Sleeve Gastrectomy as a Primary Weight Loss Procedure

Many patients have recently become aware of the laparoscopic sleeve gastrectomy as an option for surgical weight loss. The news has spread from various sources including: medical societies, insurance companies, internet articles, newspapers, and patient word of mouth. A most recent and very high profile acceptance of the sleeve gastrectomy as a surgical procedure for weight loss came from “CMS” which stands for “Centers for Medicare & Medicaid Services”. This is the government organization which oversees Medicare & Medicaid and it granted coverage approval for the procedure in June 2012. Before CMS coverage was approved, a number of medical studies were reviewed. Simultaneously, other insurance companies and medical societies reached similar conclusions. What follows is a brief discussion as to how these determinations were made. The sleeve gastrectomy was first performed as an open procedure with large incisions in the 1980’s. Initially, it was part of a larger weight loss operation known as the Duodenal Switch. With the advent of laparoscopic weight loss surgery in 1990’s, innovative surgeons began to develop techniques to do these complicated large procedures with telescopes through small incisions. Noting high complications with the large incisions it was hoped that small incisions would be beneficial to patients. Recognizing that very heavy patients still had higher complication rates then smaller ones when doing these complicated procedures, surgeons began to stage weight loss surgery in the hope of getting patients to lose some weight first thereby lowering their risk and then completing the operation at a second stage. An unexpected finding with this approach was that the first stage (sleeve gastrectomy), was very beneficial by its own right. With this observation came the refinement of techniques and medical studies that has resulted in the sleeve gastrectomy being offered as a stand-alone weight loss procedure. When considering surgical weight loss the risks and benefits of a procedure must be evaluated as well the life style modifications that will be imposed. Risks usually include things like bleeding, infection, blood clots, heart & lung problems, obstructions, need for further surgery, and even death. Benefits include the amount of weight lost usually measured as a percentage of one’s weight and resolution or improvement of weight related medical conditions like diabetes, high blood pressure, sleep apnea, elevated cholesterol, etc. On October 28, 2011 and after a number of medical studies involving hundreds of patients, the American Society for Metabolic & Bariatric Surgery published an updated position statement endorsing the sleeve gastrectomy as a primary weight loss operation. What follows is a brief summary of the medical literature results seen with sleeve gastrectomy:

    • Estimated weight loss 50-60% with 5 year follow-up
    • Diabetes resolution or remission 60-80%
    • Staple line leak 1%
    • Need for secondary operation for weight loss 3%
    • Serious complications 2.2%, Death 0.4% or less

These results place the sleeve gastrectomy in a position for effectiveness between the lesser effective adjustable banding and more effective gastric bypass for both weight loss and co-morbidity resolution but closer to the bypass then the band. Its complication rate is also between the slightly lower risk adjustable band and slightly greater risk bypass. In present day Bariatric Surgery, all three of these options are considered safe and effective. As of the time of this writing, in addition to “CMS”, the majority of insurance companies that we deal with also will cover sleeve gastrectomy. Choosing the appropriate procedure can be a complex task with the balance between risk and benefits usually being an important consideration.

Michel Gunn

Michel Gunn