Rebecca from Houston Sent us this question: “I’ve already has achalasia surgery 10 years ago where the stomach lining was wrapped around the esophagus can I still have a gastric bypass and if so, can it be done laparoscopically?”

Heller myotomy and partial fundoplication surgery is commonly performed for achalasia. During a Heller myotomy, your surgeon cuts open the muscle fibers of the lower esophageal sphincter to facilitate swallowing. The myotomy, (cutting muscle fiber) is typically extended into the proximal stomach where gastric pouch for gastric bypass surgery is constructed.

Your bariatric surgeon needs to first undo the partial fundoplication. Then, the bariatric surgeon constructs a gastric pouch away from the myotomy was performed to minimize staple line leak. Conversion of Heller myotomy to gastric bypass is typically done through tiny incisions or laparoscopically.

A second option is to convert a Heller myotomy and partial fundoplication to gastric sleeve surgery. This approach is feasible, but not recommended due to increased acid reflux after fundoplication take down.

A third option is to keep the fundoplication intact and construct a gastric pouch below the wrap. This approach is particularly used when dense adhesions are encountered between the wrap and posterior esophagus.

In summary, weight loss surgery is feasible after Heller myotomy. Extra care must be taken to prevent staple line leak. Overall, the surgery is safe and easily performed through tiny incisions.

Rhonda from Pasadena sent us this question: “I had the gastric sleeve in Tijuana Mexico Feb 2015.  All was good the first couple years.  Since then I have had heartburn that is getting progressively worse.  I have been prescribed 40MG Pantoprazole twice /day. My question: Is gastric bypass the only solution for curing this acid reflux?”

Dear Rhonda,

Late onset acid reflux, many years after sleeve gastrectomy, is indicative of either recurrent hiatal hernia or new hiatal hernia formation. Recurrent hiatal hernia may develop secondary to weight regain or incomplete esophageal mobilization during initial repair. De novo hiatal hernia following sleeve gastrectomy may result from functional narrowing of gastric sleeve lumen. Functional narrowing occurs when the incisura angularis, the junction between lower one third and upper two thirds of the stomach is narrowed during gastric sleeve surgery. It is a fairly common mistake when bariatric surgeons use a very small size bougie during sleeve gastrectomy.

Functional narrowing of incisura angularis alters gastric emptying pattern and promotes backflow of gastric content towards the esophagus. Initially, in the setting of a competent acid reflux barrier, you will not have acid reflux. With time, the anti-reflux barrier fails, and acid reflux develops. This result in several acid reflux related symptoms like heartburn and food regurgitation. Acid reflux is a major cause of hiatal hernia development. Consequently, a hiatal hernia slowly develops leading to gradual gastric sleeve migration into the chest. When part of the gastric sleeve lumen is in the chest, bile reflux in addition to acid reflux develop and GERD symptoms worsen to the point that high dose PPIs no longer control symptoms.

The treatment for acid reflux after sleeve gastrectomy entails hiatal hernia repair with or without gastric bypass. In the absence of gastric sleeve narrowing, hiatal hernia repair is more than enough to restore the anti-reflux barrier and control acid reflux. If, however, the gastric sleeve is narrowed, conversion to gastric bypass is needed in addition to hiatal hernia repair.

Jennifer from Houston sent us this question: “I just had conversion from sleeve to bypass along with hiatal hernia repair for GERD. It’s been a month. Started having reflux again about 2 weeks out 😭”.

Dear Jennifer,

I am not sure what do you mean by having “reflux” again. Acid reflux is a medical disease diagnosed by an acid reflux specialist. Reflux is not a symptom. Heartburn, food regurgitation, cough, globus and epigastric pain are symptoms commonly experienced by patient with acid reflux disease. Symptoms however do not always correlate with acid reflux disease presence and severity. Therefore, the first thing I recommend to patients with recurrent acid reflux related symptoms after anti-reflux surgery, is to repeat upper endoscopy with ambulatory pH testing. 24-hour pH impedance may be added to check for non-acid reflux especially in the case of gastric bypass.

Gastric bypass is an effective anti-reflux procedure. Fast gastric pouch emptying into alimentary limb contribute to acid reflux control. Furthermore, diverting most of the stomach acid away from esophagus further add to acid reflux control.  A short alimentary limb may result in bile reflux into esophagus. Treatment in this case consists of lengthening the alimentary limb. A gastro-gastric fistula, a connection between remnant stomach and gastric pouch may also lead to acid reflux. This condition is less likely to occur in cases of sleeve to bypass conversion. Lastly, if your bariatric surgeon resected most of the remaining gastric sleeve during sleeve to bypass conversion, a retained gastric antrum syndrome may occur. Retained gastric natrum syndrome is characterized by elevated gastrin levels in the blood. Gastrin stimulates acid secretion in gastric pouch. Gastrin hormone is secreted by G cells located in stomach antrum. Stomach acid inhibits gastrin hormone secretion. An unresected gastric antrum constantly exposed to bile from the duodenum and no acid from the stomach, may lead to elevated gastrin hormone blood levels. Treatment in this case consist of gastric antrum resection.

Irrespective of cause, proper evaluation by an acid reflux specialist and bariatric surgeon in Houston is highly recommended to choose the most effective solution for your problem.

Gastric Sleeve or Bypass after Nissen Fundoplication

Ronald in Houston sent us this question: “So which is better sleeve or bypass I have mesh in my stomach and have had Nissen fundoplication and several hernia repairs”.

Dear Ronald,

There is no one answer to your question. We tailor surgery to patient condition and choose the most effective and safest solution to help our bariatric patients. Both gastric sleeve and gastric bypass surgeries are effective weight loss solutions. They are equally safe and when done correctly, protect against acid reflux.

I recommend a good work-up prior to surgery by a competent acid reflux specialist and bariatric surgeon in Houston. Accordingly, a decision can be made on the most appropriate surgery for you. In certain cases, the fundoplication can be left intact and gastric bypass or sleeve gastrectomy performed below the wrap.

Question from Tonya in Clear Lake:

“A bariatric surgeon told me I might be a candidate for RYGB, but it depends on my transit times for the smart pill. If I have gastroparesis with delayed gastric and large intestinal transit but normal small intestine am I a good candidate for gastric bypass surgery?”

Dear Tonya,

For patients with severe gastroparesis, I prefer a modified sleeve gastrectomy over gastric bypass to improve gastric emptying and effectively resolve gastroparesis related symptoms. One study has shown that sleeve gastrectomy improves both gastric and small intestine emptying. Therefore, I predict that a modified sleeve gastrectomy improves intestinal motility too. I am not sure about the effect of gastric surgery on colon emptying. I am also not sure about the clinical significance of small bowel transit time in the setting of gastroparesis.

For patients with delayed gastric emptying but normal small intestine motility, will gastric bypass surgery be equally effective to modified sleeve gastrectomy in alleviating gastroparesis related symptoms? This is a very interesting question and I am not sure if we have an answer for. Gastroparesis is a heterogeneous disorder with many different subtypes. There may be a role for gastric bypass surgery in some gastroparesis patients with “normal” small bowel motility, but I am not aware of studies to support such an approach. In my own personal and limited experience, I have had great success with the modified sleeve gastrectomy for treatment of severe refractory gastroparesis.

Question from Tonya in Clear Lake:

“A bariatric surgeon told me I might be a candidate for RYGB, but it depends on my transit times for the smart pill. If I have gastroparesis with delayed gastric and large intestinal transit but normal small intestine am I a good candidate for gastric bypass surgery?”

Dear Tonya,

For patients with severe gastroparesis, I prefer a modified sleeve gastrectomy over gastric bypass to improve gastric emptying and effectively resolve gastroparesis related symptoms. One study has shown that sleeve gastrectomy improves both gastric and small intestine emptying. Therefore, I predict that a modified sleeve gastrectomy improves intestinal motility too. I am not sure about the effect of gastric surgery on colon emptying. I am also not sure about the clinical significance of small bowel transit time in the setting of gastroparesis.

For patients with delayed gastric emptying but normal small intestine motility, will gastric bypass surgery be equally effective to modified sleeve gastrectomy in alleviating gastroparesis related symptoms? This is a very interesting question and I am not sure if we have an answer for. Gastroparesis is a heterogeneous disorder with many different subtypes. Unlike longitudinal gastrectomy or modified sleeve gastrectomy, gastric bypass or resection does not address the underlying pathophysiology of gastroparesis. For this reason, most gastroparesis patients do not respond well to either gastric bypass or gastric resection.

To summarize, in my own personal and limited experience, modified sleeve gastrectomy is the best treatment for severe refractory gastroparesis independent of small bowel transit time. There may be a role for gastric bypass surgery in gastroparesis patients with “normal” small bowel motility, but I am not aware of studies to support such an approach.

Kate from Houston sent us this question: “Do you guys offer testing for hiatal hernias? I’ve been considering gastric sleeve surgery, but I have severe heartburn and food regurgitation. Was thinking if I do have a hiatal hernia, might as well do both surgeries at once”.

Dear Kate,

Hiatal hernia testing and repair is an integral part of gastric sleeve surgery. Hiatal hernia is a defect in the opening in the breathing muscle through which the stomach herniates into the chest. Hiatal hernia repair restores normal anatomy by reducing the stomach back into the chest and closing the hernia defect. Keeping part of the stomach in the chest especially after sleeve gastrectomy results in severe acid reflux. Gastric sleeve has low compliance and readily responds to negative chest pressure. Negative pressure transmitted into gastric lumen results in a plunger like effect: acid and bile are aspirated into the upper part of the sleeve and distal esophagus where there is negative pressure. The effect is reproduced with the smallest hiatal hernias necessitating repair of any size hiatal hernia during sleeve gastrectomy. Since acid reflux and hiatal hernias are prevalent in the obese patient population careful testing for hiatal hernias prior to gastric sleeve surgery is routinely performed at Houston Weight Loss Surgery Center. Testing is performed using upper endoscopy. Additional tests like ambulatory pH testing and esophageal manometry are added if needed. Using this approach, we have prevented new onset acid reflux after sleeve gastrectomy and cured pre-existing acid reflux with proper hiatal hernia repair and gastric sleeve surgery.

“Determining the health benefits of sleeve gastrectomy in patients with body mass index, BMI less than 35” is a new article published in Surgery for Obesity and Related Diseases journal. The authors compare the outcomes of sleeve gastrectomy in 1073 patients with low BMI to 44511 patients with BMI more than 35 (mean BMI 46.7).

Statistical analysis shows comparable rates of hypertension, diabetes and hyperlipidemia medication discontinuation. Low-BMI patients were more likely to achieve a healthy BMI (less than 25). The authors conclude that despite being older and with higher rates of metabolic disease, low-BMI sleeve gastrectomy patients benefited from bariatric surgery. Furthermore, low-BMI sleeve gastrectomy patients were more likely to achieve a healthy weight. Therefore, abolishing the BMI threshold for sleeve gastrectomy should be considered.

I wholeheartedly agree with these conclusions. Sleeve gastrectomy is currently one of the safest general surgeries we perform with very high success rate. Why wait to lose weight? Bariatric surgery is currently the most effective treatment for type 2 diabetes. Denying low-BMI patients with metabolic disease a safe and effective procedure like sleeve gastrectomy is not reasonable. BMI is a statistical tool established more than 50 years ago by insurance companies to predict mortality in a population. BMI, however, is not a personalized measure of one’s health. A diabetic low-BMI patient is at higher risk for cardio-vascular disease then a non-diabetic high-BMI patient. Eliminating diabetes at a lower BMI and younger age should be the norm rather than the exception. Sleeve gastrectomy is a powerful tool to safely control and cure metabolic disease. It is time to update our guidelines.