Gastric sleeve surgery, formally known as Sleeve Gastrectomy (SG), is a common weight-loss procedure that fundamentally changes the anatomy of the stomach. The surgery involves removing a large section of the stomach, leaving behind a narrow, tube-like structure, which drastically restricts food intake and promotes satiety. Gastroesophageal Reflux Disease (GERD), commonly called acid reflux, is a condition where stomach acid frequently flows back up into the esophagus, causing a burning sensation known as heartburn. The potential for new or worsened GERD symptoms following SG is a major concern for both patients and medical professionals planning bariatric surgery.
The Link Between Gastric Sleeve and Reflux
The question of whether gastric sleeve surgery causes acid reflux is complex, but current medical data indicates a strong association with the development or worsening of symptoms. Studies show that between 14% and 35% of patients who did not have reflux before the operation may develop new-onset, or de novo, GERD after the procedure. Conversely, a subset of patients who had mild or moderate GERD symptoms before surgery may experience improvement due to significant weight loss and the corresponding reduction in intra-abdominal pressure. However, for patients with pre-existing GERD, especially those with severe symptoms or esophageal damage, the sleeve gastrectomy may not be the ideal procedure, as their symptoms often worsen. The overall prevalence of GERD symptoms in patients following SG is significant. This risk has led to a consensus that patients with severe pre-existing reflux may be better candidates for a different procedure, such as a Roux-en-Y gastric bypass, which is known to resolve GERD.
Anatomical Changes Contributing to GERD
The physical alterations made during a sleeve gastrectomy are directly responsible for creating an environment conducive to acid reflux. The procedure transforms the stomach from a low-pressure, expandable reservoir into a high-pressure, narrow gastric tube. This tube experiences significantly higher internal pressure, which mechanically pushes stomach contents and acid upward toward the esophagus.
A major part of the stomach removed during the surgery is the fundus, the upper, dome-shaped section. The fundus is a primary reservoir and the main location of acid-producing cells. Its removal eliminates a natural buffer that would normally help accommodate food and prevent pressure from building up, which further contributes to the upward propulsion of acid.
Furthermore, the surgical stapling along the stomach’s curvature can compromise the integrity of the lower esophageal sphincter (LES) and disrupt the Angle of His. The Angle of His is a sharp angle formed where the esophagus meets the stomach, functioning as a flap-valve mechanism that normally helps prevent reflux. Damage to this natural anti-reflux barrier reduces the sphincter’s ability to remain closed, allowing stomach acid to move into the esophagus more easily.
Treatment Options for Post-Surgical Reflux
Managing reflux that develops after a sleeve gastrectomy begins with conservative, non-surgical approaches. Initial steps include lifestyle and dietary modifications, such as eating smaller, more frequent meals to keep pressure low within the sleeve. Patients are often advised to avoid eating for several hours before lying down and to elevate the head of their bed. Identifying and avoiding trigger foods, like spicy, fatty, or acidic items, can also significantly reduce the frequency and severity of symptoms.
When lifestyle changes are insufficient, medical management typically involves the use of acid-reducing medications. Proton Pump Inhibitors (PPIs) are the most effective class of drugs, working by strongly suppressing the production of stomach acid. For patients whose symptoms persist despite high-dose PPI therapy, or those who develop severe complications like Barrett’s esophagus, surgical revision may be required. The definitive surgical treatment for refractory post-sleeve GERD is the conversion of the sleeve gastrectomy to a Roux-en-Y Gastric Bypass (RYGB). This revision surgery effectively routes stomach acid away from the esophagus, resulting in the resolution of reflux symptoms for over 90% of patients.