Laparoscopic Gastric Sleeve

 More and more patients who are researching bariatric procedures are asking us about a “new” procedure called the ”Sleeve Gastrectomy.” Sleeve gastrectomy, gastric sleeve and vertical sleeve gastrectomy (VSG) are all names describing the same surgical procedure. This operation for weight loss is done in the laparoscopic technique. About 5 or 6 small incisions on the abdominal wall are used to introduce the surgical instruments and camera, in order to allow the surgeon to complete the operation without making a long midline abdominal incision. The Sleeve Gastrectomy, or Gastric Sleeve procedure, involves removing about 4/5 of the stomach. This results in a restrictive pouch which looks like a thin banana. The nerves to the stomach and the outlet valve (pylorus) remain intact. The removal of the majority of the stomach results in the elimination of most of the gastric hormones which cause or stimulate hunger. The remission of Type II adult onset diabetes (the metabolic syndrome) is thought to be related to the changes in the gastric and intestinal hormones. This effect starts to happen before any significant weight loss occurs. This demonstrates that the Sleeve Gastrectomy works in a restrictive and metabolic fashion to produce the desired results of weight loss and elimination or improvements of co-morbid diseases.

The Sleeve Gastrectomy is a simpler operation than the Gastric Bypass, as there is no re-routing or reconnecting of the intestines. Stapling instruments are used to create the sleeve shape of the remaining stomach. Because no part of the GI tract is bypassed, there is virtually no problem with vitamin or protein deficiencies, as those which could occur with the gastric bypass.

The excess weight loss after the Sleeve Gastrectomy, at five years, approaches that of the gastric bypass and is probably greater than the REALIZE™ Band and  LAP-BAND®. The operative risk of the vertical sleeve gastrectomy is probably slightly higher than the adjustable gastric band Realize and LAP-BAND, but lower than the gastric bypass.

For those patients who have voiced concern about the implantation of a foreign body (the silicone band), the adjustable gastric band is not an option. For those patients who object to the idea of bypassing a part of the intestine, the gastric bypass is not an option. For those patients, the Sleeve Gastrectomy is an excellent choice due to low risk, no rerouting or bypassing of the intestines and no implantation of a foreign body or device. Also the Sleeve Gastrectomy has a very acceptable excess weight loss compared to other weight loss procedures. As with any weight loss surgery, there are risks.

Advantages of the Sleeve Gastrectomy

• The stomach functions normally, except for the restriction of volume of food ingested at one time.
• Small meals satisfy the appetite.
• Hunger is reported by most patients to be greatly diminished or almost eliminated. (This is due to the removal of the portion of the stomach which generates the hormone of hunger, ghrelin.
• The risk is lower than the gastric bypass, but the weight loss is similar.
• Weight loss after a Sleeve Gastrectomy is much faster than that of the adjustable gastric band.
• There are fewer food intolerances with the Sleeve Gastrectomy compared to the adjustable gastric band.
• There is no implantable device which could lead to problems in the future; such as slips or prolapse of the band, erosions or problems with the injection port.
• The follow-up regimen of fills or adjustments – as in the adjustable gastric band – is not necessary, as there is no device implanted.
• If a Sleeve Gastrectomy patient regains weight or needs more weight loss, a revision of the Sleeve Gastrectomy to a Gastric Bypass can lead to additional weight loss.
• Those patients who take NSAIDS (non-steroidal anti-inflammatory drugs) for arthritis can continue the medication after Sleeve Gastrectomy. (These medications are to be avoided after the adjustable gastric band (erosion) and especially after the gastric bypass (ulcers).

Disadvantages of the Sleeve Gastrectomy

• The risk is slightly higher than the risk with the Realize Band or LAP-BAND.
• Since the Sleeve Gastrectomy incorporates stapling of the stomach, there is possibility of a leak at the staple line (<0.5 - 1% ).  A staple line leak with the Vertical Sleeve Gastrectomy may be more serious or complicated than a staple line leak with the gastric bypass.
• Sleeve Gastrectomy is not adjustable like the Realize Band or LAP-BAND.
• Sleeve Gastrectomy is not reversible like the Realize Band or LAP-BAND.
• Although the existing data indicates the long term weight loss success of Sleeve Gastrectomy, we do not have studies out longer than five years.

Individuals who should consider Sleeve Gastrectomy:

• Patients concerned about long term effect of gastric bypass with potential ulcer, anemia, osteoporosis, protein and vitamin deficiency and intestinal hernia or obstruction.
• Patients concerned about a foreign body (device) implanted in their body.
• Patients with history of prior abdominal surgery in mid or lower abdomen, or with history of adhesions or scar tissue.
• Patients with complex medical conditions; autoimmune diseases, Crohn’s disease, anemia, etc.
• Patients who need to continue their NSAID medications for arthritis.
• For high risk patients with BMI >60 who wish to have a laparoscopic procedure, the Sleeve Gastrectomy is probably a safer operation.
• For patients who have failed attempts to lose weight with the adjustable gastric band, revision of the band to Sleeve Gastrectomy is a good option.
• Patients paying cash. This may decrease risk of financial responsibilities in the future if complications develop requiring surgery or medical treatment. Most complications with Sleeve Gastrectomy will occur in the first 30 days. After that, complications are very uncommon. (Complications from gastric bypass or adjustable gastric band can occur years later.)

At Oxford Bariatric, we are very excited about the Sleeve Gastrectomy, or Gastric Sleeve. We feel that this operation has many positives and few negatives. The procedure can be done safely and the excess weight loss is excellent, late complications are uncommon and resolution of co-morbidities are similar to more complex procedures. The metabolic effect of the Sleeve Gastrectomy, which leads to remission of Type II adult onset diabetes, is impressive. This result is separate from the effect incurred by weight loss and adds to the ability of this procedure to make our patients healthier and happier in their lives.

 To view an animation of the Laparoscopic Sleeve Gastrectomy, click here.

  
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