Sleeve, Impact on Acid/Gerd, Hiatel Hernia, and Size does Matter-

Hi,

I am heading into gallbladder surgery and via this process a "large" hiatel hernia was discoverd. I am doing a little digging around due to this being  4 years darn near to the day of my Vsg and origianl hiatel hernia repair. Anyway, just read this article and it directly addresses very common questions here and completely dispels the idea that in order to be succussful you need a sleeve smaller than 40. I will post highlights, but here is a link for the details. These are all direct quotes unles otherwise noted.

Acid/Gerd if hiatel hernia is repaired:

1. ..."Consensus statement from the International Sleeve Gastrectomy Expert Panel, more than 70% of whom agreed that it was essential to identify and treat hiatal hernias when performing a sleeve procedure."
2. GERD symptoms appeared for the first time in 22.9% of the patients undergoing sleeve alone, compared with 0% of patients undergoing sleeve and hiatal hernia repair.
3. ...important pressure changes occur at the lower oesophageal sphincter following sleeve gastrectomy procedures. Crucially, this study also highlighted that stapling away from the sling fibres (1-2 cm from the GE junction) during the gastrectomy can lead to the appearance of reflux symptoms and oesophagitis post-procedure.
4. laparoscopic sleeve gastrectomy significantly increased lower oesophageal pressure independent of weight loss, and suggested that a sleeve gastrectomy may protect obese patients from GERD
5. atfour years has shown that 100% (23/23) of the patients had improved quality of life measures for GERD and 80% (20/25 were no longer using proton pump inhibitors to alleviate their reflux.
6. if a hiatal hernia is present it should be repaired simultaneously, although if GERD persists beyond 12 months then a second stage Roux-en­Y gastric bypass should be considered.

Bougie size- why 40+ is recommended:

1. ...importance of using a larger bougie when creating the sleeve, in order to reduce leakage rates
2. 112 studies and 9,991 sleeve patients, that the risk of leakage decreased with bougie sizes equal or over 40 Fr (p=0.0009) with no difference in excess weight loss between bougies under 40 Fr and over 40 Fr up to 36 months (p=0.273).
3. distance from the pylorus does not impact leak or weight loss and buttressing does not seem to impact leak.
4. Edited to add-- Taken from a different article: 

   Michel Gagner commented that the reason the failure rate was probably so high was the use of 60fr bougie, and by reducing the bougie to 30 or 40, the failure rate could fall to as little as 10%.

   "In our institution we use 40fr bougie to reduce the failure rate, and avoid over sewing to reduce strictures,"

My personal experience/thoughts:

I have a large sleeve, up in the 40s. I had no issues at all making it to goal, and I am 4 years out with crazy good restriction. Doesn't matter though when I choose to eat around my sleeve. I am highly skilled at overeating, so even with a much smaller sleeve I could eat around it. Hunger is still minimal 4 years post op, but my recent bouts with acid issues does mimic it. There was a slight regain during the period of untreated acid issues (eating makes it feel better briefly). 

I had terrible reflux prior to surgery. The doc repaired the hiatel hernia during the vsg. The surgery was worth the relief I experienced from that alone. This past summer I started having a lot of stomach issues- acid, vomiting, nauseau, bloating primarily. I was put on 40 mg omnaprazole (Prilosec) which helped a lot. But the gallbladder went bad. While getting that diagnosed the CT scan showed a "large" hiatel hernia again- probably not a coincidence the acid issues reared up again. My surgeon thinks that the CT was misread, so I was sent in for an upper gi today. I will know the results Monday just in time for surgery and will post an update. 

So, can acid be an issue post sleeve? Yes. BUT, if the hernia is repaired during surgery folks tend to do well. Unless, like in my case, the hernia returns. I just saw in this article that a revision to Rny is recommended. Oh goodness, I hope that is not if my future given I have no desire to lose more weight other than putting about 5 pounds worth of wiggle room back in. But, if that is the path that is recommended then I will travel it. 

Educate yourself when learning about the process both pre and post surgery! 

thank you for sharing this information.  Every pt is so different and so is each physician...we must educate ourselves on many things in regards to our WLS procedure.

Best of luck with your findings and any procedure that may follow.

My hiatal hernia was repaired with my VSG, but it has returned (although it is small . . .too small to do anything about according to my surgeon).  I'm one of the unlucky few who is now suffering from pretty significant GERD (Im on the maximum dose of PPI and have added in 150mg of Zantac a day).  I'm discussing solutions with my surgeon and we both agree that a revision is not in my future.  So, there are other options out there!  Good luck!!!

Thank you for posting this.  It was very informative.  And it once again proves that WLS, particularly the sleeve, is not a one size fits all solution.

Curious to hear the outcome with the original post. 7 years post of RNY and told I have a hiatal hernia.  

I am about 6 weeks out from surgery. The first few weeks I could tell it was swollen a bit, had a little trouble with swallowing pills- very similar to the first time through. Now it seems to have healed pretty well. Still being careful with what I eat- soft food. I am still taking a PPI though. I had the gallbladder out at the same time, and that is taking a while to get the digestive system back on track so I am not sure if the acid is caused a bit due to the gallbladder situation. Overall though- it went well.