Lakisha from Houston sent this question: “I had gastric sleeve surgery 3 years ago and since then, my GERD has worsened. I am now taking a medication that my insurance is fighting me about paying for but I’ve tried everything else and this is the only med that works. I have also read extensively about this medication and the long-term effects of it. I truly would love another option rather than a medication with so many life-threatening side effects. Thank you.”

Dear Lakisha,

A properly performed sleeve gastrectomy does not only prevent acid reflux from developing but it also cures existing acid reflux. Here are the surgical steps for the perfect sleeve gastrectomy.

1. Repair any size hiatal hernia. There is a strong association between obesity and hiatal hernia. A hiatal hernia is more likely to develop with increased abdominal girth possibly due to increased intra-abdominal pressure forcing the stomach and to move upward into the chest area. More than 90% of Houston Weight Loss Surgery Center patients are found to have hiatal hernia on upper endoscopy prior to surgery. the purpose of hiatal hernia repair is to:

• Bring the stomach and intra-abdominal esophagus back into the abdomen. This moves the gastro-esophageal junction or the reflux valve away from negative chest pressure to positive intra-abdominal pressure.
• Mobilize and reduce herniated upper stomach from chest into abdomen to allow proper gastric sleeve resection.

2. Preserve the antrum which is the lower one third of the stomach. The antrum is the pump that contributes to food breakdown and emptying into intestine. Preserving the antrum accelerates gastric emptying and prevents food and acid stasis in sleeve lumen.
3. Avoid narrowing the incisura angularis, stomach angulation, at the junction of the upper two thirds and the lower one third of the stomach. Narrowing this part of the stomach is a recipe for acid reflux. For this purpose, stomach resection starts around 6 cm from the pylorus without a bougie in place. Only after navigating the incisura angularis, a bougie is placed along the lesser curvature and gastric sleeve resection is completed. Avoiding a functional obstruction at the level of the incisura angularis, is the most important step in gastric sleeve surgery.
4. Completely resect gastric fundus to avoid an acid pocket forming below the lower esophageal sphincter leading to acid reflux. The gastric fundus must be properly mobilized during surgery to allow for complete resection. Following complete mobilization, the gastric fundus is retracted laterally towards the spleen and then resected.

In your case Lakisha, I suspect the incisura angularis was narrowed during initial surgery. Consequently, acid reflux develops. Severe acid reflux causes a hiatal hernia to develop. This in turn further weakens the anti-reflux barrier leading to worsening acid reflux. Luckily the incisura angularis dilates over time and the functional obstruction resolves. Acid reflux, however, continues because a hiatal hernia has already developed. Medical treatment for GERD relies on proton pump inhibitors, (PPIs), like Dexilant, Nexium and Omeprazole. These medications are associated with long-term side effects. Furthermore, in the setting of sleeve gastrectomy, PPIs are not enough to control GERD related symptoms. At Houston Weight Loss Surgery Center, we offer hiatal hernia repair to restore the anti-reflux barrier. This approach is effective in controlling acid reflux in more than 95% of cases. If, however, the incisura angularis is still narrowed then the only solution to stop acid reflux is to convert your gastric sleeve to gastric bypass.