GERD, EGD results, and Sleeve vs. Bypass?

[carolinafirefly 21]

I'm new here and haven't even introduced myself yet, so forgive me for skipping that part and jumping straight in with a question, but my surgery is scheduled for exactly 1 week from today and I'm feeling the need to get a decision made quickly.

I've been in preparations for bariatric surgery for a year now. The plan was always for sleeve. The intestinal rerouting thing just scares the bejeezus out of me, but it's really the rates of longterm complications that scare me the most about RNY, especially the "lightning strike" complications like internal hernia that can pop up unexpectedly years down the road, probably when you're hiking and about 100 miles from any decent hospital if you have my luck. I was much more comfortable with the idea of VSG.

However... I have a long history of GERD. It's milder when I lose weight but still there, and I had to switch from ranitidine to a daily PPI (omeprazole 20 mg) several months ago because the ranitidine just wasn't doing it for me anymore. Even with the PPI, I've sometimes had breakthrough heartburn and admit I've taken a second omeprazole later in the day every now and then for it. I figured I'd just have to stay on a PPI after surgery and convinced myself that would be a better option than taking on the added risks of RNY, but my pre-op EGD this morning showed LA grade A esophagitis (i.e. mild esophagitis) and a small hiatal hernia. Those were just the initial impressions and the final report and biopsy results aren't in yet, but the surgeon showed me about how big the hernia is and I'd guess it's 2-3 cm.

He says no problem, it can be fixed during surgery and we can treat GERD with medications or, eventually, even LINX if needed, but I'm concerned for a few reasons. It seems ominous to me that I have even mild esophagitis after several months adherence to a PPI regimen that's supposed to heal acid damage. I'm thinking that means I'd have to be bumped up to a higher/more frequent PPI dose after surgery just to keep things stable if I'm lucky. I'm a research person, so I've reviewed most of the recent research regarding GERD and the sleeve, and it looks like there is a large chance of the esophagitis worsening in grade after VSG. It also looks like there's a huge chance of recurrent hernia despite repair and as much as a 1 in 8 chance (according to one small study) of needing revision to RNY later. With that factored in, my chances of needing additional surgery after a sleeve actually appear to be the same or higher than my chances of needing additional surgery after RNY. I also wouldn't look forward to having to pay for EGDs every year to reassure myself that my esophagitis hasn't turned into Barrett's.

The general consensus of everything I've read leans toward RNY over sleeve for preexisting GERD, but this doesn't match my surgeon's encouragement to go with sleeve. Then again, he might have that can-do attitude because he knows how much I originally wanted the sleeve? I don't know. Anyway, needless to say, I'm having major second thoughts about the sleeve, but I have so little time left to decide and I'm worried about making the wrong decision. I was hoping my EGD results would give more clarity, but they just seem to have made the waters even murkier.

If you made it through that longgg post, I guess my question for you guys is: Am I being overdramatic about a little heartburn? Did any of you have esophagitis on your pre-op EGD? Which surgery did you choose and how did it work out? All opinions and anecdotes welcome and thank you in advance!

Edited January 14, 2019 by carolinafirefly

[trasib 37]

i had some mild heartburn pre Gastric sleeve back in 2015. Nothing I would ever classify as terrible - I and my doctor attributed it to a side effect of carrying so much extra weight.

Fast forward to today. I have major GERD, all the makings of Barretts, a healthy hernia I've named Herbert and reflux levels off the charts. I am going in for a revision from sleeve to RNY on Wednesday.

My surgeon (same for both procedures) wishes he had gone with his gut and ordered the EGD before surgery last time as his method may have changed. I dont blame him one bit, however, and we're both pretty sure it came about as a result of the sleeve- both are known complications, unfortunately

Whatever you decide is best for you - I wish you all the luck in the world!

[notmyname 593]

I had GERD before surgery. No esophagitis, but I did have a hernia. Before surgery I was on 40mg Nexium 2x/day. For a lot of the same reasons as you, I didn't want to do RNY. I went to three different surgeons to discuss. One refused to do the sleeve, the other two were fairly comfortable with the sleeve (one of which still said he'd prefer RNY). Ultimately, I did a sleeve with hernia repair last October. I started having break-through reflux even on my meds about 3 weeks ago. Doc put me on another PPI (so that's 3 reflux meds a day). He said we won't really know if this is permanent for a few more months. If I still have GERD at my next appt, I'll have to do another endoscopy. So far, it isn't bad enough to regret it, but I bet it hasn't been long enough for me to form a real opinion one way or another. So, I don't really have any advice for you, just wanted to let you know my experience. I did find it useful to talk to the three different doctors about it, and would advise a 2nd opinion, just to see what another doc would say.

Also, I will say that one woman in my support group who had RNY ended up with reflux afterwards. Although I understand that is exceedingly uncommon.

Edited January 14, 2019 by notmyname

[mskami77 295]

I'm 5 years out RNY. I also had Gerd pre-op and my doctor would only do RNY. I haven't had any complications, strictures, hernias or anything of the sort. I stay pretty active and hike often. I think better time is spent researching your surgeon and their rates of complication. That has a much greater effect on your personal outcome than overall averages. If you're confident in your surgeon, I'd say go with the sleeve but be open to revision if necessary. Good luck on your surgery.

HW 314 SW 296 GW 177 CW 169

[GreenTealael 25,358]

56 minutes ago, carolinafirefly said:

I'm new here and haven't even introduced myself yet, so forgive me for skipping that part and jumping straight in with a question, but my surgery is scheduled for exactly 1 week from today and I'm feeling the need to get a decision made quickly.

I've been in preparations for bariatric surgery for a year now. The plan was always for sleeve. The intestinal rerouting thing just scares the bejeezus out of me, but it's really the rates of longterm complications that scare me the most about RNY, especially the "lightning strike" complications like internal hernia that can pop up unexpectedly years down the road, probably when you're hiking and about 100 miles from any decent hospital if you have my luck. I was much more comfortable with the idea of VSG.

However... I have a long history of GERD. It's milder when I lose weight but still there, and I had to switch from ranitidine to a daily PPI (omeprazole 20 mg) several months ago because the ranitidine just wasn't doing it for me anymore. Even with the PPI, I've sometimes had breakthrough heartburn and admit I've taken a second omeprazole later in the day every now and then for it. I figured I'd just have to stay on a PPI after surgery and convinced myself that would be a better option than taking on the added risks of RNY, but my pre-op EGD this morning showed LA grade A esophagitis (i.e. mild esophagitis) and a small hiatal hernia. Those were just the initial impressions and the final report and biopsy results aren't in yet, but the surgeon showed me about how big the hernia is and I'd guess it's 2-3 cm.

He says no problem, it can be fixed during surgery and we can treat GERD with medications or, eventually, even LINX if needed, but I'm concerned for a few reasons. It seems ominous to me that I have even mild esophagitis after several months adherence to a PPI regimen that's supposed to heal acid damage. I'm thinking that means I'd have to be bumped up to a higher/more frequent PPI dose after surgery just to keep things stable if I'm lucky. I'm a research person, so I've reviewed most of the recent research regarding GERD and the sleeve, and it looks like there is a large chance of the esophagitis worsening in grade after VSG. It also looks like there's a huge chance of recurrent hernia despite repair and as much as a 1 in 8 chance (according to one small study) of needing revision to RNY later. With that factored in, my chances of needing additional surgery after a sleeve actually appear to be the same or higher than my chances of needing additional surgery after RNY. I also wouldn't look forward to having to pay for EGDs every year to reassure myself that my esophagitis hasn't turned into Barrett's.

The general consensus of everything I've read leans toward RNY over sleeve for preexisting GERD, but this doesn't match my surgeon's encouragement to go with sleeve. Then again, he might have that can-do attitude because he knows how much I originally wanted the sleeve? I don't know. Anyway, needless to say, I'm having major second thoughts about the sleeve, but I have so little time left to decide and I'm worried about making the wrong decision. I was hoping my EGD results would give more clarity, but they just seem to have made the waters even murkier.

If you made it through that longgg post, I guess my question for you guys is: Am I being overdramatic about a little heartburn? Did any of you have esophagitis on your pre-op EGD? Which surgery did you choose and how did it work out? All opinions and anecdotes welcome and thank you in advance!

Hi,

I don't know what your insurance is like but usually the approval of surgery and coverage is very specific (based on the surgical coding) so you may not be able to simply substitute or change it at the last minute (surgeon maybe able to under extreme emergencies during surgery). You may want to check on that first.

Next speak with your Surgeon one more time and tell them you are strongly considering RNY now, get their feedback. Seems like you've done all the research and have all the information, no one can make this choice besides you and the surgeon, together.

GERD can transform into more serious conditions, I personally would not have risked it. But you must do what is absolutely best for you.

Safe Journey 🎈

[carolinafirefly 21]

2 minutes ago, GreenTealael said:

I don't know what your insurance is like but usually the approval of surgery and coverage is very specific (based on the surgical coding) so you may not be able to simply substitute or change it at the last minute (surgeon maybe able to under extreme emergencies during surgery). You may want to check on that first.

Very good point. I signed a consent for both surgeries when I was there for my last pre-op visit, and it only took 1 day for my insurance approval to come through, so hopefully it wouldn't be held up. You never know with insurance companies, though.

[elcee 3,341]

Lightning strike complications, what the heck are they? I have 2 days to go to my revision to RNY and thought I was well educated and well prepared but I haven’t seen lightning strike complications in anything I have read!

I still don’t understand why people fear RNY with its rerouting that technically can be reversed if it has to be but they don’t fear having most of their stomach chopped off and thrown in the bin never to be seen again!

I wouldn’t have a sleeve if I had Reflux. It is fairly common knowledge now that the sleeve is not a cure for Reflux and can exacerbate it if you already have it.

[carolinafirefly 21]

9 minutes ago, elcee said:

Lightning strike complications, what the heck are they? I have 2 days to go to my revision to RNY and thought I was well educated and well prepared but I haven’t seen lightning strike complications in anything I have read!

lol Sorry for causing confusion, elcee. For some reason, that's just how I think of the later complications. With sleeve, complications other than GERD tend to happen peripoperatively and not years later, but certain risks with RNY are ongoing and there are small chances of complications even many years later (e.g. ulcers, internal hernias, bowel obstruction). Even if the risks were equal, this sorta freaks me out a bit since I hope to travel places that might not have the best medical care in the future. I liked the idea of there being a point in time a couple of months after surgery when I could relax a bit and think, "Well, if something bad was gonna happen, it probably would have happened already" if that makes sense.

Edited January 14, 2019 by carolinafirefly

[GreenTealael 25,358]

8 minutes ago, elcee said:

Lightning strike complications, what the heck are they? I have 2 days to go to my revision to RNY and thought I was well educated and well prepared but I haven’t seen lightning strike complications in anything I have read!

I still don’t understand why people fear RNY with its rerouting that technically can be reversed if it has to be but they don’t fear having most of their stomach chopped off and thrown in the bin never to be seen again!

I wouldn’t have a sleeve if I had Reflux. It is fairly common knowledge now that the sleeve is not a cure for Reflux and can exacerbate it if you already have it.

Lightning strike as in very rare occurrence

[GreenTealael 25,358]

1 minute ago, carolinafirefly said:

lol Sorry for causing confusion, elcee. For some reason, that's just how I think of the later complications. With sleeve, complications other than GERD tend to happen peripoperatively and not years later, but certain risks with RNY are ongoing and there are small chances of complications even many years later (e.g. ulcers, internal hernias, bowel obstruction). Even if the risks were equal, this sorta freaks me out a bit since I hope to travel places that might not have the best medical care in the future. I liked the idea of there being a point in time a couple of months after surgery when I could relax a bit and think, "Well, if something bad was gonna happen, it probably would have happened already" if that makes sense.

You'd be surprised how well physicians are trained all over the planet... You can pay for travellers medical coverage too.

We live in a Global society now.

[elcee 3,341]

There are quite a few with a VSG too, maybe not lightning strikes but definitely rumbling thunder possibly building to thunder claps!

https://www.verywellhealth.com/long-term-complications-after-gastric-sleeve-surgery-4158320

[carolinafirefly 21]

Thanks, y'all. I feel a little calmer about it tonight. I read the prior auth I got from my insurance company, and it just says "surgery for morbid obesity" is approved, so I think it may (hopefully) be good for either/or. Still weighing the options, and all your comments have really helped with that.

[Noot 3]

I had revision surgery from sleeve to bypass on 1/10. The revision was needed to address my out of control GERD that was not responding to medications. I have unfortunately hit the “trifecta” of weight loss surgeries. Banded in 2007, sleeved in 2015 after the band began leaking, and now in the process of recovering from bypass. I never had GERD until I had the sleeve. Wish I had skipped the sleeve and gone to bypass directly. To top it off, I was self pay all the way! BUT - I have no regrets. Good luck with your decision making journey and I wish you the best❤️

[carolinafirefly 21]

Well, I spent most of the day still trying to make a decision, and then the phone rang. As soon as I heard my surgeon's voice, I knew what he was gonna say because surgeons don't just call you themselves for no good reason.

The biopsy of the "LA Grade A esophagitis" showed Barrett's. Decision made. But man, am I scared about surgery on Monday. The weirdest fear running through my mind tonight: What if the zombie apocalypse happens and I survive the zombies just to run out of Vitamins and die a slow death from malnutrition? My son's been playing The Last of Us lately, so that might have something to do with it, but it's true that I'm nervous about being so reliant on vitamins.

My family, who didn't support me that much in my decision to get WLS in the first place, is even more worried now, especially my mother. I get it. I'd be anxious if it were my son getting the surgery. I'd be like, "What? I made you with a perfectly good intestine, and now you wanna go cutting it up?" No, not really, but I'd think it. Speaking of my son, he's pretty anxious about the whole thing, and I hate worrying him. Another stressor is the fact that GreenTealael was right! They have to resubmit to my insurance company! The surgeon mentioned this, and we're both just hoping it gets approved in time for my surgery date to stay the same. The sleeve was approved in only 1 business day, so hopefully it won't take longer than that.

On top of all of that, I'm now scared about the Barrett's. I didn't even find out from the doctor if I have any dysplasia with it before hanging up. He just said we'd do another EGD in a couple of years. I'd imagine we'd be doing more than that, maybe, if there were already dysplasia, but I really don't know. I'll have to call and ask tomorrow. Right now, I'm scouring bariatricpal forums for stories from others who had Barrett's and had a really good outcome from gastric bypass. If any of you have a story like that or know of any, please share!

[GreenTealael 25,358]

Best thing about the zombie apocalypse and being marooned on Mars is you'll likely run out of food before vitamins...

Silver linings

You'll do great, eventually the villi (sp) grow back in the intestines and malabsorption risks decrease the further out you get. The body is wonderful and resilient (like it's owner)

You're going to be amazed by what a difference a year will make, promise.

Edited January 16, 2019 by GreenTealael