By Bahar Gholipour

Savannah, Ga.—Weight loss surgery (specifically, gastric bypass) has always been thought to have the side benefit of treating reflux, but doctors are learning that in fact, weight lost surgery is not always the end of the disease.

In a presentation at the 2017 Bariatric Summit, Leena Khaitan, MD, MPH, described her research with patients experiencing reflux after bariatric surgery and proposed an algorithm for how to evaluate and treat these patients.

“The old thinking is that reflux improves after weight loss surgery and symptoms go away,” said Dr. Khaitan, associate professor of surgery and director at UH Digestive Health Institute, in Cleveland. “But in my practice, I’m learning more and more that people actually can have acid reflux after gastric bypass, and that it’s not the perfect ultimate procedure for reflux disease—even though it does make it a lot better.”

Physicians are also noticing that the occurrence of reflux disease after weight loss surgery is on the rise. The reason for that is changing trends in techniques used in bariatric surgery—specifically, the increasing popularity of sleeve gastrectomy.

“Gastric sleeve is a weight loss operation that has gained momentum in the United States over a decade now,” Dr. Khaitan said. “As we do more and more gastric sleeve procedures, we see more and more patients with reflux following the surgery.”

The data on the extent of the problem are not conclusive. There’s just as much literature saying reflux gets worse as saying reflux gets better after the gastric sleeve, Dr. Khaitan said. “But the bottom line is that we know reflux after gastric sleeve is a real entity and can be devastating for patients.”

The trend has even raised questions about whether this popular weight loss procedure is the best option for everyone.

“There are more and more reports coming out showing patients after sleeve gastrectomy see that their reflux gets worse,” said Raul J. Rosenthal, MD, FACS, FASMBS, professor of surgery and chairman of the Department of General Surgery at Cleveland Clinic, in Weston, Fla. “The reasons for reflux are multifactorial. What we need is to develop an algorithm for studying patients that are having weight loss surgery and do randomized trials [from which] we can better understand if a patient gets better or worse after a gastric bypass or sleeve gastrectomy.”

To prevent a reflux problem in future patients, endoscopy should be mandatory in all patients seeking weight loss surgery, he said. “If a patient has gastroesophageal reflux disease, then the patient should be counseled to rather have a gastric bypass. If there are no signs of reflux, that patient should probably have a sleeve gastrectomy.”

Solving Reflux After Bariatric Surgery

The common approach to treat reflux after a gastric sleeve has been to convert it to a bypass. But Dr. Khaitan believes this approach needs rethinking. Sometimes patients’ symptoms are due to a problem with the lower esophageal sphincter (LES), which can be fixed without a conversion to bypass. Other times, patients are no longer obese and may not want a bypass. “So I started thinking maybe we can be a little bit more scientific about this. Let’s see what other things we can do,” she said. “So I studied people to get a better handle on what the cause of their reflux is.”

As with any patients who have reflux symptoms, doctors should start by prescribing proton pump inhibitors and later add other medications, such as metoclopramide or sucralfate, if needed. If problems persist, reflux should be evaluated using endoscopy, manometry, a pH study and other methods used to evaluate reflux.

But while evaluation of reflux in patients after weight loss surgery involves the same methods as for any reflux patient, the results should be put in the context of the surgical anatomy. Additionally, treatment options are different for bariatric patients.

After gastric sleeve surgery, the stomach can become a high-pressure system, causing malfunctioning of the sphincter. Other causes of reflux could be anatomic issues with the sleeve. Alternatively, symptoms could be due to hiatal hernia or a hypotensive LES.

First, surgeons need to locate the source of the problem. When doing endoscopy, Dr. Khaitan recommended looking for esophagitis, hiatal hernia, an anatomic cause of poor emptying (such as stricture in the stomach), infection, gastritis and bile reflux.

Studying her patients, Dr. Khaitan found that one of the more common reasons for reflux after a gastric sleeve was a narrowing in the middle of the sleeve. “In those patients, a bypass conversion is a good option. Some people have tried to stretch the area and have shown some reasonable success, but those studies are small.”

When the gastric sleeve does not have any narrowed areas, then manometry can be used to examine the motor function of the esophageal sphincter. An esophagram can be useful, too, by giving another view of esophageal function and mechanics at the LES, and can reveal anatomic abnormalities.

“We can also see from the manometry whether there’s a lot of pressure in the sleeve,” Dr. Khaitan said. The stomach after gastric sleeve surgery becoming a high-pressure system is something that is not seen with the gastric bypass. “If the patient has a lot of pressure in the sleeve, no matter how much you strengthen the sphincter, the tension of the stomach is always going to be high so it’s always going to pop open the sphincter.” In the case of a high-pressure sleeve, convert to a bypass to lower the pressure, she recommended.

Patients who don’t have pressure in the gastric sleeve may have more options. “If they have a hiatal hernia, you have to fix it. About 30% of reflux in the LES area is hiatal hernia,” Dr. Khaitan said.

“If the sphincter is loose, there are options available with newer technologies. Now we can do an augmentation of the sphincter,” Dr. Khaitan said. Augmentation can be done using technologies such as magnetic sphincter augmentation, radiofrequency energy delivery or neuromodulation (the latter of which is currently in FDA trials).

Dr. Rosenthal noted that the long-term outcome of newer technologies is not yet available. “With diseases like obesity and reflux, you want to know what happens at 10 years from now on, not at 10 months. But short-term outcomes suggest these techniques are going to work. It is a patient’s choice to have one of those if they don’t want to have bypass.”