Surgery for obesity & metabolic diseases
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This is one of the most frequently asked questions by patients considering weight loss surgery, specifically gastric sleeve surgery.
And it is also one of the most controversial issues regarding the pros and cons of gastric sleeves surgery compared to other procedures, such as gastric bypass.
Before delving into the subject, we must describe "gastroesophageal reflux or GERD." In simple terms and as its name says, it is the return flow of the stomach contents into the esophagus, which due to its acid content, causes damage to the esophageal lining/cells to a greater or lesser extent.
As we have mentioned in other articles, it is necessary to evaluate every patient who considers undergoing weight loss surgery carefully.
But for those who suffer from reflux before surgery, a more detailed analysis of their situation is required, preferably with upper endoscopy, manometry, and esophageal pHmetry to determine reflux severity, since if it is present and is pathological, gastric sleeve surgery is not recommended.
Based on our experience with many patients who have already undergone surgery and statistical research articles carried out in the last decade, those patients who suffer from occasional reflux or without endoscopic (or other) evidence of severe reflux, it is very likely that once they lose weight, said reflux improves or disappears if it occurs.
The controversy lies in the fact that some studies confirm with certainty that gastric sleeve favors or worsens gastroesophageal reflux. In contrast, other studies confirm the complete opposite, that in most cases, reflux improves or disappears (Reference article, systematic analysis of 15 studies 1.)
In the case of gastric bypass, it is known that the vast majority of patients suffering from gastroesophageal reflux will benefit from the resolution or improvement of this symptom. Going from 88% of patients with symptoms to only 22% after surgery (Reference article 2).
At Obesity Free, we think that the ideal way to convey the message as clearly as possible would be to separate patients into two main groups:
1.- Patients suffering from reflux before having a gastric sleeve surgery
Those previously described in this article fall into this group. In patients who suffer from this problem and require frequent or daily treatment, gastric sleeve surgery is not recommended, at least initially.
In this type of case, I suggest an exhaustive analysis of the patient with studies such as those mentioned above (endoscopy, manometry, and pHmetry) to confirm or rule out its severity. Always keep in mind that many patients believe they are suffering from significant reflux but that there is no clear evidence of pathological reflux at the time of being studied. It could be thought that it is the minority of cases. Still, there are studies where more than 50% of the patients who reported severe reflux symptoms did not show objective evidence of such reflux (Reference article 3).
Despite this, less than 50% of those studied will have evidence of reflux to a greater or lesser degree. It is based on its severity together with the informed decision of the patient as it will be determined if they can undergo a gastric sleeve surgery or not. Many patients are looking for this procedure because it is currently the most performed and has the most references from previous patients and acquaintances. We must not ignore that outside reflux, the gastric sleeve is the perfect combination of the noblest procedure (with fewer side effects) with the most effective, just a little below the gastric bypass.
In the case of not having pathological reflux, performing a gastric sleeve is entirely acceptable as long as your bariatric surgeon is sure it is not contraindicated. Since if it is contraindicated, the patient must follow his doctor's recommendation.
We must also remember that it has been demonstrated that gastroesophageal reflux is closely related to the degree of obesity, so when losing weight, many patients will show a considerable improvement in their symptoms, or in some cases, they will only return to the symptoms (frequency and intensity) before surgery.
2.- Patients suffering from reflux after gastric sleeve surgery
In these cases, there is also great controversy since some patients think that they should have chosen another procedure because they have a symptom that they did not have before.
In this regard, a high percentage of our patients who do not suffer from reflux before surgery and suffer symptoms to a greater or lesser extent after the procedure manage to return to normal after 3 to 6 months. In the case of occasional reflux before surgery, on many occasions, it disappears by decreasing the pressure inside the abdomen that exerts pressure against the sphincter that prevents reflux at the level of the esophagus.
We estimate that in approximately 60 to 70% of the cases where our patients develop reflux after surgery (de novo), it disappears within six months. The remaining 30 to 40% of patients with reflux similar to that suffered/suffered by the majority when we eat copiously or with foods high in fat or drink alcohol. And only a tiny proportion of patients suffer from a level of reflux that requires anti-reflux medication on a chronic basis.
In our personal opinion, based on what we have seen with patients, we have concluded the following:
If the patient has non-pathological reflux and has no desire to undergo a gastric bypass, and their obesity is considerable, a gastric sleeve is an excellent option.
As we mentioned before, this procedure is the combination of "the best of both worlds," a procedure that has very few "cons," specifically reflux being the main and almost the only one (when it happens), versus its excellent results in terms of weight loss and improvement of the general health of the patient, being only behind gastric bypass in percentage effectiveness.
Supposing the situation arises that the patient undergoes a gastric sleeve and suffers from severe reflux that does not improve with non-surgical measures after 18 to 24 months. In that case, the option of thinking about a gastric bypass will always exist. This will help improve this symptom and continue to help with the initial goal, which is health through weight loss with surgery.
Do you suffer from obesity and do not know which procedure is ideal for you? Contact us, and we will gladly guide you.
1. Chiu S, Birch DW, Shi X, et al. Impact of sleeve gastrectomy on gastroesophageal reflux disease: a systematic review. Surg Obes Relat Dis. 2011;7:510–5. [PubMed] [Google Scholar]
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