Sleeve Gastrectomy

Sleeve gastrectomy, or gastric sleeve, is a surgical weight-loss procedure in which the stomach is reduced to about 15% of its original size, by surgically removing a large portion of the stomach. The open edges are then attached together (typically with surgical staples, sutures, or both) to leave the stomach shaped more like a tube or banana. The procedure permanently reduces the size of the stomach and most patients can expect to lose 30% to 50% of their excess body weight over a 6-12 month period with the sleeve gastrectomy.

This procedure generates weight loss by restricting the amount of food (and therefore calories) that can be eaten by removing 85% or more of the stomach without bypassing the intestines or causing any gastrointestinal malabsorption. It is a purely restrictive operation.

By comparison, in a Roux-en-Y gastric bypass, the stomach is divided, not removed, and the pylorus is excluded or “bypassed.” Note that there is no intestinal bypass with sleeve gastrectomy…only stomach reduction. The lack of an intestinal bypass avoids potentially costly, long term complications such as marginal ulcers (ulcers at the cut edge of the stomach and intestines), vitamin deficiencies and intestinal obstructions.

The sleeve gastrectomy can usually be done laparoscopically, even in larger patients. The stomach restriction that occurs allows these patients to lose more than 100 pounds. This dramatic weight loss allows significant improvement in health and resolution of associated medical problems such as diabetes and sleep apnea.

Individuals who should consider this procedure include:

• Those who are concerned about the potential long term side effects of an intestinal bypass such as intestinal obstruction, ulcers, anemia, osteoporosis, protein deficiency and vitamin deficiency.
• Those who are considering a Lap-Band® or Realize™ band but are concerned about a foreign body, worried about frequent adjustments or finding a band adjustment physician.
• Those who have other medical problems that prevent them from having gastric bypass surgery such as anemia, Crohn’s disease, extensive prior surgery, severe asthma requiring frequent steroid use, and other complex medical conditions.

All surgical weight loss procedures have certain risks, complications and benefits. The ultimate result from weight loss surgery is dependent on the patients risk, how much education they receive from their surgeon, commitment to diet, establishing an exercise routine and the surgeons experience.

Advantages and Disadvantages of Vertical Sleeve Gastrectomy

Advantages of Vertical Sleeve Gastrectomy

• Reduces stomach capacity but tends to allow the stomach to function normally so most food items can be consumed, albeit in small amounts.

• Eliminates the portion of the stomach that produces the hormones that stimulates hunger (Ghrelin).

• Dumping syndrome is avoided or minimized because the pylorus is preserved.

• Stomach volume is reduced, but it tends to function normally so most food items can be consumed in small amounts.

• Minimizes the chance of an ulcer occurring.

• By avoiding the intestinal bypass, the chance of intestinal obstruction (blockage), anemia, osteoporosis, protein deficiency and vitamin deficiency are significantly reduced.

• Appealing option for people with existing anemia Crohn’s disease, irritable bowel syndrome, and numerous other conditions that make them too high risk for intestinal bypass procedures.

• Appealing option for people who are concerned about the foreign body aspect of Banding procedures.

• Can be done laparoscopically in patients weighing over 500 pounds, thereby providing all the advantages of minimally invasive surgery; fewer wound and lung problems, less pain, and faster recovery.

Disadvantages of Vertical Sleeve Gastrectomy

• Potential for inadequate weight loss or weight regain. While this is true for all procedures, it is theoretically more possible with procedures that do not have intestinal bypass.

• Soft calories such as ice cream, milk shakes, etc. can be absorbed and will slow weight loss.

• This procedure does involve stomach stapling and therefore leaks and other complications related to stapling may occur.

Comparison to prior Gastroplasties (stomach stapling of the 70s-80s)

The sleeve gastrectomy is a significant improvement over prior gastroplasty procedures for a number of reasons:

• Rather than creating a pouch with a ring or mesh, the sleeve gastrectomy actually resects or removes the majority of the stomach. The portion of the stomach which is removed is responsible for secreting Ghrelin, which is the hormone that is responsible for appetite and hunger. By removing this portion of the stomach rather than leaving it in place, the level of Ghrelin is reduced to zero, actually causing loss of or reduction in appetite. Currently, it is not known if Ghrelin levels increase again after one to two years. Patients do report that some hunger and cravings do slowly return.
• The removed section of the stomach is actually the portion that “stretches” the most. The long vertical tube shaped stomach that remains is the portion least likely to expand over time and it creates significant resistance to volumes of food. Remember, resistance is greatest the smaller the diameter and the longer the channel. Not only is appetite reduced, but very small amounts of food generate early and lasting satiety(fullness).
• Finally, by not having rings or mesh wrapped around the stomach, the problems which are associated with these items are eliminated (infection, obstruction, erosion, and the need for synthetic materials). An additional discussion based on choice of procedures is below.

Alternative to a Roux-en-Y Gastric Bypass

The Sleeve Gastrectomy is a reasonable alternative to a Roux-en-Y Gastric Bypass for number of reasons:

• Because there is no intestinal bypass, the risk of malabsorptive complications such as vitamin deficiency and protein deficiency is minimal.
• There is no risk of marginal ulcer which occurs in over 2% of Roux-en-Y Gastric Bypass patients.
• The pylorus is preserved so dumping syndrome does not occur or is minimal.
• There is no intestinal obstruction since there is no intestinal bypass.
• It is relatively easy to modify to an alternative procedure should weight loss be inadequate or weight regain occur.

Vertical Sleeve Gastrectomy (VSG) – Frequently Asked Questions

How big will my stomach be after surgery?
The size of the stomach will vary depending on the surgeon. All surgeons use a tube to guide them when stapling the stomach. The tube size can vary from as small as 32 French Bougie (1-2 ounces) to as large as 64 French Bougie(6-8 ounces). We typically use a 32-38 French Bougie.

Is removing the stomach safe?
This type of stomach removal has been performed with the Duodenal Switch procedure since the mid 1980’s. It does involve stapling, just like in the gastric bypass and has similar risks. Interestingly, patients do not ever return asking for their stomach back but many do wonder if it is possible to reduce the size again.

Will I need to take vitamins?
Vitamin deficiencies are rare with this procedure because there is no intestinal bypass. However, the procedure is very restrictive and we will ask you to maintain a specific vitamin regimen.

Will I regain weight?
All patients undergoing weight loss surgery are at risk for weight regain. None of the operations can prevent this. Those patients who maintain good dietary habits and exercise patterns are more likely to keep the weight off than those who do not exercise and who snack frequently.

What will my diet be like after surgery?
The diet will progress over the first year. It starts with a 2 week full liquid diet. Patients progress to a 2 week pureed/blended diet, followed by a soft food diet and then onto a regular diet to begin at around day 30. During the first year, caloric intake will range from 800-1000 calories per day. The diet will be low in fat and carbohydrates. Protein goal will be a minimum of 60 grams per day. Carbohydrate intake will be below 60 grams per day. The final calorie intake will depend on your level of activity, age and gender.