From the Guidelines
Chronic vomiting after sleeve gastrectomy requires a systematic approach to diagnosis and treatment, starting with ruling out mechanical causes like stricture or obstruction through upper endoscopy and contrast studies, as recommended by the most recent guidelines 1.
Initial Management
Initial management should include small, frequent meals, thorough chewing, and avoiding liquids with meals.
- For medication therapy, start with proton pump inhibitors like omeprazole 40mg daily or pantoprazole 40mg daily for 8-12 weeks to address potential gastroesophageal reflux.
- For nausea and vomiting, metoclopramide 10mg three times daily before meals (maximum 12 weeks due to risk of tardive dyskinesia) or ondansetron 4-8mg every 8 hours as needed can be effective, as supported by recent studies 1.
Nutritional Support
Nutritional support is crucial, so monitor for dehydration, electrolyte imbalances, and vitamin deficiencies with regular blood tests.
- Psychological support may help patients cope with dietary changes.
- Chronic vomiting often results from altered gastric anatomy causing reduced stomach capacity, increased intragastric pressure, or pyloric dysfunction.
Surgical Revision
If conservative measures fail after 3-6 months, surgical revision may be necessary, particularly for anatomical issues like sleeve stenosis or twisting, as indicated by the latest research 1.
- The endoscopic management of these strictures with balloon dilatation or stent placement is reported to be successful in 88–94% of cases 1.
- When endoscopic methods are unsuccessful, sleeve gastrectomy conversion to RYGB should be considered 1.
- A multimodal approach to preventing nausea and vomiting, including total intravenous anesthesia with Propofol (TIVA), avoidance of volatile anaesthetics and fluid overload, and minimization of intra- and postoperative opioids, is recommended by recent guidelines 1.
From the Research
Chronic Vomiting after Sleeve Gastrectomy
- Chronic vomiting is a common complication after sleeve gastrectomy, with a study finding that 60.0% of patients experienced vomiting after the procedure 2.
- Gastric sleeve stenosis (GSS) is a potential cause of chronic vomiting, with symptoms including dysphagia, reflux, and obstructive symptoms 2, 3.
- Upper gastrointestinal series (UGIS) is commonly used to diagnose GSS, but has been found to have low negative predictive value (NPV) and is not necessary for diagnosis 2.
- Endoscopy is a more effective diagnostic tool for GSS, with a study finding that 87.1% of patients were diagnosed with GSS on endoscopic evaluation 2.
- Treatment for GSS typically involves endoscopic dilation, with a study finding that 86.6% of patients had resolution of symptoms with a mean of 1.97 dilations 2.
Risk Factors for Chronic Vomiting
- Female gender, smoking, preoperative GERD, gastropexy, and severity of pain have been found to be independent risk factors for the development of postoperative nausea and vomiting (PONV) after laparoscopic sleeve gastrectomy (LSG) 4.
- Antral preservation, opioid-free analgesia, and intraoperative combined analgesia have been found to be independent protective factors against the occurrence of PONV 4.
- Helicobacter pylori status has been found to have no role in the development of PONV after LSG 4.
Management of Chronic Vomiting
- Combined intravenous ondansetron and metoclopramide has been found to improve PONV in 92.6% of patients 4.
- Dexamethasone and antihistamines have been used to treat persistent PONV after initial treatment with ondansetron and metoclopramide 4.
- Pain management postoperatively using opioid-free analgesia has been found to be effective in managing PONV 4.