Vertical Sleeve Gastrectomy (VSG) removes a large portion of the stomach to create a narrow, tube-like reservoir, making it one of the most common bariatric surgeries performed globally. While highly effective for weight loss, the procedure impacts the risk of Gastroesophageal Reflux Disease (GERD), commonly known as acid reflux. This condition, where stomach acid flows back into the esophagus, is a primary concern for patients considering or recovering from VSG.
Studies show that a significant portion of patients (20% to 40%) experience new-onset GERD, or “de novo” reflux, after the operation, even if they had no prior symptoms. This new reflux can sometimes manifest as esophagitis, an inflammation of the esophageal lining, which can become a long-term issue if not managed properly.
The weight loss resulting from VSG can actually benefit patients who had pre-existing GERD symptoms linked to obesity. Weight loss reduces the overall intra-abdominal pressure, a major factor contributing to reflux. For some patients, particularly those with milder symptoms before surgery, GERD may improve or even resolve completely following the procedure.
A subset of patients who already had GERD before the surgery, however, may find their symptoms worsen after the sleeve procedure. This varied response highlights the need for careful pre-operative evaluation, especially since the anatomical changes inherent to VSG tend to be pro-reflux. The risk of developing new or worsened reflux is a main factor distinguishing VSG from other bariatric procedures like Roux-en-Y Gastric Bypass.
Anatomical Changes That Influence GERD
The mechanics of the gastric sleeve create an environment in the upper digestive tract that promotes acid reflux. A primary factor is the creation of a high-pressure gastric tube, where the stomach is reduced by up to 80% of its original volume. This narrow reservoir has a significantly higher internal pressure compared to a normal stomach, which can force contents and acid upward toward the esophagus.
The procedure also impacts the lower esophageal sphincter (LES), the muscle valve that separates the esophagus from the stomach and prevents backflow. The surgery can compromise LES function by disrupting the angle of His, the acute angle formed by the esophagus meeting the stomach. This angle functions as a natural anti-reflux barrier, and its alteration or “blunting” during the sleeve procedure weakens the mechanical defense.
The surgical removal of the stomach’s dome-shaped upper section, known as the fundus, also contributes to the issue. The fundus is the most compliant part of the stomach and acts as a reservoir to accommodate food without a large pressure increase. Without this compliant area, the remaining tubular stomach is less able to buffer pressure changes, increasing the upward force on the LES.
Another anatomical factor is the presence of a hiatal hernia, where a portion of the stomach pushes up through the diaphragm. Hiatal hernias are common in patients with obesity and greatly increase the risk of GERD. If a hiatal hernia is present but not repaired during VSG, or if a new one develops, it can exacerbate severe post-operative reflux by compromising the LES.
Treatment Options for Post-Surgical Reflux
Managing acid reflux after a gastric sleeve typically begins with a non-surgical approach combining lifestyle changes and pharmacological treatment. Patients are advised to adopt specific eating behaviors, such as consuming smaller, more frequent meals to reduce volume and pressure in the sleeve. Avoiding trigger foods like carbonated drinks, caffeine, chocolate, and spicy items can also help reduce acid production and irritation.
Lifestyle adjustments include posture; patients should remain upright for at least two hours after eating and elevate the head of their bed to prevent nighttime reflux. Pharmacological management usually involves acid-suppressing medications. Proton Pump Inhibitors (PPIs) are the first-line medical therapy, highly effective at reducing the amount of acid the stomach produces.
If symptoms persist despite optimized PPI use and adherence to lifestyle modifications, other medications, such as H2 receptor blockers, may be added, particularly to control nocturnal acid production. For a small percentage of patients, the reflux remains severe, leading to complications like esophagitis or difficulty eating. This is described as refractory GERD.
For patients with severe, refractory GERD following VSG, a surgical revision is often considered the definitive treatment. The most common revisional procedure is converting the gastric sleeve to a Roux-en-Y Gastric Bypass (RYGB). The RYGB procedure is mechanically an anti-reflux operation because it completely diverts the acid-producing stomach from the esophagus, effectively resolving symptoms in a large majority of patients.