Twelve years after sleeve gastrectomy, why am I still experiencing post‑prandial vomiting and persistent gastro‑esophageal reflux despite taking vonoprazan, sucralfate, and an anti‑emetic?

Persistent Vomiting and Reflux 12 Years After Sleeve Gastrectomy

You need urgent evaluation for anatomic complications—persistent vomiting and reflux 12 years post-sleeve gastrectomy is not normal and requires investigation for gastric stenosis, hiatal hernia, or consideration of conversion to Roux-en-Y gastric bypass, which is the only proven treatment for intractable reflux after sleeve gastrectomy. 1

Why This Is Happening After 12 Years

Sleeve gastrectomy causes progressive anatomic and functional changes that worsen over time:

• Your lower esophageal sphincter (LES) pressure has likely deteriorated—patients with reflux symptoms after sleeve gastrectomy show LES resting pressures of only 9.8 ± 2.1 mmHg compared to 13.3 ± 4.2 mmHg in those without symptoms 2

• Late anatomic changes are common—65.1% of sleeve gastrectomy patients develop reflux symptoms at long-term follow-up, with 77.5% showing positive acid reflux tests and mean DeMeester scores of 41.7 2

• The gastric remnant may have migrated into your chest—intrathoracic migration of the remnant stomach is a recognized late complication that worsens reflux 3

• Your gastric remnant has reduced compliance—this provokes increased transient LES relaxations and creates a higher gastroesophageal pressure gradient 3

Serious Complications You Must Rule Out Immediately

Do not dismiss persistent vomiting as "normal" post-sleeve symptoms:

• Gastric stenosis is a recognized cause of severe dysphagia and vomiting after sleeve gastrectomy and requires endoscopic evaluation 4

• Hiatal hernia occurs in 5.7% of long-term sleeve patients and significantly worsens reflux 2

• Barrett's esophagus develops in 4.8% of patients at late follow-up after sleeve gastrectomy 2

• Esophagitis is found in 29.4% of patients during endoscopy at long-term follow-up 2

Required Diagnostic Workup

You need comprehensive evaluation beyond just symptom management:

• Upper endoscopy to assess for esophagitis, Barrett's esophagus, gastric stenosis, and hiatal hernia 2

• 24-hour pH monitoring to quantify acid exposure—this is positive in 77.5% of symptomatic patients with mean DeMeester scores reaching 41.7 2

• Esophageal manometry to measure your LES pressure and esophageal motility 2

• Barium esophagogram to evaluate for anatomic abnormalities, gastric remnant migration, and hiatal hernia 2, 3

Why Your Current Medical Therapy May Be Insufficient

Medical management alone often fails for post-sleeve reflux:

• 57.7% of sleeve gastrectomy patients require long-term PPI therapy, yet many remain symptomatic despite treatment 2

• Vonoprazan and sucralfate address acid but not the anatomic problem—the fundamental issue is mechanical (low LES pressure, altered anatomy, increased gastroesophageal pressure gradient) 2, 3

• Persistent vomiting for >2-3 weeks requires thiamine supplementation to prevent neurological complications, regardless of your other treatments 4

Definitive Treatment Options

The only proven cure for intractable reflux after sleeve gastrectomy is surgical revision:

• Conversion to Roux-en-Y gastric bypass is the only proven method for treating intractable reflux after sleeve gastrectomy 1

• If hiatal hernia is present, repair with posterior hiatoplasty may improve symptoms 5

• Magnetic sphincter augmentation or radiofrequency ablation are alternative options that supplement LES anatomy, though evidence is limited compared to bypass conversion 1

Critical Pitfalls to Avoid

Persistent symptoms 12 years out warrant aggressive investigation:

• Do not accept this as "normal" post-sleeve symptoms—the duration and persistence suggest anatomic complications requiring intervention 4, 2

• Check for thiamine deficiency immediately—persistent vomiting puts you at high risk for rapid-onset neurological damage, and IV thiamine should be given empirically while awaiting lab confirmation 4, 6

• Monitor hydration aggressively—dehydration both causes and exacerbates vomiting and reflux symptoms 4, 7

• Ensure adequate protein intake of 60-80 g/day—chronic vomiting leads to protein-energy malnutrition 4

• Do not delay endoscopy—Barrett's esophagus develops in nearly 5% of long-term sleeve patients and requires surveillance 2