GERD After Sleeve Gastrectomy: What You Need to Know and How to Manage It Effectively

Gastroesophageal reflux disease (GERD) is a common concern for many patients undergoing bariatric surgery, particularly those opting for a sleeve gastrectomy (SG). This procedure, while effective in managing obesity, has been linked to varying degrees of GERD. Understanding the potential outcomes can help both patients and healthcare professionals better navigate postoperative care and set expectations for symptom management.

What is GERD?

GERD occurs when stomach acid frequently flows back into the esophagus, causing irritation and discomfort. This can lead to symptoms such as heartburn, chest pain, regurgitation, and difficulty swallowing. While GERD is relatively common among the general population, its prevalence and severity can increase after certain types of bariatric surgery, particularly the sleeve gastrectomy.

GERD Before and After Sleeve Gastrectomy

One of the primary concerns for patients considering sleeve gastrectomy is the impact of the procedure on GERD. According to data from the image provided, the statistics on GERD post-sleeve are striking:

• GERD Pre-Sleeve: 19% of patients who already have GERD before undergoing a sleeve gastrectomy may experience worsening symptoms.
• De-novo GERD Post-Sleeve: GERD can develop in 6-23% of patients who had no prior history of reflux before surgery.

These numbers suggest that for some patients, a sleeve gastrectomy could exacerbate or even trigger GERD symptoms that weren't previously present.

Complications Associated with GERD Post-Sleeve

In addition to worsening reflux symptoms, other complications related to the esophagus can arise post-sleeve, including:

• Erosive Esophagitis: This occurs when the esophagus becomes inflamed due to constant acid exposure. After a sleeve gastrectomy, erosive esophagitis is found in 37% of patients.
• Barrett’s Esophagus: Chronic GERD can lead to changes in the esophageal lining, a condition known as Barrett’s esophagus, which can increase the risk of esophageal cancer. This develops in 11% of patients at 3 years post-sleeve.
• Hiatal Hernia: Hernias at the esophageal opening of the diaphragm (hiatal hernias) can develop or worsen after surgery. These are seen in 6-13% of patients within 1 year post-sleeve.

Structural Issues Post-Sleeve

The sleeve gastrectomy also changes the anatomy of the stomach, which can lead to mechanical or structural issues:

• Stricture at the Incisura: This refers to a narrowing at the curve of the stomach (incisura angularis), which occurs in 6% of patients. It can make it more difficult for food and liquids to pass into the intestines, potentially worsening GERD symptoms.
• Proximal Sleeve Dilation: Approximately 12% of patients experience dilation or stretching of the upper portion of the sleeve, which may contribute to reflux as it alters the pressure dynamics between the stomach and esophagus.
• Post-Obesity Surgery Esophageal Dysfunction (POSED): This is a newly described condition that occurs in 2.5% of patients post-sleeve. POSED is characterized by abnormal esophageal motility and difficulty in clearing food and acid, leading to severe GERD symptoms.

Managing GERD Post-Sleeve

Given these potential complications, how do surgeons and patients manage GERD after a sleeve gastrectomy?

1. Preoperative Screening: It’s important to assess for GERD before surgery. Patients with severe, pre-existing GERD may benefit from alternative surgical options, such as the Roux-en-Y gastric bypass, which has been shown to be more effective in resolving GERD symptoms.
2. Postoperative Lifestyle Changes: Patients can adopt strategies to reduce GERD symptoms, including eating smaller meals, avoiding foods that trigger reflux (like spicy or fatty foods), and not lying down immediately after eating.
3. Medical Management: For patients who develop or continue to have GERD after surgery, medications such as proton pump inhibitors (PPIs) or H2 blockers may be prescribed to reduce stomach acid production and manage symptoms.
4. Surgical Revisions: In some cases, patients with severe GERD or related complications may require a surgical revision, such as converting the sleeve to a gastric bypass. The bypass procedure creates a smaller stomach pouch and reroutes food to bypass part of the small intestine, which significantly reduces acid exposure to the esophagus.

Conclusion

While sleeve gastrectomy offers effective weight loss results for many patients, GERD remains a notable complication that should not be overlooked. Preoperative evaluation, postoperative monitoring, and a personalized treatment plan are key to managing GERD symptoms. Patients experiencing persistent or worsening reflux should work closely with their healthcare team to explore all management options, including lifestyle changes, medication, or, in some cases, surgical revisions.

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References:

1. Chris DuCoin, MD. Bariatric Channel Presentation on GERD Post-Sleeve Gastrectomy.
2. Melissas J, et al. Sleeve Gastrectomy: A Restrictive Procedure? Obes Surg. 2007.
3. Braghetto I, et al. Gastroesophageal Reflux Disease After Sleeve Gastrectomy. Obes Surg. 2009.