Laura from Houston Sent us this question:
“Hello. I have a BMI of 32.6 and high blood pressure, which has landed me in the ER twice this year. Additionally, I was diagnosed with Barrett’s esophagus over a decade ago and have been treated with PPIs and monitored regularly. Although I do not meet the criteria for weight loss surgery for insurance, I am interested in off label (self-pay) for the sake of my health. I have tried many times to lose weight without success. The gastric bypass has been recommended to me in lieu of the sleeve, but that seems quite extreme for my BMI. I am very interested in your thoughts on this, given your knowledge of reflux and bariatric surgery. Both of my grandmothers died of strokes early in life, and I am very concerned about my health as I near 50. I appreciate your thoughts and have greatly appreciated your blog and research as well. Thank you!”
I greatly enjoyed your question. Thank you for sharing with us your health concerns and a medical problem with no clear guidelines to address it. First, allow me to mention that BMI criteria for weight loss surgery are outdated. Our weight loss surgery complication rate is very low. For someone, with BMI between 30 and 35 and two comorbidities (uncontrolled hypertension and Barrett’s esophagus) who is struggling to lose weight and failing to achieve durable and significant weight loss, weight loss surgery is indicated.
Second, I agree with you that gastric bypass, while effective and safe, is slightly more aggressive than gastric bypass especially for someone with a lower BMI. Gastric sleeve surgery is an equally effective weight loss procedure but less invasive than gastric bypass. Gastric sleeve surgery is not associated with long-term complications like marginal ulceration and internal hernias.
A number of published studies have shown increased acid reflux after gastric sleeve surgery. A meta-analysis of 46 studies including 10718 sleeve gastrectomy patients was recently published in the Annals of Surgery journal. The study shows a 19% increase in post-sleeve gastrectomy GERD and 23% new onset acid reflux. Long-term prevalence of esophagitis was 28% and Barrett esophagus was 8%. 4% of all patients required conversion to gastric bypass for severe reflux.
At Houston Heartburn and Reflux Center, my sleeve gastrectomy outcomes have been different. I have found that a properly performed sleeve gastrectomy in conjunction with a properly performed hiatal hernia repair lead to acid reflux resolution. Gastric sleeve lumen must be uniform with no narrowing or twisting. Herniated stomach and distal esophagus must be reduced into the abdominal cavity and initial normal anatomy restored. Gastric antrum must be preserved to promote gastric emptying. All my sleeve gastrectomy patients, with proven acid reflux, have reported complete acid reflux symptom resolution immediately following sleeve gastrectomy and prior to any significant weight loss. Most published studies that shown increased acid reflux after sleeve gastrectomy do not comment on the presence or absence of hiatal hernia, gastric sleeve lumen narrowing… If we control for these variables will post-operative acid reflux symptoms and incidence decrease?
Furthermore, patients who underwent sleeve gastrectomy somewhere else and presented to Houston Heartburn and Reflux Center for evaluation of acid reflux have invariably been found to have hiatal hernias. Those patients with no narrowing of gastric sleeve lumen, underwent hiatal hernia repair resulting in complete acid reflux symptom resolution. Consequently, over the past 5 years, I have come to the conclusion that a properly performed sleeve gastrectomy/hiatal hernia repair is an effective anti-reflux procedure. Does the same apply to Barrett’s mucosa? Unfortunately, I don’t have any data or personal experience with patients with Barrett’s esophagus undergoing sleeve gastrectomy at Houston Heartburn and Reflux Center. One would assume that Barrett’s esophagus is likely to improve or stabilize after sleeve gastrectomy if acid reflux is cured, but studies are needed to confirm such an assumption. Furthermore, if Barrett esophagus progresses to cancer and resection is needed, the remaining stomach is used as a conduit to replace the resected esophagus. Sleeve gastrectomy eliminates this option should the patient need esophageal cancer resection. I should mention that we currently have effective noninvasive and endoscopic treatment options for Barrett’s esophagus that ablate Barrett’s mucosa before it progresses to cancer. Consequently, if you have Barrett’s esophagus, you are most likely to continue periodic surveillance. Your chances of progressing to esophageal cancer are low.
Recently, a group of surgeons from France developed a procedure called the N-sleeve. The procedure is a hybrid of Nissen fundoplication and sleeve gastrectomy. A Nissen fundoplication is first constructed then a sleeve gastrectomy is added below the wrap. The published study shows good early weight loss results and excellent acid reflux control. Additional studies are needed to corroborate these findings.
Back to your question, what is the best weight loss procedure in your case? Would I offer sleeve gastrectomy to a patient with Barrett’s esophagus? I don’t think there is a clear answer or guideline. The general consensus is to offer gastric bypass for patients with Barrett’s esophagus. I don’t agree with the general consensus and I think Barrett’s esophagus is likely to improve and/or not progress to cancer following sleeve gastrectomy. This is my personal opinion. Should acid reflux worsen after sleeve gastrectomy (I have not yet seen this with my own patients), gastric sleeve to bypass conversion can be easily performed.