Lakisha, a patient from Houston, recently sent me a message that I hear in some form almost every week: she had a gastric sleeve three years ago, and her acid reflux has gotten progressively worse since. She’s now on a medication her insurance won’t cover, she’s read about the long-term risks of staying on it, and she’s asking if there’s another way.

There is. But to explain it, I need to walk through what actually causes GERD to worsen after sleeve gastrectomy and what the surgical steps are to prevent it from happening in the first place.

The Problem Isn’t the Sleeve Itself, It’s How It Was Done

A properly performed sleeve gastrectomy does not cause acid reflux. Done correctly, it can resolve existing reflux. When GERD worsens after sleeve surgery, it almost always comes down to one or more technical errors made during the original procedure. Understanding those errors is the first step toward finding the right fix.

The Four Steps of a Sleeve Gastrectomy That Prevent GERD

Step 1: Repair Any Hiatal Hernia Before Resecting the Stomach

Obesity and hiatal hernia are closely linked. Increased abdominal pressure from excess weight pushes the stomach upward into the chest cavity, displacing the gastroesophageal junction, the valve that prevents acid from refluxing. At Houston Weight Loss Surgery Center, more than 90% of our patients are found to have a hiatal hernia on upper endoscopy before surgery.

Repairing the hiatal hernia before proceeding with the sleeve accomplishes two things: it moves the reflux valve back into the abdomen where positive pressure supports it, and it fully reduces the herniated portion of the stomach so that the sleeve can be properly formed.

Skipping this step – or missing a hernia that wasn’t diagnosed preoperatively – is one of the most common reasons patients develop or worsen GERD after surgery.

Step 2: Preserve the Antrum

The antrum is the lower third of the stomach. It acts as the pump that breaks down food and moves it into the small intestine. When the antrum is preserved during sleeve construction, gastric emptying is faster and more efficient. When it’s removed or compromised, food and acid sit in the sleeve longer, and that stasis drives reflux.

Step 3: Avoid Narrowing the Incisura Angularis

This is the most critical step in preventing post-sleeve GERD, and the most overlooked.

The incisura angularis is the natural curve at the junction of the upper two-thirds and lower third of the stomach. If the sleeve is created too tightly at this curve, a functional obstruction forms. Food backs up, pressure rises, and acid refluxes upward. This is the step I suspect caused the problem for Lakisha and many patients like her.

To avoid this, I start the resection approximately 6 cm from the pylorus without a calibration tube in place. Only after safely navigating through the incisura angularis do I place the calibration tube along the lesser curvature to complete the sleeve. That sequence, calibration tube out first at the angularis, then in, is the difference between a reflux-preventing sleeve and a reflux-causing one.

Step 4: Fully Resect the Gastric Fundus

The fundus is the uppermost portion of the stomach, located just beneath the lower esophageal sphincter. If it is not completely removed, a pocket forms where acid collects below the sphincter and then refluxes upward. Proper mobilization of the fundus (retracting it laterally toward the spleen before resection) ensures complete removal and eliminates this acid reservoir.

What’s Likely Happening in Lakisha’s Case

When I read her message, the clinical picture is clear. In most patients who develop worsening GERD in the years following sleeve surgery, the sequence goes like this: the incisura angularis was narrowed at surgery, creating a partial obstruction. That obstruction drives acid reflux. Chronic acid reflux puts upward pressure on the esophagus and, over time, causes or worsens a hiatal hernia. The hiatal hernia then further weakens the anti-reflux barrier – and now you have two problems compounding each other.

There is some natural recovery. The incisura angularis typically dilates over time as the restriction softens, which relieves the functional obstruction. But by then, a hiatal hernia has already developed and a hiatal hernia does not resolve on its own.

Why PPIs Alone Aren’t Enough

Medical management for GERD centers on proton pump inhibitors like omeprazole, Nexium, and Dexilant. These medications reduce acid production and can manage symptoms in many patients. But in the setting of a sleeve gastrectomy, they treat the symptom while leaving the structural problem untouched. For patients like Lakisha, who has already tried multiple medications, surgical correction of the underlying anatomy is the more durable path forward.

What We Can Do Surgically

At Houston Weight Loss Surgery Center, we offer two surgical options for post-sleeve GERD.

For patients whose gastric lumen at the incisura angularis has stretched over time, an isolated hiatal hernia repair is often sufficient. This restores the anti-reflux barrier at the gastroesophageal junction and, in our experience, controls acid reflux in more than 95% of appropriately selected cases.

For patients where the gastric sleeve lumen at the incisura angularis is still narrowed, meaning the functional obstruction is still present, the most effective solution is conversion from gastric sleeve to gastric bypass. This eliminates the structural bottleneck entirely while also rerouting acid away from the esophagus.

Key Clinical Points

• Worsening GERD after sleeve gastrectomy is almost always caused by one or more correctable surgical factors, not an inevitable consequence of the procedure itself.
• More than 90% of bariatric surgery candidates at Houston Weight Loss Surgery Center are found to have a hiatal hernia before surgery; repairing it at the time of sleeve is essential.
• Narrowing of the incisura angularis during sleeve construction is the most common structural cause of post-operative acid reflux.
• Proton pump inhibitors do not address the underlying anatomical cause of GERD in sleeve patients and are often insufficient for long-term control.
• Surgical options – hiatal hernia repair or conversion to gastric bypass – resolve reflux in the large majority of post-sleeve patients when the correct procedure is selected.

If You’re Dealing With This, Don’t Wait

If you’ve had a gastric sleeve and your acid reflux has worsened since surgery, or if you’re managing symptoms with medication that isn’t working well enough, I’d encourage you to seek an evaluation from a bariatric surgeon who specializes in revision surgery and reflux. The right workup will identify exactly what’s driving your symptoms, and there are effective surgical solutions available.

To schedule a consultation at Houston Weight Loss Surgery Center, contact us today.

Written by Elias Darido, MD, FACS
Acid Reflux & GERD Specialist | Founder of Houston Weight Loss Surgery Center

References:

Does Sleeve Gastrectomy Expose the Distal Esophagus to Severe Reflux?: A Systematic Review and Meta-Analysis. Annals of Surgery. 2020. Yeung KTD, Penney N, Ashrafian L, Darzi A, Ashrafian H.

Incidence of Post-Operative Gastro-Esophageal Reflux Disorder in Patients Undergoing Laparoscopic Sleeve Gastrectomy: A Systematic Review and Meta-Analysis. Obesity Surgery. 2024. Trujillo AB, Sagar D, Amaravadhi AR, et al.

Do We Understand the Pathophysiology of GERD After Sleeve Gastrectomy?.

Annals of the New York Academy of Sciences. 2020. Felinska E, Billeter A, Nickel F, et al.

Pathophysiological Mechanisms of Gastro-Esophageal Reflux After Sleeve Gastrectomy.

Annals of Surgery. 2022. Johari Y, Lim G, Wickremasinghe A, et al.

Impact of Laparoscopic Vertical Sleeve Gastrectomy (LVSG) on Lower Esophageal Sphincter Pressure (LESP), Lower Esophageal Sphincter Length (LESL) and Gastroesophageal Reflux Disease (GERD) Using Esophageal Function Tests (EFTs): A Systematic Review and Meta-Analysis. International Journal of Obesity. 2025. Memon MA, Yunus RM, Alam K, Hoque Z, Khan S.