It has become a routine to publish at least one article on the effect of sleeve gastrectomy on GERD in the monthly SOARD publication of the American Society of Bariatric and Metabolic Surgery, ASMBS. Acid reflux is threatening to undermine the very low long-term complication rate of gastric sleeve surgery. “Gastroesophageal reflux disease and Barrett’s esophagus after laparoscopic sleeve gastrectomy: a possible, underestimated long-term complication” is a new study by Nicola Basso el al from Rome, Italy. The authors show a significant increase in esophagitis, Barrett’s esophagus and upward migration of the Z line in 110 patients following sleeve gastrectomy performed between 2007 and 2010. Interestingly, they have noticed that most reflux is bilious in nature and describe it in their article as “biliary-like reflux”. The authors report that 14% of the patients underwent a concomitant hiatal hernia repair. They performed what they describe as a “radical fundectomy”. Gastric sleeve resection started at 6 cm from the pylorus and was performed over a 48 F bougie. The staple line was reinforced with a running suture. The gastric remnant measured 60-80 ml, however, the authors do not mention how they measured the gastric sleeve volume.

The most striking finding in this study is the very high incidence of post sleeve gastrectomy GERD related symptoms. All sleeve patients had esophagitis on repeat post-operative EGD and 75% developed Z line migration which in certain cases may represent de-novo hiatal hernia formation. These are the highest reported numbers in the literature and by far, they do not reflect my experience with gastric sleeve surgery. Indeed, when properly performed sleeve gastrectomy resolves pre-existing acid reflux and it prevents the development of de-novo GERD. Hence, is Nicola Basso and colleagues doing something wrong?
The most common cause of post-sleeve gastrectomy GERD is functional narrowing of the incisura angularis. Is it possible that the authors have inadvertently narrowed the incisura angularis? Over sewing the staple line can cause a functional stricture especially when the staple line is too close to the bougie. Adding a “radical fundectomy” and resecting most of the antrum results in a narrow rigid tube that is a recipe for acid and bile reflux. Indeed, when the stomach is mutilated in this a fashion to achieve a “60 to 80 ml” pouch, the tube-like sleeve and the esophagus becomes one continuous cavity that is subject to the negative intra-thoracic pressure. With every breath, the negative intrathoracic pressure is directly transmitted to the sleeve lumen promoting bile reflux into the gastric lumen. Bile and acid accumulate in the proximal stomach above the narrowed incisura. Bile and acid then reflux into the esophagus resulting in severe esophagitis and favoring the development of Barrett’s esophagus. With time, the Z line migrates into the chest favoring the development of a hiatal hernia and the migration of the sleeve into the chest leading to worsening GERD.

When gastric sleeve surgery mutilates the stomach, GERD is an inevitable consequence. I have advocated for a long time, antrum preservation, and a wide incisura angularis (at least 2.5 cm or 75 F). Unfortunately, most bariatric surgeons across the world are driven by the concept of mechanical restriction. Mechanical restriction by itself does not result in durable weight loss. Excessive restriction in the case of sleeve gastrectomy results in GERD. By the same token, inadequate gastric sleeve resection that leaves too much gastric tissue results in poor weight loss. Sleeve resection must be tailored to the stomach shape and must follow basic principles to achieve the most optimal result. Gastric sleeve surgery like any other surgery remains an art with a scientific basis. Mastering the art of sleeve gastrectomy while understanding basic physiology and anatomy can save many patients from unwanted complications.