Late Onset GERD after Sleeve Gastrectomy

Rhonda from Pasadena sent us this question: “I had the gastric sleeve in Tijuana Mexico Feb 2015.  All was good the first couple years.  Since then I have had heartburn that is getting progressively worse.  I have been prescribed 40MG Pantoprazole twice /day. My question: Is gastric bypass the only solution for curing this acid reflux?”

Dear Rhonda,

Late onset acid reflux, many years after sleeve gastrectomy, is indicative of either recurrent hiatal hernia or new hiatal hernia formation. Recurrent hiatal hernia may develop secondary to weight regain or incomplete esophageal mobilization during initial repair. De novo hiatal hernia following sleeve gastrectomy may result from functional narrowing of gastric sleeve lumen. Functional narrowing occurs when the incisura angularis, the junction between lower one third and upper two thirds of the stomach is narrowed during gastric sleeve surgery. It is a fairly common mistake when bariatric surgeons use a very small size bougie during sleeve gastrectomy.

Functional narrowing of incisura angularis alters gastric emptying pattern and promotes backflow of gastric content towards the esophagus. Initially, in the setting of a competent acid reflux barrier, you will not have acid reflux. With time, the anti-reflux barrier fails, and acid reflux develops. This result in several acid reflux related symptoms like heartburn and food regurgitation. Acid reflux is a major cause of hiatal hernia development. Consequently, a hiatal hernia slowly develops leading to gradual gastric sleeve migration into the chest. When part of the gastric sleeve lumen is in the chest, bile reflux in addition to acid reflux develop and GERD symptoms worsen to the point that high dose PPIs no longer control symptoms.

The treatment for acid reflux after sleeve gastrectomy entails hiatal hernia repair with or without gastric bypass. In the absence of gastric sleeve narrowing, hiatal hernia repair is more than enough to restore the anti-reflux barrier and control acid reflux. If, however, the gastric sleeve is narrowed, conversion to gastric bypass is needed in addition to hiatal hernia repair.