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In the almost 20 years since the gastric sleeve became a standalone procedure, it’s still stunning that there is no well-defined standard for performing the procedure. Ultimately, I try to impart my experience to the other surgeons I train so they can avoid some of the pitfalls we, as bariatric surgeons, had to navigate in the early days of creating the gastric sleeve.
I’m also fascinated by how many patients and medical practitioners alike think that the gastric sleeve is a simple procedure. I would call it “straightforward,” but it’s definitely not simple. There are numerous issues that can arise – even today, with the technology we have – that ultimately lead to an unsatisfactory patient outcome.
The Problem of Reflux
While there is a list of potential risks and considerations for a gastric sleeve (as with any major surgical procedure), the one I emphasize most to my patients is the risk of new or worsened reflux after sleeve surgery. It’s important enough that, if the patient has a history of reflux or significant concern about the potential for reflux, we consider a different procedure entirely: the gastric bypass.
The empty gastric pouch is like a deflated, low-pressure football, and we can eat quite a bit of food without experiencing regurgitation. However, when we remove approximately 75% of the stomach while leaving the lower esophageal sphincter (LES) and the pylorus (the upper and lower valves, respectively), we create a markedly higher-pressure tube. The gastric juices contained within the stomach don’t have anywhere to go and typically push upwards because the LES is the weaker of the two valves, especially in patients with obesity.
What We Can Do About It
As a surgeon familiar with the realities of a gastric sleeve, I take several steps to reduce the risk of reflux.
First, it begins with prevention. I screen my patients carefully, and while I do believe that the gastric sleeve is the best procedure for most patients with obesity who qualify for bariatric surgery, I will gladly perform a gastric bypass on a patient whom I feel is not suitable because of the risk of reflux.
Second, we ensure there is no visible hernia during the primary bariatric procedure, and if a hernia is found, we repair it meticulously to ensure the new sleeve sits correctly in the abdomen. Hiatal hernias, in which the stomach protrudes into the chest cavity through the diaphragmatic hiatus (hole), are relatively common due to intra-abdominal pressure from excess weight. Hiatal hernias are also a significant source of postoperative reflux.
The manner in which the stomach is stapled also matters.
It takes approximately 4 to 5 “bites“ of a stapler to divide the entire stomach pouch. This means we must be cautious to ensure that each bite is uniform and creates a clean staple line along the stomach. Jagged edges and misfires can narrow or twist, increasing intra-abdominal pressure within the gastric pouch and leading to reflux. This is where patience, as a bariatric surgeon, is essential.
Making the Sleeve Too Small
Yet another common mistake, often seen in surgeries performed by inexperienced bariatric surgeons, or surgeons not trained in the procedure, is the tendency to make the gastric pouch too small. It’s easy to think that the smaller the gastric pouch, the more weight a patient will lose. To some degree, that is true. However, to ensure our patients’ comfort and the long-term viability of the procedure, it’s often more prudent to leave a slightly larger sleeve. This reduces the risk of reflux and the potential for revisional surgery. It also allows the patient to be more comfortable in their postoperative period, which tends to improve outcomes by enhancing compliance with postoperative instructions.
What If I Am Experiencing Reflux?
For patients who are experiencing reflux, there are always options. We try to modify diet and exercise habits first to reduce the consumption of foods that may cause reflux or minimize exercises that increase intra-abdominal pressure. Failing that, surgical interventions can be beneficial for facilitating additional weight loss and for improving or eliminating reflux.
First, converting a gastric sleeve to a gastric bypass could be a great way to eliminate the intra-abdominal pressure that we now know causes much of the reflux. In addition to being an excellent revisional procedure for patients with sleeve gastrectomy who have not achieved reflux control, gastric bypass can also improve weight-loss outcomes. Adding malabsorptive components to the procedure reduces calorie absorption and may contribute to sustained, enhanced long-term weight loss.
Dr. Jacobs is also an expert in a reflux procedure known as the Single Anastomosis Stomach-Ileal (SASI) bypass. During this procedure, a loop of intestine is brought up and attached to the gastric pouch along the staple line, thereby creating two outlets for ingested food and fluid. This reduces intragastric pressure caused by the gastric sleeve and may, as a result, help patients lose additional weight.
Bottom Line
The gastric sleeve is an excellent option for most patients with obesity for whom other, more conservative interventions have not succeeded. That said, this seemingly simple procedure entails several caveats and pitfalls that only an experienced sleeve surgeon like Dr. Jacobs can navigate. Ultimately, we want the primary sleeve procedure to succeed, and with an expert approach, our reflux rate is well below 10%. However, in cases where reflux occurs, we have options for any circumstance a patient may experience. Call our office to learn more about a primary sleeve procedure or the management of reflux after a sleeve procedure you may have had.
