Yolanda from Houston sent us this question:

“Hello, in June 2014 I had VSG surgery and hiatal hernia repair. I lost 135 pounds, and my acid reflux was better for a while but slowly came back over the years. I regained all the weight and became sick with acid reflux. In June of this year, I had gastric bypass and hiatal hernia repair to fix the reflux. My Demeester score before surgery was around 35. Since surgery in June, I have lost 80 pounds, but my reflux has become so much worse. I can’t sleep because my stomach and esophagus stay on fire. It doesn’t matter if I eat or don’t eat, it’s the same. I had an endoscopy in August where my surgeon just wrote he believes I am sabotaging myself with food and doesn’t see anything on the endoscopy which is totally untrue. It’s 6am and I haven’t had food since yesterday evening (a protein bar) and I am on fire. I then had a barium swallow which showed a small hiatal hernia which was supposed to have been repaired. The barium swallow showed mild reflux, but the radiologist only had me drink a very small portion since I’d had bypass. Most recently I had manometry with pH impedance which came back with a Demeester score of 56, mostly non-acidic contents. My surgeon still dismisses me. He sent me home with baclofen and told me to come back in a month. It seems to help some, but it makes me sleep all day which is impossible for me to function like that. I’m also on 40mg omeprazole which does nothing and Carafate 4 times a day which helps some but not much. I am refluxing into my throat during the night which is very scary. I really need help because I don’t know where to go from here and I am miserable. Thanks”.

Dear Yolanda,

The most common cause for acid reflux after VSG is narrowing of incisura angularis during stomach resection. The incisura angularis in the junction of the vertical and horizontal parts of the stomach. It can be easily narrowed especially if the bariatric surgeon is using a small size calibration tube. Conversion of VSG to gastric bypass is usually a good solution to bypass the functional obstruction and aloe free flow of gastric content away from esophagus into intestines. If the hiatal hernia is not properly repaired during this procedure and the gastric pouch is left too long/large, reflux may persist. In addition, if the alimentary limb of the gastric bypass is too short, bile reflux may also occur. This condition is less likely, however, to occur as most bariatric surgeon choose a 70 to 100 cm alimentary limb length. You mention you had esophageal manometry. I am interested in knowing the lower esophagus sphincter, LES, pressure. If LES pressure is low, reflux is more likely to occur. You also have a very high Demeester score after gastric bypass. The Demeester score reflects how acidic the esophagus is. Typically, with gastric bypass there is decreased stomach acid content because most of the stomach is bypassed. Non-acidic reflux is more likely to be present as you have mentioned. In this case, I am suspecting food stasis in the gastric pouch or esophagus. Food stasis is associated with food fermentation which decreases pH values and lead to falsely elevated Demeester score. Food stasis occurs in cases of ineffective esophageal motility or narrowing of gastric pouch outlet.

Baclofen, a GABA receptor agonist, reduces transient lower esophagus sphincter relaxation and increase LES basal pressure but is associated with drowsiness and dizziness, thus limiting its efficacy. Omeprazole helps reduce stomach acid secretion, but it has no effect on non-acid reflux. Carafate covers the esophagus lining and helps alleviates heartburn, but it does not stop reflux.

Hiatal hernia repair to move the gastric pouch and LES from the negative pressure of the chest is indicated in your case. If the gastric pouch is large, size reduction is needed to reduce acid secretion. Additional procedures may be needed depending on your workup findings.

Please refer to our previous blog on the same subject: https://houstonsleevesurgeon.com/persistent-heartburn-following-sleeve-to-bypass-conversion.

Key Points

• Acid reflux after VSG is mostly caused by narrowing at the incisura angularis.
• Conversion from VSG to gastric bypass usually improves reflux by relieving functional obstruction.
• Persistent reflux after conversion may be due to an unrepaired hiatal hernia, an oversized gastric pouch, or a short alimentary limb.
• Low LES pressure, ineffective esophageal motility, or a narrowed pouch outlet can contribute to acid reflux.
• Medications such as baclofen, omeprazole, and Carafate may relieve symptoms but do not correct mechanical causes of reflux.
• Hiatal hernia repair and, if needed, pouch size reduction are key steps in treating persistent reflux after conversion.
• Additional interventions may be required depending on diagnostic findings.