Gastric bypass surgery is reserved for revisions and advanced diabetes cases. We don’t offer adjustable gastric banding, however, we offer gastric band adjustments and management to patients who has already received a band. Our revision surgery mainly consist of band conversion to gastric bypass. Continue reading “The rise of Gastric Sleeve procedure for weight loss”
The incidence of heartburn in our overweight patient population is very high. Heartburn results when acid backs up into the esophagus. Normally, a competent lower esophageal sphincter, LES, acts as a barrier against acid reflux into the esophagus. With weight gain, fat accumulates inside the abdomen increasing the pressure on the stomach and leading to acid reflux. Furthermore, a higher intra-abdominal pressure increases the incidence of a hiatal hernia. A hiatal hernia occurs when part of the stomach herniates into the chest thereby leading to a weak LES. To make things worse, overweight individuals tend to overeat especially at dinnertime. Overeating stretches and weakens the LES, further aggravating the reflux of acid. Delayed gastric emptying and a dilated gastric fundus (upper part of the stomach) promote the development of a permanent “acid bubble” in close proximity to the LES which in turn may contribute to the increased incidence of acid reflux in this patient population.
At Houston Weight Loss Surgery Center, we offer the sleeve gastrectomy for most patients with a body mass index (BMI) higher than 35 and suffering from heartburn. Sleeve surgery allows for long-term effective weight loss leading to alleviation of most acid reflux symptoms. Sleeve gastrectomy is currently the most commonly performed weight loss procedure around the world. During sleeve surgery 85% of the stomach is resected ending up with a banana shaped stomach. As you loose weight following sleeve surgery, heartburn tends to resolve. A recent study published in the Annals of Surgery by Dr. Morino showed that heartburn resolves after sleeve gastrectomy in the majority of patients who suffered from gastro-esophageal reflux disease (GERD) prior to surgery. The study also showed that new onset acid reflux after sleeve gastrectomy is rare. Interestingly, the study demonstrated that sleeve surgery increases the pressure of the lower esophageal sphincter, LES, hence strengthening the acid reflux barrier. This is an additional anti-reflux property for the sleeve that is independent of weight loss.
At Houston Weight Loss Surgery Center, the only contraindication for sleeve surgery in GERD (gastro-esophageal reflux disease) patients is the presence of Barrett’s esophagus. Barrett’s esophagus results from long standing severe acid reflux and possible bile reflux into the lower esophagus. In this case, gastric bypass surgery is a better option for weight loss. Gastric bypass diverts acid and bile from the lower esophagus therefore preventing and halting the progression of Barrett’s into cancer. Gastric bypass also preserves the rest of the stomach in case it is needed in the future for reconstructive surgery if esophageal surgery is ever needed.
If you have persistent heartburn and interested in weight loss, Dr. Darido offers state of the art effective solutions for both heartburn and excess weight. Please give us a call at 281.205.3205 for a free private consultation at Houston weight loss surgery center.
Gastric plication also known as greater curvature plication is a new procedure for weight loss that was introduced few years ago to the United States. The procedure involves reducing the gastric size by folding the stomach wall inside its lumen. Stitches are then placed to hold the folded stomach in place. The surgery mechanism of action for gastric plication is restriction, i.e. forcing the patient to eat less by reducing stomach size. This assumption has never led to any durable weight loss throughout the history of bariatric surgery.
Unlike sleeve gastrectomy or gastric bypass there is no stapling or cutting. The procedure was introduced to the public as safe, less invasive and as effective as a sleeve gastrectomy. Some surgeons went on to add an adjustable gastric band to gastric plication, assuming that the more restriction the better. Within 2 to 3 years, the initial enthusiasm about this novel procedure quickly faded. Weight loss, as expected, was not that great. Patients had excessive nausea and vomiting after surgery. The folded stomach herniated through the suture line causing leaks in certain cases. Hunger feeling was not controlled most likely because gastric plication did not decrease hunger hormones like Ghrelin. As a result weight loss was not sustainable and gastric plication failed to prove itself as a safe, durable and effective weight loss procedure.
Understanding weight loss surgery mechanism of action is crucial for the development of new effective weight loss procedures. Obesity is a complex multifactorial disease that results in functional deficiency of many neuro-hormonal signals that would normally arise after a meal. Restoring these signals, rather than restriction, should be the guiding principle for developing new weight loss procedures.