Continuous belching following gastric sleeve surgery

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.