BMI

In Part One, we outlined the nature of gastroesophageal reflux and how it occurs, as well as how we detect it clinically.

So let us now assume that you are awaiting bariatric surgery and have reflux symptoms. So how does your reflux have an implication on your surgery? Will bariatric surgery (after all, we are operating on the stomach) make your reflux worse or better?

Let us take this procedure by procedure:

The Band: The band produces a mechanical obstruction right below the junction of the food pipe and the stomach. While this produces a barrier for the downward descent of food and accounts for the restriction in food intake after its placement, it does just the reverse for acid reflux. In other words, it tends to make reflux symptoms worse. Not to waste too many words on this, the Band is out if you have reflux.

The Gastric Bypass: This is the ultimate anti-reflux operation. It has a nearly 100 percent success in banishing reflux. After all, the pouch is separated from the stomach, where most of the acid is produced. What more, the small gut (jejunum) that is connected to the pouch acts to drain the acid away from the food pipe downwards. The special “Roux-en-Y” way in which we attach the jejunum to the pouch is the key to banishing reflux disease.

Sleeve Gastrectomy: Sleeve gastrectomy converts the stomach into a straight tube. In addition, it removes the part of the stomach from where muscle fibers go as a sling to loop around the LES (Lower Esophageal Sphincter). So it is possible that this operation weakens the sphincter and enhances reflux. In fact, clinically, most patients tend to have some degree of reflux after the sleeve, but this is self-limited and resolves soon. Once weight loss is begins, reflux also tends to reduce and go away.

In patients with a lax esophageal hiatus (the gap in the diaphragm through which the food pipe enters the abdomen) or with hiatus hernia, the sleeve can be done along with a repair of the hiatus (a procedure known as cruroplasty). This is also an accepted modality of treating reflux in the bariatric patient.

So the sleeve is a good bariatric procedure with a fairly good tolerance for the patient with some degree of pre-existing reflux symptoms.

The Duodenal Switch: This operation does not do much more than the sleeve for reflux. Indeed, the sleeve gastrectomy is the first part of the DS operation.

To sum up, if you are looking at bariatric surgery and you have symptoms and evidence of reflux esophagitis, then you should NOT consider the Band. If reflux is making your life miserable, then a bypass will be the best operation for you. If you don’t want the bypass for any reason, by all means consider the sleeve procedure.

In Part Three, we will examine the rest of the reflux story.