Persistent Heartburn Following Sleeve to Bypass Conversion

Sally from Katy, Houston, TX sent us this question: “I had gastric sleeve in 2016. Gallbladder removed 2017, and now a revision into a Gastric bypass in 2021. I’ve had corrosive esophagitis and GERD for who knows how long, but I was diagnosed last year. Even though they repaired my hiatal hernia in April along with the sleeve to bypass revision… why do I still have GERD? It doesn’t make sense. I was given Protonix after surgery which I had been taking since then (April) but I realized it has been causing me a very slow digestion to the point of not being able to eat. I stopped Protonix and found I can finally eat but now all of my GERD symptoms have come back. My Bariatric office had me contact my GI doctor. GI gave me Dexilant 30mg and we’ve got an Endoscopy scheduled for next month. I just want answers or a suggestion since I’m tired of being miserable”.

Dear Sally,

A poorly performed gastric sleeve surgery is a recipe for acid reflux development. Narrowing the area where the horizontal and vertical parts of the stomach meet, during gastric sleeve surgery, creates a functional obstruction. This results in backflow of acid and bile from gastric sleeve lumen into esophagus. Acid reflux gradually leads to hiatal hernia development or gastric sleeve migration into chest which in turn worsens acid and bile reflux. As a result, corrosive esophagitis develops as you have mentioned.

Luckily, the narrowed mid portion of the gastric sleeve dilates over time. Functional obstruction, the primary cause for acid reflux, resolves. However, a hiatal hernia has already developed, and it continues to be a major cause of bile and acid reflux. Consequently, our initial approach to managing acid reflux after poorly performed sleeve gastrectomy is hiatal hernia repair. The majority of patients respond with excellent GERD symptom control with no need to convert gastric sleeve to gastric bypass. Should hiatal hernia repair fail to stop acid reflux we then recommend sleeve to gastric bypass conversion.

Gastric bypass is an excellent anti-reflux procedure. However, in the setting of gastric sleeve to gastric bypass conversion care must be taken to avoid bypassing most of the stomach. Bypassing most of the sleeved stomach diverts the acid secreting gastric body from gastric antrum. An alkaline environment in gastric antrum leads to excessive gastrin hormone secretion. Increased amounts of gastrin stimulate excessive acid secretion in gastric pouch. Some of this acid escapes into the esophagus, and results in acid reflux related.

Work-up include blood gastrin level, upper endoscopy and ambulatory pH testing. Treatment requires gastric antrum resection to decrease gastrin levels and reduce acid secretion.