Gastric Sleeve

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The Sleeve Gastrectomy, Gastric Sleeve or Vertical Sleeve Gastrectomy (VSG) is an interesting new procedure that seems to combine the reliable weight loss and low maintenance of the gastric bypass with a similar risk profile of gastric banding, but without having to rely on an implanted device. The VSG works primarily by reducing the size of the stomach so the patient feels full after eating much less food. As a result, the patient consumes fewer calories, and therefore loses weight. In addition, the procedure removes the portion of the stomach that produces a hormone that can cause hunger (ghrelin; clinical significance unproven), so patients aren’t as hungry and don't feel like eating as much. This procedure can be an excellent alternative to gastric bypass or gastric banding. VSG is a much less complex surgery than the Gastric Bypass procedure and therefore carries less risk.  Unlike the gastric banding procedure, the VSG doesn’t require the use of an artificial banding device to be implanted around a portion of the stomach. However, the procedure is not reversible and not adjustable.
 
The VSG was originally derived from the more complex procedure we refer to as the Biliopancreatic Diversion with Duodenal Switch (BPD-DS).  Many surgeons who planned to perform a BPD-DS on some of their very high-risk patients would perform part of the operation which involved removing the majority of the stomach as a first stage, and then planned to return 1-2 years later to complete the operation.  Those surgeons observed that many patients who had the large reservoir capacity of the stomach removed had excellent sustained weight loss, and therefore the “gastric sleeve” operation began to develop into a procedure in and of itself.

Because the VSG does not involve “cutting,” “rerouting” and “reconnection” of the intestines, the surgical risk and risk of complications are significantly less than Gastric Bypass. Patients therefore do not suffer the complications of the intestinal bypass such as intestinal obstruction, anemia, osteoporosis, vitamin deficiency and protein deficiency. It also makes it a suitable option for patients who are already suffering from anemia, Crohn's disease and a variety of other conditions that would place them at high risk for surgery involving intestinal bypass. VSG has been shown to create reliable weight loss without the substantial risks of Gastric Bypass. And again, because there is no re-routing of the intestines, it is also without the long term effects of nutrient malabsorption.  Because of the significantly lower risk of the Sleeve Gastrectomy, it is also gaining acceptance as an operation for patients with lower BMI (even as low as a BMI of 30).  VSG is also starting to gain acceptance as a revisional procedure for patients who have had complications with the Gastric Band (Lap-Band or Realize band).

 
Several studies have reported resolution of obesity related health conditions (Co-morbid conditions) 12 to 24 months after sleeve Gastrectomy in a significant numbers of patients. Sleeve gastrectomy patients experienced resolution rates for type 2 diabetes, high blood pressure, high cholesterol, and obstructive sleep apnea that were similar to resolution rates for other restrictive procedures such as gastric banding in several studies.
 
Details of the Gastric Sleeve Operation
 
The surgery is typically performed in a hospital, with the patient under general anesthesia. The Sleeve Gastrectomy is usually performed laparoscopically through several tiny incisions, using long fine instruments. In some cases, the surgery will need to be performed via open (traditional surgery with a larger incision).
The surgeon will remove up to 85% of the stomach called the greater curve of the stomach using a special laparoscopic stapling device. While dividing the tissue, the device also re-approximates the stomach tissue together with very tiny staples. This procedure leaves a much smaller tubular shaped stomach roughly about the same size and shape of a banana. The sphincter muscles at the top and the bottom of the stomach and the stomach nerves are left completely intact, with the idea of preserving the functions of the stomach while reducing the volume. By comparison, in a Roux-en-Y gastric bypass, the stomach is divided, not removed, and the pylorus is excluded.
 
 
The long tubular stomach fills easily with only small amounts of food, and therefore the patient feels full (satiety) quickly and is therefore no longer hungry.
Again, because the procedure does not involve rerouting or rearranging the intestines as in the Gastric Bypass, the Sleeve Gastrectomy does not create any changes in nutrient absorption.
Some patients also choose the VSG over the Gastric Band because there is no implanted foreign object in the body and also because there is less frequent follow-up office visits required (although lifestyle changes are still an important part of success). In addition, there is no need for adjustments as there is with the band.
It remains possible that, over the years, the narrow tubular stomach pouch may expand and the patient’s food capacity may return.  Initial research results are encouraging, but the fact is that the real long term outcome of the Gastric Sleeve weight loss will not be known until 2015 or later.

Recovery Timeline
  • Hospital stay averages 24-48 hours
  • Most patients return to normal activity in one to two weeks
  • Full surgical recovery usually occurs in two to three weeks
 
Post-Op Dietary Plan for Vertical Gastrectomy Weight-Loss Surgery Patients
 
As with all surgical weight-loss programs, it is imperative that VSG patients adhere to a strict postoperative diet. Patients must stick to a liquid-based diet for 2 weeks after surgery; At 2 weeks after surgery patients graduate to a 600-800 calorie/ day soft diet. And at 4 weeks, patients then transition to a regular solid diet. Once goal weight is achieved, usually 1-2 years after surgery, most patients consume a normal healthy diet with the appropriate number of calories for their height and build to maintain their weight.
 
Who should consider Sleeve Gastrectomy?
 
  • 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 Gastric Band (Lap-Band® or Realize™ band) but are concerned about an implanted foreign body, regular follow-up or the need for adjustments.
  • Those who have other medical problems (that prevent them from having other weight loss surgeries) such as anemia, Crohn's disease, Ulcerative Colitis, Lupus, extensive prior surgery, and other complex medical conditions.
  • People who need to take anti-inflammatory medications may also want to consider VSG as these medications need to be avoided after a gastric bypass because the risk of ulcer is higher and also after Gastric Band because of the potentially increased risk of erosion.
 
Advantages of the Vertical Gastrectomy Weight Loss Surgery
 
  • Can performed using minimally invasive techniques whivh makes recovery time much faster.
  • The stomach is reduced in volume but functions normally so most food items can be consumed.
  • Eliminates the portion of the stomach (clinical significance unknown) that produces the hormones that stimulates hunger (Ghrelin).
  • Rarely have dumping syndrome because the pylorus is preserved.
  • The surgical risk is lower than with the gastric bypass procedure, but the weight loss is similar.  
  • Minimizes the chance of an ulcer occurring and No risk of marginal ulcer as with gastric bypass.
  • By avoiding the intestinal bypass, the chance of intestinal obstruction (blockage), anemia, osteoporosis, protein deficiency and vitamin deficiency are almost eliminated.
  • Very effective as a first stage procedure for high BMI patients (BMI>55 kg/m2).
  • Limited results with low BMI patients (BMI 35-45 kg/m2); appear promising as a single standalone procedure.
  • Appealing option for people with existing anemia, Crohn's disease and numerous other conditions that make them too high risk for intestinal bypass procedures.
  • Can be done laparoscopically in patients weighing over 500 pounds.
  • Fewer food intolerances than with the gastric band.
  • Weight loss generally is faster with the sleeve than with the gastric band.
  • There is no implantable band device, so slippage and erosion are not a risk.
  • No device that needs adjustment is inserted, so the follow-up regimen is not as intense as it would be with the band.
  • If inadequate weight loss, the patient can then be converted to a gastric bypass.
  • Good option for patients with contraindication for gastric bypass and Lap Band
  • Long-term results (>  5 years) are not available.
Disadvantages of the Vertical Gastrectomy Weight Loss Surgery
 
  • Soft calories such as ice cream, milk shakes, etc can be easily eaten and may slow weight loss.
  • This procedure does involve stomach stapling and therefore leaks and other complications related to stapling may occur.
  • Because a large portion of the stomach is removed, it is not reversible. It can, although, be converted to almost any other weight loss procedure.
  • Considered investigational by some surgeons and insurance companies.
  • Since the sleeve gastrectomy is a newer procedure, it hasn’t been tested as long as gastric banding or gastric bypass.
  • Long staple line with potential for leaks in 1-2% of patients.
  • Possibility of stricture/kinking of long narrow stomach tube.
  • Sleeve gastrectomy is non-adjustable and non-reversible, unlike gastric banding.
  • Complication risks are slightly higher than with the band.
  • Gastric Sleeve Dilation - Over time, a patient's stomach can stretch, becoming larger in volume, allowing the patient to eat more food, and thus may cause some weight regain.
  • When gastric sleeve patients eat more than their stomach can hold comfortably they risk significant discomfort, including vomiting, diarrhea, and other gastrointestinal symptoms.
 
Vertical Gastrectomy: Risks and Complications
 
As with any surgery, there can be complications. Sleeve gastrectomy shares many risks with Roux-en-Y gastric bypass, the REALIZE™ Adjustable Band surgery, and the LAP-BAND® Adjustable Gastric Band surgery, but is one of the safer surgical weight loss options available. Though sleeve gastrectomy is very safe and serious problems are rare, it is a major surgery and complications are still possible, including:
  • Deep vein thrombosis (blood clots) 0.5%
  • Non-fatal pulmonary embolus 0.5%
  • Pneumonia 0.2%
  • Acute respiratory distress syndrome 0.25%
  • Splenectomy 0.5%
  • Gastric leak and fistula (due to poor healing and may require revision) 1.0%
  • Postoperative bleeding 0.5%
  • Small bowel obstruction 0.0%
  • Death 0.25%
 
Long-Term Weight-Loss Results
 
On average, patients who undergo Vertical Gastrectomy surgery experience ~60% loss of excess weight.

Insurance and Finance
 
Currently in 2009, most insurance companies consider the Sleeve Gastrectomy to be “experimental” or “investigational,” and so this specific procedure is usually not a covered benefit.  However, there are signs of progress with multiple insurance companies, and we have had some covered by insurance. So patients who are interested should definitely check directly with their insurance carrier.
 
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