Is Barrett’s Esophagus a Contraindication for Sleeve Gastrectomy?

Is Barrett’s Esophagus a Contraindication for Sleeve Gastrectomy?

Laura from Houston Sent us this question:

“Hello. I have a BMI of 32.6 and high blood pressure, which has landed me in the ER twice this year. Additionally, I was diagnosed with Barrett’s esophagus over a decade ago and have been treated with PPIs and monitored regularly. Although I do not meet the criteria for weight loss surgery for insurance, I am interested in off label (self-pay) for the sake of my health. I have tried many times to lose weight without success. The gastric bypass has been recommended to me in lieu of the sleeve, but that seems quite extreme for my BMI. I am very interested in your thoughts on this, given your knowledge of reflux and bariatric surgery. Both of my grandmothers died of strokes early in life, and I am very concerned about my health as I near 50. I appreciate your thoughts and have greatly appreciated your blog and research as well. Thank you!”

Dear Laura,

I greatly enjoyed your question. Thank you for sharing with us your health concerns and a medical problem with no clear guidelines to address it. First, allow me to mention that BMI criteria for weight loss surgery are outdated. Our weight loss surgery complication rate is very low. For someone, with BMI between 30 and 35 and two comorbidities (uncontrolled hypertension and Barrett’s esophagus) who is struggling to lose weight and failing to achieve durable and significant weight loss, weight loss surgery is indicated.

Second, I agree with you that gastric bypass, while effective and safe, is slightly more aggressive than gastric bypass especially for someone with a lower BMI. Gastric sleeve surgery is an equally effective weight loss procedure but less invasive than gastric bypass. Gastric sleeve surgery is not associated with long-term complications like marginal ulceration and internal hernias.

A number of published studies have shown increased acid reflux after gastric sleeve surgery. A meta-analysis of 46 studies including 10718 sleeve gastrectomy patients was recently published in the Annals of Surgery journal. The study shows a 19% increase in post-sleeve gastrectomy GERD and 23% new onset acid reflux. Long-term prevalence of esophagitis was 28% and Barrett esophagus was 8%. 4% of all patients required conversion to gastric bypass for severe reflux.

At Houston Heartburn and Reflux Center, my sleeve gastrectomy outcomes have been different. I have found that a properly performed sleeve gastrectomy in conjunction with a properly performed hiatal hernia repair lead to acid reflux resolution. Gastric sleeve lumen must be uniform with no narrowing or twisting. Herniated stomach and distal esophagus must be reduced into the abdominal cavity and initial normal anatomy restored. Gastric antrum must be preserved to promote gastric emptying. All my sleeve gastrectomy patients, with proven acid reflux, have reported complete acid reflux symptom resolution immediately following sleeve gastrectomy and prior to any significant weight loss. Most published studies that shown increased acid reflux after sleeve gastrectomy do not comment on the presence or absence of hiatal hernia, gastric sleeve lumen narrowing… If we control for these variables will post-operative acid reflux symptoms and incidence decrease?

Furthermore, patients who underwent sleeve gastrectomy somewhere else and presented to Houston Heartburn and Reflux Center for evaluation of acid reflux have invariably been found to have hiatal hernias. Those patients with no narrowing of gastric sleeve lumen, underwent hiatal hernia repair resulting in complete acid reflux symptom resolution. Consequently, over the past 5 years, I have come to the conclusion that a properly performed sleeve gastrectomy/hiatal hernia repair is an effective anti-reflux procedure. Does the same apply to Barrett’s mucosa? Unfortunately, I don’t have any data or personal experience with patients with Barrett’s esophagus undergoing sleeve gastrectomy at Houston Heartburn and Reflux Center. One would assume that Barrett’s esophagus is likely to improve or stabilize after sleeve gastrectomy if acid reflux is cured, but studies are needed to confirm such an assumption. Furthermore, if Barrett esophagus progresses to cancer and resection is needed, the remaining stomach is used as a conduit to replace the resected esophagus. Sleeve gastrectomy eliminates this option should the patient need esophageal cancer resection. I should mention that we currently have effective noninvasive and endoscopic treatment options for Barrett’s esophagus that ablate Barrett’s mucosa before it progresses to cancer. Consequently, if you have Barrett’s esophagus, you are most likely to continue periodic surveillance. Your chances of progressing to esophageal cancer are low.

Recently, a group of surgeons from France developed a procedure called the N-sleeve. The procedure is a hybrid of Nissen fundoplication and sleeve gastrectomy. A Nissen fundoplication is first constructed then a sleeve gastrectomy is added below the wrap. The published study shows good early weight loss results and excellent acid reflux control. Additional studies are needed to corroborate these findings.

Back to your question, what is the best weight loss procedure in your case? Would I offer sleeve gastrectomy to a patient with Barrett’s esophagus? I don’t think there is a clear answer or guideline. The general consensus is to offer gastric bypass for patients with Barrett’s esophagus. I don’t agree with the general consensus and I think Barrett’s esophagus is likely to improve and/or not progress to cancer following sleeve gastrectomy. This is my personal opinion. Should acid reflux worsen after sleeve gastrectomy (I have not yet seen this with my own patients), gastric sleeve to bypass conversion can be easily performed.

Houston Bariatric Surgery

Houston Bariatric Surgery

Are you contemplating bariatric surgery for 2020? If you live in Houston and have been struggling with excess weight for a number of years, we may be able to help you. Houston weight loss surgery center offers one of the safest, and most effective weight loss solutions in the greater Houston area.

Gastric sleeve surgery remains our most commonly performed weight loss procedure. Combined with proper hiatal hernia repair, gastric sleeve surgery offers excellent weight loss results along with resolution of heartburn and acid reflux. Gastric sleeve surgery is an overnight minimally invasive procedure. Recovery is fast and complications rate is very low.

If you suffer from Diabetes, high blood pressure, sleep apnea, and fatty liver disease bariatric surgery may be your best treatment option. If weight loss is one of your 2020 new year resolutions give us a call at 281-205-3205.

Intermittent Fasting: Beyond Weight Loss

Intermittent Fasting: Beyond Weight Loss

I read with great interest the review article on intermittent fasting recently published in the New England Journal of Medicine. The authors start by showing that numerous studies in animals have shown increased lifespan with calorie restriction. Chronic disorders like obesity, diabetes, and cancer respond to intermittent fasting. The assumption was that calorie restriction reduces oxygen free radical production and consequently reduces cellular damage. Weight loss, however, and reduced free-radical production secondary to intermittent fasting on partly explains fasting numerous benefits. Intermittent fasting activates pathways that improves glucose regulation, increase stress resistance, and suppress inflammation. During fasting, triglycerides are converted to ketones bodies in the liver. Ketone bodies are used by organs as fuel. However, ketone bodies are not just fuel. They are signaling molecules with effect on major cellular pathways that influence health and aging. The exact mechanisms of intermittent fasting beneficial effect on our health are not fully understood. There is plenty of evidence, however, to recommend intermittent fasting for our bariatric and weight loss patients. There are a number of intermittent fasting protocols. I prefer and personally adopt daily time restricted feeding. I limit my food intake to 6 hours a day and fast for the remaining 18 hours. Others have found 5:2 intermittent fasting regimen more practical. In this regimen, calorie intake during 2 days of the week is restricted to 500 calories a day.

The authors conclude that combined with exercise, intermittent fasting results in many long-term adaptations that improve “mental and physical performance and increase disease resistance”.

The Dumbbell Gastric Sleeve: A Recipe for Heartburn

The Dumbbell Gastric Sleeve: A Recipe for Heartburn

A 45-year-old female patient presented herself to my weight loss surgery clinic with severe heartburn and food regurgitation of two-year duration. She underwent sleeve gastrectomy 7 years ago by a bariatric surgeon in Houston who is no longer in practice. Patient did well initially and lost around 100 pounds. However, over the past 4 years she started experiencing acid reflux symptoms. Her acid reflux was initially managed with medications and lifestyle changes. However, over the past two years GERD symptoms have gotten worse and difficult to control even with high dose proton pump inhibitors. Patient reports excellent restriction and good appetite control. She still maintains her 100-pound weight loss.

Upper endoscopy, performed in Houston by a general gastroenterologist with limited experience in bariatric surgery, showed moderate gastritis and distal esophagitis. No description of hiatal hernia, sleeve shape, gastric fundus size, incisura diameter mentioned. I performed an UGI that showed a dumbbell shape gastric sleeve with significant narrowing at the level of the incisura angularis and gastric body. Gastric fundus was dilated and appeared like a perfect circle with air fluid level on the X-ray pictures. Contrast emptying from stomach into duodenum appeared to be accelerated but there was contrast pooling in the gastric fundus. I repeated the upper endoscopy to confirm upper GI findings and demonstrate significant laxity at the diaphragmatic opening. There was also narrowing and twisting at the level of the incisura angularis creating a functional obstruction.

Aggressive gastric sleeve resection over a small bougie size results in a narrowed incisura angularis. A narrowed incisura angularis leads to functional gastric sleeve obstruction; as a result, gastric fundus, cardia and hiatal opening dilate over time. This slowly leads to hiatal hernia formation and a dumbbell looking gastric sleeve. A dilated gastric fundus in the setting of a hiatal hernia results in severe heartburn and food regurgitation. Treatment requires surgical correction of hiatal hernia and conversion of gastric sleeve to gastric bypass. Gastric bypass alleviates the functional obstruction at the level of the incisura. In certain cases, adhesion formation around the incisura angularis form and narrow this area. Scar tissue resection at this level alleviates the obstruction. The associated hiatal hernia still needs to be repaired to control acid reflux symptoms. The dilated gastric fundus is either resected or plicated around the distal esophagus.

Sleeve Gastrectomy in Patients with Previous Nissen fundoplication

Sleeve Gastrectomy in Patients with Previous Nissen fundoplication

I read with great interest the case series published this month in Surgery for Obesity and Related Diseases, SOARD, by Yerdel et al. “Sleeve Gastrectomy in patients with previous antireflux surgery. Preliminary results of the “no-touch to posterior wrap” technique. The authors converted 14 Nissen fundoplication patients with morbid obesity to sleeve gastrectomy. Mean follow up time was around 2 years after conversion surgery. Conversion surgery preserved the posterior and right lateral aspect of the wrap. Continue reading “Sleeve Gastrectomy in Patients with Previous Nissen fundoplication”

Duodeno-gastric Bile Reflux after Sleeve Gastrectomy

We have previously discussed the pathophysiology associated with bile reflux from duodenum into gastric sleeve lumen ending into distal esophagus in the setting of hiatal hernia. At Houston Weight loss Surgery Center, we have made the observation of increased incidence of bile gastritis in gastric sleeve patients with hiatal hernia and distal esophagitis. Continue reading “Duodeno-gastric Bile Reflux after Sleeve Gastrectomy”

Endoscopic Sleeve Gastroplasty Under Fire

Endoscopic Sleeve Gastroplasty Under Fire

“Without data, you are just another person with an opinion”, concluded R. Cohen MD his attack and critique of the novel weight loss procedure, endoscopic sleeve gastroplasty also known as Endosleeve. Cohen et al conducted a systemic review regarding the efficacy and safety of endoscopic sleeve gastroplasty. The authors found no supporting scientific evidence to recommend the use of endoscopic sleeve gastroplasty for treatment of obesity in clinical practice. Continue reading “Endoscopic Sleeve Gastroplasty Under Fire”