Question about Nissen Fundoplication

An Interesting and important Question from Julie. She writes:

Hello and thank you for this article.

I am currently scheduled to have the Nissen fundoplication w/ hiatal hernia repair after being sleeved last Nov 11/13/15. I never had heartburn of any kind before the sleeve. About 2 months after my surgery I started experiencing severe GERD w/ regurgitation. We tried Carafate, Reglan and PPI’s. I improved w/ medicine until late Oct and after adding OTC meds & other antacids along w/ the twice a day max dose of PPI’s I am now having chest pain, a lump in my throat and regurgitate at least once a day sometimes more than once.

I had another upper GI a few weeks ago and regurgitated twice when they laid me down after just drinking the thin barium. We could not even proceed w/ the other barium.

The report stated my GERD was Severe multiple times, they actually said it was “Profound.” I have read a lot about this surgery in patients who have not had gastric surgery and many gastric patients that had a hiatal hernia repairs when the sleeve was performed but your article is the closest I can find with all three.

I am very nervous for a few reasons. There is only so much stomach my surgeon has to work with so it seems like it will not be the typical Nissen Fundoplication w/ hernia repair. I am scared that I will have trouble swallowing, that the surgery will be difficult, I am scared of having to convert to open, I am scared of getting sick from the anesthesia and it affected the surgery, I am scared of not being able to eat much and losing more weight. I am comfortable at 140 now.

Anyways, are you able to share any additional experience with a one year post op sleeve patient that will be undergoing this surgery? My surgery was done in the States by the way.

My surgeon blocked off 3.5 hours OR time and it sounds like recovery will be about 2 weeks before I can return to work if done laparoscopic. Does that sound right?  I am trusting that the benefits will outweigh the risks and down time b/c at this rate I will get barretts and possibly esoph. cancer. 

Thank you for your time!

Dear Julie,

Your question and concerns are quite relevant. New onset acid reflux or GERD following gastric sleeve surgery is an important issue that is subject to lot of debate among bariatric surgeons. I happen to specialize in both acid reflux and weight loss surgery. I am very interested in this issue. At Houston Weight Loss Surgery Center, I treat acid reflux disease in overweight individuals by performing a hiatal hernia repair with gastric sleeve surgery. I have had great results and I believe that a properly performed sleeve and hiatal hernia should not lead to increased or new onset acid reflux disease.

Patients who present to my office with post gastric sleeve acid reflux undergo extensive workup including upper endoscopy, pH impedance, esophageal manometry and upper GI contrast study. We try to delineate the cause of acid reflux before embarking on any type of revision surgery.

There are several causes for acid reflux after sleeve surgery:

1. Unrepaired hiatal hernia
2. Poorly repaired hiatal hernia during gastric sleeve surgery
3. Retained gastric fundus
4. Narrowed gastric sleeve lumen especially at the incisura angularis (where the stomach naturally bends)
5. Twisted gastric lumen

There are many options to correct the problem depending on the underlying cause. In cases where there is gastric sleeve narrowing, a gastric bypass is the only solution.

Nissen fundoplication or 360-degree wrap is, theoretically, not feasible after gastric sleeve surgery. There is not enough gastric fundus to wrap around the entire esophagus. Your surgeon may be offering you a partial anterior or posterior fundoplication. There are few reports in the literature about the efficacy of such an approach in controlling reflux in the setting of gastric sleeve surgery. I have personally not tried this approach.

I hope these general guidelines are of help to you. Should you have any additional questions or concerns please do not hesitate to discuss with your bariatric surgeon prior to surgery.

Warm Regards,

Dr. Darido