A Safe and Effective Surgical Weight-Loss Procedure for Higher-Risk Patients or those who Want to Minimize the Risk of Weight Loss Surgery
The laparoscopic sleeve Gastrectomy procedure (also called vertical Gastrectomy, Greater Curvature Gastrectomy, Parietal Gastrectomy, Gastric Reduction and even Vertical Gastroplasty) is an emerging procedure that is becoming increasingly popular worldwide. It causes weight loss by restricting the amount of food that can be eaten without any bypass of the intestines or malabsorption.
What is Sleeve Gastrectomy and how does it work?
This procedure generates weight loss solely through gastric restriction (reduced stomach volume). In this procedure, a narrow tube of the stomach, approximately the same diameter as the esophagus and duodenum is fashioned by dividing it vertically. The part of the stomach along the medial (lesser) curvature, which is in continuity with the food pipe (esophagus), is retained as the tube and the part outside the tube, which is the greater curvature of the stomach and the fundus, is removed.
Almost 85% of the stomach is removed. The removed section of the stomach is actually the portion that "stretches" the most on eating food, has the reservoir function and is responsible for storing the food. The stomach that remains is shaped like a banana and measures from 2-4 ounces (60-120cc) depending on the surgeon performing the procedure. The holding capacity of the stomach is thereby drastically reduced. This procedure significantly restricts the volume of the food that can be consumed. Very small amounts of food will now evoke feeling of extreme fullness. The nerves to the stomach and the outlet valve (pylorus) remain intact with the idea of preserving the functions of the stomach while reducing the volume. There is no intestinal bypass with this procedure, only stomach reduction. By comparison, in a Roux-en-Y gastric bypass, the stomach is divided, not removed, and the pylorus is excluded.
Laparoscopic sleeve gastrectomy procedure was initially performed laparoscopically as a first stage procedure in very high BMI patients to try to reduce the overall risk of weight loss surgery. In patients with BMI above 60Kg/m2, it is difficult to perform a Roux en Y gastric bypass or a Duodenal Switch laparoscopically. Additionally, Roux en Y gastric bypass may not yield adequate weight loss for patients with a BMI greater than 60Kg/ m2 since
these patients may not attain a healthy BMI of 30 after gastric bypass. Duodenal Switch is very effective for high BMI patients but unfortunately it may also be quite risky. First stage Laparoscopic Sleeve Gastrectomy emerged as a reasonable solution to this problem. It can be done laparoscopically in patients weighing over 500 pounds. The stomach restriction that occurs allows these patients to lose more than 100 pounds and in many patients more than 200 pounds. This weight loss allows significant improvement in health and effectively "downstages" a patient to a lower risk group. Once the patient’s BMI is lower (35-45) they can return to the operating room for the "second stage" of the procedure, which can either be the Duodenal Switch, Roux en Y gastric bypass or even a Lap Band®.
Soon it was realized that some patients with laparoscopic sleeve gastrectomy not only lose significant weight but also maintain their weight loss for longer than expected and may not opt for a second stage procedure. This gave birth to the idea of Laparoscopic Sleeve Gastrectomy as the sole procedure for weight loss. It had been originally conceived of by Dr. Johnston in England (Magenstrasse and Mill operation). The procedure was slightly modified and the stomach pouch is made smaller than the pouch that Duodenal Switch patients have. It is a significant improvement over prior gastroplasty procedures, which are rarely done due to problems related to the placement of staples, silastic rings and mesh around the stomach pouch.
Advantages of the Sleeve Gastrectomy Weight Loss Surgery:
The stomach is reduced in volume but tends to function normally so most food items can be consumed, though in small amounts.
The excess stomach volume is removed, not left in place. This possibly eliminates most Ghrelin hormone (secreted from the fundus of the stomach and stimulates hunger) production and helps to reduce the sensation of hunger these people have.
As there is no bypass of the intestinal segment involved, absorption of minerals (calcium, iron) and vitamins does not suffer and it is not necessary to supplement these minerals and vitamins in the diet as is essential after the gastric bypass. This may also be important in older patients who are likely to be on multiple medications and may later develop cancer or other serious medical conditions.
Since the pylorus (sphincter that regulates release of food from stomach into the intestines) is intact after the sleeve gastrectomy, there is no dumping (of food into the intestines) and its symptoms (palpitation, sweating, tremors, and abdominal colicky pain) which occur after gastric bypass with high carbohydrate liquid foods.
By avoiding the intestinal bypass, the chance of intestinal obstruction (blockage), anemia, osteoporosis, protein deficiency and vitamin deficiency are almost eliminated.
Minimizes the chance of an ulcer occurring.
It can be converted to almost any other weight loss procedure.
When compared to lap Band procedure, Laparoscopic sleeve gastrectomy is a one time procedure and no subsequent adjustments are required. It also avoids the possible complications of a long term foreign body with no possible risks of slippage, erosion, infection etc. The 4 year weight loss results seem to be superior to lap Band.
Laparoscopic Sleeve Gastrectomy in Low BMI patients (BMI 35-45 Kg/M2):
This procedure was started in England as a stand alone weight loss procedure for anyone with a BMI greater than 35 Kg/M2 (Johnston D. Obesity Surg 2003; 13:10-16). It proved to be quite safe and quite effective even at 5 years. 10% of the patients did fail to achieve a BMI below 35 at 5 years and these tended to be the heavier patients, the same ones we would expect to go through a second stage as noted above. Low BMI individuals who should consider this procedure include:
Those who are concerned about the potential long term side effects of an intestinal bypass such as anemia, osteoporosis, protein and vitamin deficiency, intestinal obstruction, ulcers etc.
Those who are considering a LapBand® but are concerned about a foreign body or are not sure that they have access to regular filling of the band which is mandatory for optimal weight loss after this procedure. In patients with lower BMI, initial decrease in the appetite, restriction and weight loss after the lap band may be slow till one or two fillings are done. These patients do better after sleeve gastrectomy. The restriction and weight loss after sleeve gastrectomy starts immediately, weight loss is faster and weight loss is more as compared to the band (equivalent to gastric bypass).
Those who have other medical problems that prevent them from having weight loss surgery such as anemia, Crohn's disease, extensive prior surgery, and other complex medical conditions.
People who need to take anti-inflammatory medications may also want to consider this. Usually, these medications need to be avoided after a gastric bypass because the risk of ulcer is higher.
Laparoscopic sleeve Gastrectomy is very effective as a first stage procedure for high BMI patients (BMI>55 kg/m2). It can be done laparoscopically in patients weighing over 500 pounds. Available results appear promising as a single stage procedure for low BMI patients (BMI 35-45 kg/m2). It is also a very appealing option for people with existing anemia, Crohn's disease and numerous other conditions that make them too high risk for intestinal bypass procedures.
Disadvantages of the Vertical Gastrectomy Weight Loss Surgery:
Laparoscopic sleeve Gastrectomy is a relatively newer procedure being in use as the sole procedure for weight loss only for about 4 years. This is less than lap Band and laparoscopic gastric bypass which have been in use for more than 10 years. This is an active point of discussion for bariatric surgeons. There is a possibility for inadequate weight loss or weight regain in the long term because of the pouch dilatation/enlargement. While this is true for all procedures, it is theoretically more possible with procedures that do not have an intestinal bypass. Since the stomach pouch in sleeve gastrectomy is based on the thick and muscular lesser curvature which is relatively nondistensible, this fear and skepticism may not hold true. Four years follow-up results of laparoscopic sleeve gastrectomy were discussed in the Annual Conference of American Society of Bariatric Surgery in San Diago in July 2007 and the reported weight loss results are equivalent to Laparoscopic Gastric Bypass roux en Y. Higher BMI patients (above 55) will most likely need to have a second stage procedure later to help lose the rest of the weight. Two stages may ultimately be safer and more effective than one operation for these high BMI patients. Soft calories such as ice cream, milk shakes, etc can be absorbed and may slow weight loss while after gastric bypass they will cause dumping and will be avoided due to their unpleasant symptoms. Because the stomach is removed, it is not reversible. It is considered investigational by some surgeons.
Sleeve Gastrectomy: Risks and Complications
As with any surgery, there can be complications. This procedure does involve stomach stapling and therefore leaks and other complications related to stapling may occur, though significantly less as compared to bypass. The others include: Deep vein thrombophlebitis 0.5%, Non-fatal pulmonary embolus 0.5%, Pneumonia 0.2%, acute respiratory distress syndrome 0.25%, Splenectomy 0.5%, Postoperative bleeding 0.5% and Small bowel obstruction.
Post-Op Dietary Plan for Vertical Gastrectomy Weight-Loss Surgery Patients
As with all surgical weight-loss programs, it is imperative that Sleeve Gastrectomy patients adhere to a strict postoperative diet. Patients must stick to a liquid-based diet for 2 weeks after surgery; 4-6 weeks after the operation, patients graduate to a 600-800 calorie/ day solid diet. Once goal weight is achieved, usually 1-2 years after surgery, most patients can consume about 1000-1200 calories per day.
Long-Term Weight-Loss Results
On average, patients who undergo Vertical Gastrectomy surgery experience a 60-80% loss of excess body weight. Large and rapid weight loss and very few complications make Sleeve Gastrectomy surgery a smart choice for weight-loss in many patients.
The sleeve gastrectomy seems to give the weight loss of the stronger operation (gastric bypass) with the complication profile of the band.
This is an excellent article by Dr. Gupta about the VSG. My research said that the procedure's been done since 2002 and that patients lose 70-80% of their excess body weight after three years, comparable to bypass surgery. Obviously 10-year outcome data isn't available yet. I think his analysis of advantages and disadvantages is very accurate and comprehensive.
I had a sleeve done by Dr. Alberto Aceves of the Mexicali Bariatric Center a year ago when I couldn't get WLS covered by insurance in the US. I've lost 90 lbs and am still losing 1 to 1-1/2 lbs per week. I've had almost no hunger and don't have food cravings like I used to. The desire for food no longer rules my life. My only regret is that I didn't know about this procedure (I didn't want the band or bypass) and affordable option years ago and have it done at a younger age.