Duodeno-gastric Bile Reflux after Sleeve Gastrectomy

We have previously discussed the pathophysiology associated with bile reflux from duodenum into gastric sleeve lumen ending into distal esophagus in the setting of hiatal hernia. At Houston Weight loss Surgery Center, we have made the observation of increased incidence of bile gastritis in gastric sleeve patients with hiatal hernia and distal esophagitis. We were hoping for large scale studies to be published in the literature to confirm our observations. Unfortunately, we haven’t seen such studies published yet. The recent article in Surgery for Obesity and Related Diseases journal titled “Duodenogastric biliary reflux assessed by scintigraphic scan in patients with reflux symptoms after sleeve gastrectomy: preliminary results” add very little to our observations.

The authors prospectively evaluate 22 gastric sleeve patients with reflux symptoms using scintigraphy and upper endoscopy. From 2014 till 2016, 47 out of 167 sleeve gastrectomy patients developed de novo acid reflux symptoms. Of the 47 gastric sleeve patients with reflux, 36 had esophagitis on EGD and two had Barrett’s esophagus. 22 gastric sleeve patients with reflux symptoms (9 of 22 had no esophagitis on EGD) underwent duodeno-gastric reflux scintigraphy evaluation to check for bile reflux from duodenum into stomach. Only 7 had a positive test (4 out of 7 had no esophagitis). Patients with pre-operative hiatal hernia or acid reflux were not included in this sample. However, there is no mention of hiatal hernia evaluation after gastric sleeve surgery. We know that gastric sleeve patients with acid reflux tend to develop hiatal hernia, also described as sleeve migration into the chest. Authors used a 34 French bougie size during gastric sleeve surgery. Gastric sleeve resection starts 2 to 3 cm close to the pylorus and staple line is reinforced with absorbable sutures.

Study design and small patient size are major flaws in this article that prevent us from drawing any meaningful conclusion. Furthermore, the authors fail to discuss the impact of two important factors, hiatal hernia and narrowing of incisura angularis, on acid and bile reflux development in their patients. They have adopted an aggressive sleeve gastrectomy technique that resect most of the gastric antrum, and narrow the incisura (34 French bougie, and staple line reinforcement). No wonder 30% of their gastric sleeve patients developed de novo acid reflux symptoms. Patients with pre-operative GERD were excluded from this study but I suspect most of these patients continued to have acid reflux symptoms after sleeve gastrectomy. At Houston Weight Loss Surgery Center, we strongly believe that a properly performed sleeve gastrectomy and hiatal hernia repair, cure acid reflux in the majority of bariatric patients. Unfortunately, poor sleeve gastrectomy surgical technique led by the wrong assumption of aggressive resection and maximal mechanical restriction of gastric lumen, invariably results in severe postoperative acid and bile reflux.

Last but not least, bile reflux is more commonly seen in gastric sleeve patients with an unrepaired concomitant hiatal hernia. A narrowed incisura angularis in the absence of hiatal hernia leads to acid reflux in the early post-operative period. Persistent acid reflux results in hiatal hernia formation also known as sleeve migration into the chest. At this stage, the negative intra-thoracic pressure is transmitted though the herniated gastric sleeve lumen into duodenum leading to bile reflux. This observation may explain the negative scintigraphy scan in gastric sleeve patients with de novo reflux symptoms. Unfortunately, the authors did not elaborate on the presence or absence of hiatal hernia on upper endoscopy in this study.