Houston Weight Loss Surgeon - Obesity Trumps Underweight for first time

Post-Sleeve GERD As A Weight Loss Predictor

I read with great interest a new study by Luigi Angrisani, M.D. et al that was recently published in SOARD, Surgery For Obesity And Related Diseases. It is a small size retrospective study with a 5-year follow-up period. 105 obese patients underwent gastric sleeve surgery with excellent weight loss outcomes at 5 years and significant improvement in multiple obesity associated co-morbidities.

The authors showed that weight loss was lower in patients with postoperative GERD. They also found that concomitant hiatal hernia repair with sleeve gastrectomy did not increase postoperative GERD remission. Two patients underwent revisional surgery for severe postoperative GERD. Both patients had already received concomitant sleeve and hiatal hernia surgery. One of those two patients showed hiatal hernia recurrence on double contrast barium swallow prior to surgery while the other showed signs of reflux.

The strength of evidence in supporting lack of benefit of concomitant hiatal hernia repair and sleeve gastrectomy is weak in this study due to small sample size. However, the finding of post-operative GERD as a predictor of weight loss following gastric sleeve surgery is quite interesting. The authors attributes this finding to insufficient postoperative weight loss leading to acid reflux. However, the underlying pathophysiology of GERD and its relationship to obesity is much more complex. In my opinion, post-operative GERD is secondary to a poorly performed gastric sleeve. A retained gastric fundus will lead to both poor weight loss and acid reflux. A recent study has shown that a gastric sleeve that is too narrow is associated with increased incidence of GERD and poor weight loss. In other words, GERD and poor weight loss go in hand in hand following a poorly constructed sleeve. This finding is independent of whether a hiatal hernia is present or not. Finally, I think that a large hiatal hernia must be properly repaired in order to prevent post-sleeve GERD. Hiatal hernia repair is quite challenging in the obese patient especially in those patient with a BMI higher than 50. Extensive distal esophageal dissection and mobilization is required to properly fix a hiatal hernia. There is great variability in technique and approach to hiatal hernia repair among surgeons resulting in controversial conclusions in most studies addressing concomitant hiatal hernia repair and sleeve gastrectomy. At Houston Weight Loss Surgery Center, we advocate the proper repair of a hiatal hernia in gastric sleeve cases. For super morbidly obese patients, BMI more than 50, staging the procedure is beneficial. We perform a gastric sleeve first and after 6 months to one year we repair the hiatal hernia.