Gastric Emptying after Sleeve Gastrectomy

I read with great interest the new study: “Mechanisms of esophageal and gastric transit following sleeve gastrectomy” by Burton et al that was recently published in the journal of Obesity Surgery. 26 patients underwent gastric nuclear scintigraphy, high resolution manometry and barium contrast studies following sleeve gastrectomy. Sleeve gastrectomy was performed over a 36 French bougie starting 4 cm from the pylorus. The staple line was then imbricated with a running suture. There is no mention of hiatal hernia repair. Selected patients did not have significant reflux symptoms. “Significant” was not defined by the authors.

Nuclear scintigraphy showed increased incidence of triggered deglutitive reflux from distal to proximal esophagus in post sleeve gastrectomy patients in comparison to obese controls. This pattern is commonly seen in esophageal outflow obstruction. Rapid gastric emptying from sleeve into small bowel was noted as expected. More interestingly, the authors found a co-dependent emptying pattern between esophagus and stomach. in other words, esophageal emptying and motility contributed to gastric emptying. Typically, esophageal and gastric emptying are two separate processes.

Stress barium studies showed rapid flow of thin barium within a narrow gastric tube into duodenum as expected. The authors describe a cyclical filling and emptying pattern of gastric sleeve vertical and horizontal components. They report filling of vertical component, distention and then emptying into the horizontal component through incisura angularis opening. The horizontal component or what is left of the antrum, contracts as a reflex due to distention then rapidly delivers content into duodenum. Multiple reflux events were noted from sleeve into esophagus during this emptying cycle.

Esophageal manometry showed evidence of sliding hiatal hernia in 50% of the patients. Increased proximal intragastric pressure was noted following a swallow with concomitant prolongation of lower esophageal sphincter contraction. During this phase, contrast moves across incisura into antrum. This is followed by lower esophageal sphincter relaxation and reflux into proximal esophagus. Subsequently, an esophageal contractile wave is generated flushing refluxate back into stomach. This esophageal contractile wave contributes to increased proximal gastric pressure and subsequent gastric emptying across incisura angularis and then across pylorus into duodenum.

There is no doubt that gastric sleeve surgery disrupts esophago-gastric motility and food transit. This disruption is the basis for altered neuro-hormonal signaling leading to weight loss. By the same token, this disruption may lead to worsening or de-novo acid reflux disease with aggressive gastric sleeve resection and restriction. The art of gastric sleeve surgery is to optimize gastric sleeve resection in order to maximize weight loss and minimize acid reflux. Unfortunately, the guiding principle of maximal mechanical restriction has led to stomach mutilation and loss of function. For instance, starting gastric sleeve resection at appoint 4 cm from pylorus destroys the antrum. The antrum is the gastric pump and antral function is crucial to gastric emptying. Eliminating the gastric antrum reduces the stomach to a rigid immotile tube. Furthermore, using a small caliber bougie narrows the incisura angularis and results in functional obstruction to flow between the horizontal and vertical components of stomach. Functional obstruction results in acid reflux, proximal stomach pressurization and the cycling pattern of emptying as it was eloquently described in this paper.

I have always advocated a non-mutilating resection of stomach to achieve the perfect gastric sleeve. Such an approach preserves the antrum, maintains a widely open incisura angularis and eliminates most of the gastric fundus and gastric body without narrowing gastric sleeve lumen. The purpose of gastric sleeve surgery is to favor gastric emptying along the Magenstrasse pathway rather than destroy stomach function and anatomy. If the authors repeat their study on my gastric sleeve surgery patients, I would expect different outcomes and motility patterns. I don’t see de-Novo or worsening acid reflux following sleeve gastrectomy at Houston Weight Loss Surgery Center. On the contrary, acid reflux resolved after sleeve gastrectomy in my practice. The motility patterns the authors are describing are highly suggestive of functional narrowing of incisura angularis. Their surgery technique involves a small caliber bougie and aggressive rection of gastric antrum. To make things worse, the staple line is oversewn further narrowing gastric lumen. This excessive restriction is unnecessary. It transforms the stomach into a rigid tube and a barrier against esophageal emptying: a recipe for acid reflex. Over time, chronic pressurization of proximal stomach and constant reflux results in a weaker lower esophageal sphincter, decreased peristaltic wave pressure, and hiatal hernia development. The result is worsening acid reflux and progressive dilation of gastric sleeve lumen. Dilation of gastric sleeve lumen helps alleviates functional obstruction at the incisura angularis. However, acid reflux persists because of hiatal hernia development and esophageal dysmotility. Repairing the hiatal hernia at this stage has resulted in acid reflux resolution in more than 90% of patients presenting to Houston Weight Loss Surgery Center.

Heartburn after Gastric Sleeve Surgery in Dallas

James sent us this question: “Hi!  I live in Dallas and had a gastric sleeve 3 years ago.  I have severe reflux and had a scope done last week showing an esophageal ulcer and recurrent hiatal hernia.  My biopsies are pending.  I had a preop scope showing a hiatal hernia which was fixed during my sleeve.  How can I know if the incisura angularis was narrowed during my surgery? Is this something that can be seen during my scope?  I really do not want to have another surgery, but I don’t want to get esophageal cancer.”

Dear James,

The three components of successful sleeve gastrectomy include:

  1. Proper hiatal hernia repair
  2. Complete gastric fundus mobilization and resection
  3. Wide incisura angularis and preserved gastric antrum

Proper hiatal hernia repair requires distal esophageal mobilization. Most bariatric surgeons are not trained to repair properly repair hiatal hernias. The result of poorly repaired hiatal hernia is early recurrence. Recurrent hiatal hernia in the setting of sleeve gastrectomy results in severe acid reflux independent of a narrowed incisura angularis.

A narrowed incisura angularis is best diagnosed by an expert bariatric surgeon using both upper endoscopy and UGI contrast study. A gastroenterologist performing endoscopy after sleeve gastrectomy is not likely to appreciate narrowing of incisura angularis. Indeed, incisura angularis narrowing is functional rather than mechanical. It is suspected when the angle between the horizontal and vertical part of the stomach is quite sharp and requires some maneuvering to navigate during endoscopy.

We have noticed that over time, the incisura angularis dilates and repair of hiatal hernia is enough to control acid reflux in the setting of sleeve gastrectomy. Of course, severe narrowing requires sleeve to bypass conversion to remedy the acid reflux problem.

Gastroparesis after Nissen Fundoplication

Jose from San Antonio sent us this question: “After a stomach emptying process at the beginning of 2020, the diagnosis was gastroparesis. I had a prior fundoplication in 2005. I was prescribed medication for the gastroparesis, to which I had allergic reactions to the Metoclopramide 10mg. I am still using the Ondansetron ODT 4mg for acute nausea, which helps but do not take away the nausea. I have found that ginger brings quick relieve, but it doesn’t last long. Over the last 3 months I have lost 30 lbs due to being nauseated consistently throughout the day, and would wake up at night, dry heaving. I eat several small meals throughout the day, and there are times that I eat nothing at all, as I would gag as I bring the food to my mouth. I am full after a few bites and stay full for long after. I also dry heave during the day. I am seeing my Endocrinologist monthly for type 2 Diabetes, Cholesterol, Hypothyroidism and Hypertension. Currently I am taking Synjardy XR 12.5mg-1000mg, 2 a day, Glimepiride 2g, 1 a day, and Ozempic 1mg per dose, 1 a week. I still have stomach emptying during the night, which makes my sugar spike when I least expect it. My endocrinologist suggests gastric pacemaker, but I declined based on what I read on your blog. My quality of life has gone down. Can I have the surgery to improve my health and just maybe reverse my Diabetes/High Cholesterol/Hypothyroidism. I also have osteoarthritis and will be having knee-replacement in December.”

Dear Jose,

Gastroparesis or delayed gastric emptying may develop in the setting of diabetes. Diabetic gastroparesis contributes to erratic blood sugar control in addition to debilitating symptoms like nausea, vomiting and abdominal pain. Medications like Metoclopramide, commonly known as Reglan, are used to promote gastric emptying. However, efficacy of Reglan is limited, and long-term use is associated with serious side effects. Gastric pacemakers are quite ineffective, and I do not recommend pacemaker placement for gastroparesis treatment.

An antrum preserving longitudinal gastrectomy along the greater curvature of the stomach is a promising procedure for treatment of gastroparesis. This approach was developed based on data from sleeve gastrectomy that show increased gastric emptying following gastric sleeve surgery for morbid obesity. I have personally tried the procedure in around 20 patients. All patients had immediate and complete gastroparesis related symptom resolution. Most importantly, longitudinal gastrectomy can be performed between the gastric antrum and fundoplication. Therefore, the fundoplication is preserved sparing you a potentially complicated revision surgery.

Other surgical option for gastroparesis treatment are available including pyloroplasty and gastric bypass surgery. However, in our own experience at Houston Weight Loss Surgery Center, we have found that a limited longitudinal gastrectomy to be the most effective and most reliable treatment for gastroparesis.

Gastric Sleeve Surgery after Heller Myotomy

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.

Late Onset GERD after Sleeve Gastrectomy

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.

Persistent Heartburn after Gastric Sleeve to Bypass Conversion

Persistent Heartburn after Gastric Sleeve to Bypass Conversion

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

Gastric Sleeve or Bypass after Nissen Fundoplication

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.

Bile gastritis after Sleeve Gastrectomy

Jenny from Humble sent us this question: “Had sleeve done in 2014. After EGD done 1/2020 it showed I had lots of bile in my stomach. Have bile reflux, take 40mg Omeprazole DR twice a day. Still have burning in throat, chest, esophagus. Also having hiccups and belching after eating. Cut out all caffeine, sodas, acidic fruits, and tomatoes. Still no difference. Also fried foods. Just hurting when I eat anything. EGD also showed esophagitis. 65 and getting tired of all of this daily. Will go to Dr. 5/21. Just asking for more advice or what I can do. Thanks JD”.

Dear Jenny,

Bile gastritis and bile reflux after sleeve gastrectomy is indicative of hiatal hernia. Hiatal hernia is a defect in the diaphragm hiatus. The diaphragm or breathing muscle has an opening in its center. The esophagus or food pipe goes through this opening to join the stomach in the abdominal cavity. The opening is wide enough to allow for the esophagus to go through. If the opening is large a hiatal hernia forms and the stomach herniates through the hiatal hernia into the chest.

Obesity is a major risk factor for hiatal hernia formation. Most overweight individuals have a hiatal hernia. Therefore, most obese patients undergoing sleeve gastrectomy must have a concomitant hiatal hernia repair. If hiatal hernia is not repaired, gastric sleeve herniates into the negative pressure area of the chest. This results in bile reflux from the duodenum into the stomach lumen and eventually ending in the esophagus.

Bile reflux may be worse than acid reflux in terms of damage to esophagus lining, severe burning symptoms and esophageal cancer development. Most importantly, bile reflux does not respond to proton pump inhibitors like Omeprazole and Nexium. I strongly recommend you consult with the best acid reflux and weight loss surgery specialist in your area to get evaluated and treated. Hiatal hernia repair is quite effective at stop bile reflux especially if gastric sleeve lumen is not narrowed or twisted.

Lap Band and Esophageal Damage

Lap Band and Esophageal Damage

Emily from Pasadena sent us this question: “Had lap band removed in Nov 2019. Having esophagus trouble.  Food and drink sticking.  Food still there in the morning, wheezing and coughing at night. Constant heartburn etc…”

Dear Emily,

Lap band for weight loss causes significant damage to esophagus especially when over-restricted. Many bariatric surgeons fell in the trap of over-restriction in hopeless attempts at promoting weight loss. The end result of lap band over-restriction was damage to esophagus, and dissatisfied bariatric patients. Lap band damages esophageal motility resulting in a condition called pseudo-achalasia. Pseudo-achalasia patients have a dilated esophagus secondary to chronic partial obstruction created by lap band. Heartburn, difficulty swallowing, food regurgitation, cough and wheezing (especially at night) are some of the symptoms associated with band over-restriction and pseudo-achalasia. Aspiration pneumonia is a serious side effect of lap band over-restriction.

The first step in lap band over-restriction management is fluid removal. The earlier fluid is removed the less is esophageal damage. Patients who present after years of over-restriction require lap band removal. Most patients will slowly improve, and acid reflux symptoms resolve. Some may develop irreversible esophageal function loss resulting in persistent symptoms of acid and food regurgitation. In this case, first line of treatment consists of diverting gastric content from esophagus by performing a Roux-en-Y gastric bypass. Gastric bypass is quite an effective solution for acid reflux. Dysphagia, however, may not resolve. In these rare cases and especially in the setting of recurrent aspiration episodes esophageal resection is necessary. Fortunately, Lap Band is rarely performed these days in Houston. Our understanding of weight loss surgery mechanism of action has greatly evolved. We no longer think that mechanical restriction leads to weight loss. Rather, we know that bariatric surgery modifies a number of neuro-hormonal signals that alter satiety and metabolism leading to long-term weight loss.

Gastric bypass, Gastroparesis, Sleeve Gastrectomy

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.