Reflux after a Gastric Sleeve Operation

Most patients do not have problems with reflux after a gastric sleeve operation but reflux can be bothersome for some.  Symptoms of gastroesophageal reflux include heartburn or reflux of gastric contents into the throat or mouth especially when lying down.

When a patient that has a gastric sleeve swallows food , the food travels down the esophagus past the high pressure zone called the Lower Esophageal Sphincter ( LES) at the lower end of esophagus and enters into new stomach call the gastric sleeve. The outlet of this new stomach is constricted by the circular muscle called the pylorus and food and/or drink stays in the stomach for a time and is released only very slowly. The slow release of gastric contents means food remaining in the sleeve may be under higher pressure is able to reflux up into the esophagus and even up into the mouth as the pressure in the gastric sleeve becomes higher than the pressure of the LES.

Patients that are high risk for gastroesophageal reflux after a gastric sleeve operation are those that have symptoms even before surgery. In fact, patients with severe gastroesophageal reflux with pre-cancerous changes in the esophagus called Barrett's esophagus should probably select a gastric bypass instead of a gastric sleeve operation since a gastric bypass is a much more effective way to treat severe reflux.

In my practice, if a patient needs to take medication called a Proton Pump Inhibitor, (Protonix, Previcid, Nexium) every day to control reflux I consider them to have moderate to severe reflux. These symptoms are frequently associated with a hiatal hernia since the opening in the diaphragm where the esophagus enters into the abdomen is often larger than normal allowing the upper part of the stomach to slide up into the chest. In this case if the patient prefers to have a gastric sleeve instead of a gastric bypass I will plan to add an additional component to their gastric sleeve operation by approximating the diaphragmatic muscles behind the esophagus with sutures narrowing the diaphragmatic opening for the esophagus called the hiatus making reflux much less likely. Of course since I use the da Vinci surgical robot this additional step becomes much easier. 

For those patients having reflux symptoms after a gastric sleeve operation I would suggest the following:

1). For mild occasional symptoms - use Pepcid complete or equivalent when symptoms occur. The antacid will neutralize the acid and the Pepcid will decrease the amount of acid the gastric sleeve is making.

2). For more persistant reflux take a Proton Pump Inhibitor as mentioned above each day.

3). Other suggestions include avoiding eating late into the evening, avoid spicy foods and sleep on more than one pillow if possible.

The good news is that the symptoms often improve after the patient loses significant weight and the medications may be able to be discontinued a few months after surgery.