Changes in the Anatomy and Physiology of the Distal Esophagus and Stomach after Sleeve Gastrectomy

Aim: Sleeve gastrectomy is one of the most popular surgical procedures for patients with obesity. Its performance produces several pathophysiological changes at the esophago-gastric junction, gastric acid secretion, emptying and motility. Purpose: To review all pathophysiological changes of the distal esophagus and stomach after the resection of 80% of the stomach during sleeve gastrectomy. Material and Methods: Review of all publications concerning the measurements of lower esophageal sphincter after sleeve gastrectomy, as well as acid reflux, gastric motility and gastric emptying. Results: The section of some portion of the sling fibers produces dilatation of the cardia and development of pathologic acid reflux into the distal esophagus. The great majority of reports dealing with 24 h pH measurements or impedanciometry report severe acid and non-acid reflux. Gastric acid secretion is greatly diminished after sleeve gastrectomy in about 80% but the residual acid secretion is at least 20 times greater than after gastric bypass. Gastric motility and electric activity is also compromised due to resection of most of the fundus and the gastric pacemaker located at the greater curvature. As a consequence, gastric emptying of liquids and solids are greatly enhanced. Then a new swallow of food impacts against this elevated pressure which may overcome the hypotensive lower esophageal sphincter and pathologic reflux may occur into the esophagus. Conclusion: Sleeve gastrectomy is an operation which may produce severe pathologic reflux of acid, as