Category: esophageal motility
Surgery for Reflux
August 02, 2025 6:58 pm
Surgery for Reflux
Gastroesophageal reflux disease (GERD) is a common gastrointestinal problem in both the general population and post-weight-loss surgical patients.
The general population may have GERD symptoms with weight gain, pregnancy, hiatal hernia, Helicobacter pylori infection, gallstones, ulcers, motility issues of the esophagus or stomach, and other conditions. With proper workup, they all have their specific treatment plans. In a post-weight-loss surgical patient, some of the exact causes may be present in addition to those that may be specifically related to the type of surgery and its unique side effects and complications.
There is a subset of patients with hiatal hernia who should undergo surgical repair, but do not. There has been a series of publications from over 15 years ago that have been embraced by the gastroenterologist who frequently, incorrectly, dismisses Nissen fundoplication as an effective surgical tool for the treatment of GERD and hiatal hernia.
The treatment for GERD with a hiatal hernia, regardless of size, is Nissen Fundoplication and not lifelong use of proton pump inhibitors (omeprazole, pantoprazole) and other classes of medication. It should be noted that these medications were never approved for long-term use and can cause significant metabolic and gastrointestinal side effects.
Recent publications have shown that not only the old data that gastroenterologists frequently rely on was not reliable, but also that surgery is very safe and effective with a very low rate of short and long-term complications.
Three Different Problems: Gastritis, Gastroesophageal Reflux, and Bile reflux Gastritis
June 05, 2025 4:52 am
Gastritis is a general term used for the description of symptoms associated with several very different physical conditions and require different treatments based on their ideology . Gastritis, gastroesophageal reflux, and bile reflux gastritis
Gastritis may be caused by excess acid or bile in the stomach. Some patients may have gastroesophageal reflux due to a hiatal hernia, which needs to be treated surgically with Nissen fundoplication, regardless of the size of the hernia, contrary to what gastroenterologists recommend by prescribing antacids for an extended period. I have seen patients who have had one cm hiatal hernia and have been very symptomatic, and others who have had larger hiatal hernias and have been asymptomatic. Size should not be a determinant of whether the patient has had or will have a hernia repair or not.
Billiary Diversion is the definitive surgical procedure for Bile Reflux Gastritis.
Bile Reflux Gastritis and Cholecystectomy
May 21, 2025 2:41 pm
Bile reflux gastritis is not a the result of the cholecystectomy but may be seen in a subset of patient with other confounding conditions. Bile is produced in the liver and stored in the gallbladder. In response to high fat and protein in the stomach, the gallbladder contracts to ” squeeze” the bile stored in the gallbladder into the small bowel to help absorb the fat and protein.
With the gallbladder removed, the bile produced by the liver cannot be stored and goes directly to the small bowel via the biliary tree.
It is possible and likely that some of the bile will find its way back to the stomach. In some patients, due to compounding circumstances, the bile may collect and cause gastritis. We need to dissect this a little for it to make sense.
- Not every patient after cholecystectomy will have bile in their stomach.
- Not every patient with bile in the stomach has gastritis.
To appreciate this, let’s remember that for bile to get from the small bowel to the stomach, it needs to:
- Go upstream, against the peristalsis of the small bowel, and do not be washed down by the flow of the gastric
- juices coming out of the stomach.
- Go through the pyloric valve.
- If it reaches the stomach, the acid in the stomach does not neutralize it, causing gastritis.
As I’m sure we all appreciate, other contributing factors besides cholecystectomy may cause bile reflux and bile reflux gastritis. This is why it’s also emphasized that bile in the stomach alone does not confirm biliary reflux gastritis. It is also why we always state that bile reflux gastritis is a disease of exclusion, where other conditions such as gastroparesis, acid reflux, and hiatal hernia (regardless of size, as some patients are unfortunately told that since the hernia is small it does not need to be fixed, which is incorrect) must be considered. Further information on Bile Reflux.
Billary Diversion is the only definitive surgical procedure for Bile Reflux Gastritis.
A patient story: Lap Band complication and Wegovy
October 24, 2024 4:30 pm
Not too long ago, I saw an old patient who had seen me years ago after having had a lap band placed for weight loss. At the time, I recommended that the lap band be removed and that alternative plans be made. I suspected a slipped band. We discussed the reality that after the band removal, weight gain is to be expected. Several surgical options were discussed, and the patient dismissed them as “too radical.” The patient decided to “deal” with the ongoing nausea and vomiting since it was a small price to pay for the weight loss. I warned the patient that elective removal of the band is much safer than an emergency procedure in the middle of the night when it is least convenient. The patient did end up with an emergency lap band removal and was started on GLP-1 Agonists (Wegovy) because of the weight gain that followed the band removal. The side effects of the medication were debilitating, with nausea, dizziness, and fainting due to low blood sugar. The drug has all been stopped, and most, not all, of the side effects are resolved. The plan is to get this patient in a better shape and, reevaluate the esophagus and the stomach, and formulate a strategy based on the blood work, upper endoscopy, upper GI study findings and decide if the patient will be a good candidate for the Laparoscopic sleeve or the duodenal switch operation.
Here are my recommendations:
- Patients should avoid lap bands. Those with lap bands, regardless of how they feel and whether they are having issues with them, should have the lap band removed immediately before they end up in the emergency room or have irreversible changes to the cells or function of the stomach and esophagus.
- Patients who have the lap band removed will have less weight loss with the sleeve than those who have the sleeve as the primary procedure (the lesson here is that a less invasive, seemingly easy solution is much worse long term; more on this below). Lap Band patients should be revised to the duodenal switch, SPIS, SADI, or Gastric bypass if they have substantial weight to lose.
- GLP-1 agonist medication should be avoided. It is not a solution to the underlying problem but a band-aid covering the metabolic derangement.
- GLP-1 agonist medication needs to be taken long term, and there is no exit strategy– when the patients stop taking the drug, the weight comes back, in addition to the complication associated with it.
- I have also heard that “if it were bad, then the FDA would not approve it.” well, let’s think about it: the FDA approved the Lap band and Phen-Fen, and we all know how these worked out.
- There are no shortcuts, simple injections, or a pill for the complex, multifaceted condition of obesity. Advocating solutions with no long-term outcome, significant complications, and safety concerns is irresponsible.
- A diabetic patient should take the medication LIFELONG to control their blood sugars, including the GLP-1 agonist class of drugs. The concerns are for these medications being used for the treatment of obesity
Radiology film of normal position and a slipped LapBand
SUMMARY: Buyers beware- those who choose to embark on the dangerous load of GLP-1 agonist medications should be prepared to deal with the short and long-term complications of the medication and its withdrawal. This is like the problems that are being seen with patients who choose to have a lap band because it was advocated as simple, reversible, and the Phen fen medication for weight loss with the associated cardiac complication.
https://www.dssurgery.com/wp-content/uploads/2024/09/P000008S017b.pdf
https://www.dssurgery.com/wp-content/uploads/2024/09/20-year-all-procdure-metaanalysis.pdf
https://www.dssurgery.com/weight-loss-injection/
https://www.dssurgery.com/glp-1/
https://www.dssurgery.com/weight-loss-medications-compared-to-surgery/
https://www.dssurgery.com/articles/glp-1-agonists-a…agency-clinicians/
https://www.dssurgery.com/articles/managing-the-gas…clinical-practice/Failure of Anti-Reflux Procedures
September 28, 2015 7:13 am
A recent study Published in JAMA Surgery, quoted rate of 10-20% of patients who have had anti-reflux surgical procedures will have recurrence of his symptoms within the research data. There are numerous studies that have identified predictive factors leading to return of the symptoms after surgical intervention. Some of these predictive factors are improper diagnosis, inadequate work up and technical issues.
Due to the significant rise of sleeve gastrectomy as well as a high failure rate of the lap band, we have seen several patients presenting with significant reflux disease after weight loss surgery. There is a little scientific data regarding the failure of anti-reflux procedures in patients who have had previous weight loss surgical operations. In our practice, however, we have extensive experience with anti-reflux operations in patient who have had previous weight loss surgeries including Gastric Bypass, Adjustable Gastric Banding, Sleeve Gastrectomy and Duodenal Switch operation.
Improper diagnosis, inadequate work up, and technical issues have been cited as possible causes for recurrence of symptoms in patients who have not had weight loss surgery. One could assume that those variables are still a factor in addition to other factors resulting from a previous weight loss surgery. The complications of a previous weight loss surgery can not be under-estimated; an example would be a patient with significant esophageal motility issues directly related to an Adjustable Gastric Band. Other situations that exacerbate symptoms of reflux are an hour glass shaped sleeve or a stricture mid stomach post Sleeve Gastrectomy or Duodenal Switch.
In our experience, some patients have responded well with anti-reflux surgical procedures and mesh placement if indicated after a compete work up with has included and upper endoscopy, upper GI series, manometry and Ph studies. Any patient with symptoms of reflux after weight loss surgery, should be evaluated, and a complete work up should be performed to establish the proper treatment options. It is not wise to have patients be treated with proton pump inhibitors as a default treatment without a complete work up for any patient with reflux. These class of medications have significant side effects associated with them. Furthermore, prolonged reflux is a factor in development of Barret’s Esophagus, a pre-cancerous condition.
GERD, Nausea and Vomiting- Don’t ignore it!
April 28, 2015 11:30 am
Gastroesophageal Reflux Disease is a serious matter and should not be left untreated. It is know as heartburn or reflux and if you are experiencing more than twice a week you should be evaluated by a physician to investigate the cause. Listed below are some of the causes and end results of not treating GERD.
Esophagitis – An irritant that can be acid, bile, food and digestive enzymes coming back up the esophagus can cause irritation and swelling in the esophagus. If left untreated, it can damage the lining of the esophagus to the point of erosion and scarring. Bile Reflux may also be a cause of esophagitis and Duodenogastroesphogeal reflux (DGER). Bile Reflux information here.
Esophageal Stricture – Scar tissue can cause the lumen of the esophagus to become smaller and narrow. This stricture makes it difficult or painful to swallow foods. If a stricture is narrow enough food may become stuck and require intervention for removal and treatment. This can also put a person at risk for choking. The treatment includes ballon dilation with an endoscope and in cases where it recurs surgery may be required.
Esophageal Ulceration– If GERD is left untreated it can progress to actual ulcerations in the esophagus. Patients may cough up or vomit blood or see it in their stool as dark tarry or coffee ground type stool.
Gastric Stricture– After weight loss surgery such as sleeve gastrectomy, RNY Gastric Bypass, Duodenal Switch, SADI/Loop, Adjustable Gastric Banding, or other gastric surgeries a narrowing of the inner opening of the stomach can result from scar tissue forming. This will require a surgical procedure to rectify. The symptoms can be food intolerance, full feeling, nausea and/or vomiting. (See pictures below)
Hiatal Hernia– An anatomical weakening or enlargement of the opening of the diaphragm muscle where the esophagus meets the stomach. This defect can allow a portion of the stomach to slide or roll into the chest cavity. This then causes reflux of gastric juice and content. Hiatal Hernia’s can also form on weight loss surgical patients. There are several examples within this blog here.
Breathing Difficulties– The acid aspiration while sleeping can make asthma and other breathing difficulties worst and can cause coughing and other issues.
Dental Issues – The acid, food, digestive enzymes backing up into the esophagus and mouth can cause dental issues such as erosion and tooth decay. In regards to dental issues after weight loss surgery there are also other vitamin and mineral deficiencies that can cause oral health issues. Dental Issues after WLS here.
Lower Quality of Life– GERD can affect a person’s quality of life. If you are in discomfort from acid reflux or having food intolerance it can make life difficult. It can also alter food choices and impact nutrition.
Barrets Esophagus– Pre-cancerous changes in the bottom portion of the esophagus due to long term acid exposure from gastric reflux. Diagnosis requires and endoscopic procedure (EGD) and biopsy.
Esophageal Cancer– There is a significant rise in the western world in esophageal adenocarcinoma. The main risk factors are alcohol use, smoking, untreated GERD, and poor diet.
Reflux and difficulty with swallowing caused by stricture is not normal. These problems are quite frequently encountered as complication of Adjustable gastric banding, with slipped band or a band that is too tight and scarred in placed resulting is belt effect. This results in the esophagus not being able to empty and propel the food down. The end result is significant reflux, with difficulty swallowing, nausea, vomiting etc. Similar problems are seen with Gastric bypass where the anastomosis between the stomach pouch and the small bowel RNY limb is too narrow. In Gastric Sleeve and Duodenal Switch operations, is the sleeve is made too narrow, or misshaped (hour glass, funnel, cork screw) it will result in the patient having reflux and symptoms of stricture. One specific problem with the new operation of SADI is the concern for risk of bile reflux, similar to the BillRoth I procedure.
Gastric bypass patient with stricture at the gastro-jejunostomy before and after balloon dilation. Fig A
After balloon dilation. Fig B
Fig. C : Lap band Patient with stricture where the band as removed at another facility and the scar tissue formed around the GE junction was not taken down. The patient had to be taken back to the operation room after his symptoms persisted even though the band had been removed 3 months prior.
A corkscrew stomach of a Duodenal Switch done at another facility, with the patient presented with persistent reflux, nausea and vomiting for years after surgery. Fig. D
This is not an inclusive discussion of GERD and the treatment. Please see your healthcare providers if you are experiencing any symptoms pertaining to GERD or any other health care issue.
Surgical Treatment of Esophageal Achalasia (Esophageal Motility Issue)
January 23, 2015 6:50 pm