How significant is GERD in VSG and what causes it?
I don't think that's the case, but I'm not sure. I believe that stomach acid is produced by the parietal cells of the stomach, and those line the entire organ. Most pictures show acid in the lower portion of the stomach, but that's due to gravity more than production location.
But.. IANAD! (I am not a doctor.)
VSG with Dr. Salameh - 3/13/2014
Diagnosed with Binge Eating Disorder and started Vyvanse - 7/22/2016
Reconstructive Surgeries with Dr. Michaels - 6/5/2017 (LBL & brachioplasty), 8/14/2017 (UBL & mastopexy), 11/6/2017 (medial leg lift)
Age 42 Height 5'4" HW 319 (1/3/2014) SW 293 (3/13/2014) CW 149 (7/16/2017)
Next Goal 145 - normal BMI | Total Weight Lost 170
TrendWeight | Food Blog (sort of functional) | Journal (down for maintenance)
Parietal cells which create acid are largely absent from the RNY pouch due to them (generally) being in the bottom 2/3ish of the stomach. It's both the pylorus being absent and this which prevents acid.
The alimentary limb created for the RNY and DS both also prevents bile reflux; it becomes very difficult (near impossible really) to have it after.
I follow a ketogenic diet post-op. I also have a diagnosis of binge eating disorder. Feel free to ask me about either!
It is not that we have so little time but that we lose so much...the life we receive is not short but we make it so; we are not ill provided but use what we have wastefully. -- Seneca, On the Shortness of Life
It's unclear how prevalent it is DUE to VSG, because correlation does not equal causation. For example, I've got fructose malabsorption. If I eat something that's high in fructose, it leads to stomach acid. Is that due to VSG? Nope, since I had it prior to VSG. However, my stomach is now smaller so it's more noticeable post-VSG than it was prior. (And I do wonder how much of the time acid issues are related to unrealized food intolerances.)
What causes acid to be an issue? Boyle's Law. In a nutshell this means "decreased volume leads to increased pressure." When the stomach volume decreases, the increase in pressure can cause acid that was happily hanging out in your stomach to get pushed up into the esophagus. This isn't a problem with RNY because the valve/sphincter at the "bottom" of the stomach, the pyloric valve, is removed, so the RNY stomach is not the same high pressure environment as the VSG stomach is with it's intact pyloric valve.
It has nothing to do with volume of food.
Some people have pre-existing acid issues that are caused by hernia and this can be fixed during surgery. Some people have pre-existing acid issues for other reasons - dietary or whatever. Sometimes this continues to be a problem post-VSG. Sometimes it doesn't. Sadly, it's sort of a crapshoot.
I never had problems with acid prior to surgery, at least not that I was aware of. I rarely ingest(ed) high fructose things because of my fructose malabsorption. When I accidentally did it post-op and had the acid issue, it freaked me out until I figured out the cause! Due to my paranoia, I am considering asking my bariatric surgeon for an upper endoscopy at my 4 year follow-up next month. Just to make sure everything is okay in there.
All that said, if I had a history of acid issues prior to WLS and there wasn't an obvious cause such as hernia, I would get the RNY every day of the week and twice on Sunday. There's no way I'd even consider VSG.
Thank you for your thorough and excellent explanation. It is much appreciated. I have never had any problems with GERD so I'm certainly hoping I don't develop any following the procedure. Do you know or are there any statistics on what percentage of people develop GERD following VSG surgery?
If it's fairly low, like perhaps 10%-15% I think the risk is definitely worth it; if it's 50%-60% that could be a real cause for concern.
Finally, is GERD usually controllable with PPI's or the like?
There are studies out there (I recommend searching on PubMed.gov) and some people here will claim 50% but, again, correlation is not causation so it's hard to know. It's something worth asking your surgeon about and what their rates of GERD post-op are.
As for PPIs, as a prior commenter alluded to, you do not want to be on PPIs longterm. Recent studies show that they're not safe for longterm use. So while it's fine for us to take them in the first 3-6 months post-op to get our acid production under control, revision to RNY is likely safer for longterm health.
VSG with Dr. Salameh - 3/13/2014
Diagnosed with Binge Eating Disorder and started Vyvanse - 7/22/2016
Reconstructive Surgeries with Dr. Michaels - 6/5/2017 (LBL & brachioplasty), 8/14/2017 (UBL & mastopexy), 11/6/2017 (medial leg lift)
Age 42 Height 5'4" HW 319 (1/3/2014) SW 293 (3/13/2014) CW 149 (7/16/2017)
Next Goal 145 - normal BMI | Total Weight Lost 170
TrendWeight | Food Blog (sort of functional) | Journal (down for maintenance)
It's confounded by the fact a lot of obese people have GERD pre-op - it's just silent, so it goes undetected without endoscopy. So, a lot of GERD may have been present before as well and just carried over.
I follow a ketogenic diet post-op. I also have a diagnosis of binge eating disorder. Feel free to ask me about either!
It is not that we have so little time but that we lose so much...the life we receive is not short but we make it so; we are not ill provided but use what we have wastefully. -- Seneca, On the Shortness of Life
Oh! And as for never having an issue with GERD, it can be silent - but part of the pre-op process should involve an upper endoscopy to find that out for sure. :)
VSG with Dr. Salameh - 3/13/2014
Diagnosed with Binge Eating Disorder and started Vyvanse - 7/22/2016
Reconstructive Surgeries with Dr. Michaels - 6/5/2017 (LBL & brachioplasty), 8/14/2017 (UBL & mastopexy), 11/6/2017 (medial leg lift)
Age 42 Height 5'4" HW 319 (1/3/2014) SW 293 (3/13/2014) CW 149 (7/16/2017)
Next Goal 145 - normal BMI | Total Weight Lost 170
TrendWeight | Food Blog (sort of functional) | Journal (down for maintenance)
Here's some scientific data.
https://renewbariatrics.com/heartburn-gastric-sleeve-surgery/
Why GERD may improve in some patients after gastric sleeve surgery
After gastric sleeve surgery, the weight loss leads to a reduction in intra-abdominal pressure. The resection of the fundus of the stomach significantly reduced acid production, and the rate of gastric emptying is accelerated. All these factors prevent reflux of stomach content into the esophagus resulting in a clinical improvement in the symptoms of GERD.
Why GERD may develop after gastric sleeve surgery
Following gastric resection, the large compliant stomach is converted into a less compliant banana-shaped tube. This leads to increased pressure within the stomach. Iatrogenic removal of some fibers in the lower esophageal sphincter and disruption of the anatomical anti-reflux mechanisms result in weakness of the sphincter. All these contribute to reflux of acidic contents back into the esophagus.
Stenard and Iannelli reviewed about 13 studies on gastric sleeve surgery and its effect on GERD. The mean BMI was 42kg/m2 while the average follow-up period was 29 months. One of the studies showed a persistent of GERD in up to 84% of the patients. Another study also revealed that symptoms of GERD were more in patients that had gastric sleeve surgery as compared to those that had a Laparoscopic Roux-en-Y gastric bypass.
GERD developed in about 2.1-21% of those without pre-operative evidence of GERD. A reduction in the incidence of postoperative GERD symptoms was noticed when hiatal hernia repair was added to the gastric sleeve procedure.
In another review of 12 studies involving 1863 patients by Stenard and Iannelli, the mean BMI was 51kg/m2 while the average follow-up period was 20 months. All these patients had pre-operative GERD symptoms. One of these studies showed 94% resolution of symptoms. Another study reported 41% improvement in GERD symptoms. Some of these studies showed no significant difference in symptoms between those that had sleeve gastrectomy with hiatal hernia repair and those that did not.3
The above showed that the effect of the gastric sleeve on pre-existing GERD or its role in the development of GERD varies from one individual to another and from one surgeon to the other. Surgical technique may affect the competency of the lower esophageal sphincter after gastric sleeve surgery. Doctor?s skills and experience are therefore critical in determining the outcome.
These researchers also further buttress the claim by some surgeons that gastric sleeve is not for every obese individual especially those with GERD. These set of people can have a Laparoscopic Roux-en-Y gastric bypass rather than a gastric sleeve.
Treatment of heartburn following gastric sleeve surgery involves the use of medications that reduce gastric acid secretion such as proton pump inhibitor and the use of antacids. Other maneuvers such as elevation of the head of the bed while sleeping may ameliorate symptoms. Severe cases may need a gastric sleeve revision surgery.
In conclusion, obesity is a risk factor for GERD. Many patients will have their symptoms persist after the surgery while some may experience improvement. Others without pre-operative symptoms of GERD may develop it after gastric sleeve surgery. Proper screening and patient selection should be carried out to ensure selection of patients with least risk of GERD. Those with high risk should undergo other forms of bariatric surgery. While preparing for gastric sleeve surgery, choose the best surgeon with least record of GERD complication as surgeon?s skills to play a significant role in the effect of gastric sleeve surgery on GERD symptoms.
I would want to read the actual peer-reviewed research before I'd believe claims on a site trying to sell surgeries. It's weird that this references such research, but doesn't properly cite it or provide links to it.
VSG with Dr. Salameh - 3/13/2014
Diagnosed with Binge Eating Disorder and started Vyvanse - 7/22/2016
Reconstructive Surgeries with Dr. Michaels - 6/5/2017 (LBL & brachioplasty), 8/14/2017 (UBL & mastopexy), 11/6/2017 (medial leg lift)
Age 42 Height 5'4" HW 319 (1/3/2014) SW 293 (3/13/2014) CW 149 (7/16/2017)
Next Goal 145 - normal BMI | Total Weight Lost 170
TrendWeight | Food Blog (sort of functional) | Journal (down for maintenance)
Hi ,
I am a sleeve to RNY revision. My sleeve caused major problems with GERD. Had the sleeve for 9 years. My surgeon told me that a RNY resolves 96% of GERD because of bypass. Less pressure on the esophogeal sphincter. Because of the sleeve, I was not a candidate for nissan fundoplication which is GERD surgery.
Babs in GA
HW 348 Revision SW 224 GW 165 CW 148
Revision from sleeve to RNY
Pre op: -5 M1-12 lbs M2 11 lb M3-5lb M4 -9lb M5 -2 M6-6 M7-7 M8 -4 M9-5 M10 -2 M11 -2
200 lbs lost and 17 pounds below goal !
I didn't have heartburn pre-op and I have it at least a few times per week post-op. I started having it as soon as I woke up from surgery, before eating anything and drinking only sips of water. I am slowly starting to notice what foods and patterns give me heartburn to try to avoid it for life. I don't take any medications except occasional DGL or mylanta.
