Gastric Emptying after Sleeve Gastrectomy

I read with great interest the new study: “Mechanisms of esophageal and gastric transit following sleeve gastrectomy” by Burton et al that was recently published in the journal of Obesity Surgery. 26 patients underwent gastric nuclear scintigraphy, high resolution manometry and barium contrast studies following sleeve gastrectomy. Sleeve gastrectomy was performed over a 36 French bougie starting 4 cm from the pylorus. The staple line was then imbricated with a running suture. There is no mention of hiatal hernia repair. Selected patients did not have significant reflux symptoms. “Significant” was not defined by the authors.

Nuclear scintigraphy showed increased incidence of triggered deglutitive reflux from distal to proximal esophagus in post sleeve gastrectomy patients in comparison to obese controls. This pattern is commonly seen in esophageal outflow obstruction. Rapid gastric emptying from sleeve into small bowel was noted as expected. More interestingly, the authors found a co-dependent emptying pattern between esophagus and stomach. in other words, esophageal emptying and motility contributed to gastric emptying. Typically, esophageal and gastric emptying are two separate processes.

Stress barium studies showed rapid flow of thin barium within a narrow gastric tube into duodenum as expected. The authors describe a cyclical filling and emptying pattern of gastric sleeve vertical and horizontal components. They report filling of vertical component, distention and then emptying into the horizontal component through incisura angularis opening. The horizontal component or what is left of the antrum, contracts as a reflex due to distention then rapidly delivers content into duodenum. Multiple reflux events were noted from sleeve into esophagus during this emptying cycle.

Esophageal manometry showed evidence of sliding hiatal hernia in 50% of the patients. Increased proximal intragastric pressure was noted following a swallow with concomitant prolongation of lower esophageal sphincter contraction. During this phase, contrast moves across incisura into antrum. This is followed by lower esophageal sphincter relaxation and reflux into proximal esophagus. Subsequently, an esophageal contractile wave is generated flushing refluxate back into stomach. This esophageal contractile wave contributes to increased proximal gastric pressure and subsequent gastric emptying across incisura angularis and then across pylorus into duodenum.

There is no doubt that gastric sleeve surgery disrupts esophago-gastric motility and food transit. This disruption is the basis for altered neuro-hormonal signaling leading to weight loss. By the same token, this disruption may lead to worsening or de-novo acid reflux disease with aggressive gastric sleeve resection and restriction. The art of gastric sleeve surgery is to optimize gastric sleeve resection in order to maximize weight loss and minimize acid reflux. Unfortunately, the guiding principle of maximal mechanical restriction has led to stomach mutilation and loss of function. For instance, starting gastric sleeve resection at appoint 4 cm from pylorus destroys the antrum. The antrum is the gastric pump and antral function is crucial to gastric emptying. Eliminating the gastric antrum reduces the stomach to a rigid immotile tube. Furthermore, using a small caliber bougie narrows the incisura angularis and results in functional obstruction to flow between the horizontal and vertical components of stomach. Functional obstruction results in acid reflux, proximal stomach pressurization and the cycling pattern of emptying as it was eloquently described in this paper.

I have always advocated a non-mutilating resection of stomach to achieve the perfect gastric sleeve. Such an approach preserves the antrum, maintains a widely open incisura angularis and eliminates most of the gastric fundus and gastric body without narrowing gastric sleeve lumen. The purpose of gastric sleeve surgery is to favor gastric emptying along the Magenstrasse pathway rather than destroy stomach function and anatomy. If the authors repeat their study on my gastric sleeve surgery patients, I would expect different outcomes and motility patterns. I don’t see de-Novo or worsening acid reflux following sleeve gastrectomy at Houston Weight Loss Surgery Center. On the contrary, acid reflux resolved after sleeve gastrectomy in my practice. The motility patterns the authors are describing are highly suggestive of functional narrowing of incisura angularis. Their surgery technique involves a small caliber bougie and aggressive rection of gastric antrum. To make things worse, the staple line is oversewn further narrowing gastric lumen. This excessive restriction is unnecessary. It transforms the stomach into a rigid tube and a barrier against esophageal emptying: a recipe for acid reflex. Over time, chronic pressurization of proximal stomach and constant reflux results in a weaker lower esophageal sphincter, decreased peristaltic wave pressure, and hiatal hernia development. The result is worsening acid reflux and progressive dilation of gastric sleeve lumen. Dilation of gastric sleeve lumen helps alleviates functional obstruction at the incisura angularis. However, acid reflux persists because of hiatal hernia development and esophageal dysmotility. Repairing the hiatal hernia at this stage has resulted in acid reflux resolution in more than 90% of patients presenting to Houston Weight Loss Surgery Center.

Heartburn after Gastric Sleeve Surgery in Dallas

James sent us this question: “Hi!  I live in Dallas and had a gastric sleeve 3 years ago.  I have severe reflux and had a scope done last week showing an esophageal ulcer and recurrent hiatal hernia.  My biopsies are pending.  I had a preop scope showing a hiatal hernia which was fixed during my sleeve.  How can I know if the incisura angularis was narrowed during my surgery? Is this something that can be seen during my scope?  I really do not want to have another surgery, but I don’t want to get esophageal cancer.”

Dear James,

The three components of successful sleeve gastrectomy include:

  1. Proper hiatal hernia repair
  2. Complete gastric fundus mobilization and resection
  3. Wide incisura angularis and preserved gastric antrum

Proper hiatal hernia repair requires distal esophageal mobilization. Most bariatric surgeons are not trained to repair properly repair hiatal hernias. The result of poorly repaired hiatal hernia is early recurrence. Recurrent hiatal hernia in the setting of sleeve gastrectomy results in severe acid reflux independent of a narrowed incisura angularis.

A narrowed incisura angularis is best diagnosed by an expert bariatric surgeon using both upper endoscopy and UGI contrast study. A gastroenterologist performing endoscopy after sleeve gastrectomy is not likely to appreciate narrowing of incisura angularis. Indeed, incisura angularis narrowing is functional rather than mechanical. It is suspected when the angle between the horizontal and vertical part of the stomach is quite sharp and requires some maneuvering to navigate during endoscopy.

We have noticed that over time, the incisura angularis dilates and repair of hiatal hernia is enough to control acid reflux in the setting of sleeve gastrectomy. Of course, severe narrowing requires sleeve to bypass conversion to remedy the acid reflux problem.