The Sleeve Gastrectomy

When patients come to the office for their first visit, some know which procedure they would like to undergo. Others, are unfamiliar with bariatric surgery or are skeptical about the outcomes and are fearful of complications. Some patients hesitate to consider the sleeve as they think we do not have long term data to document its success and safety.

The sleeve gastrectomy was originally conceived as the first stage of the duodenal switch or gastric bypass in high risk patients in 1988. The sleeve gastrectomy was a bridge to a more technically challenging gastric bypass or biliopancreatic diversion. It was found to reduce weight, comorbidities, and operative risk in high risk patients. A significant amount of patients demonstrated durable weight loss and resolution of comorbidities after sleeve gastrectomy. In 2009, the American Society for Metabolic and Bariatric Surgery (ASMBS) recognized sleeve gastrectomy as a primary bariatric procedure. It was found to have low complication and mortality rates. In 2011, it was the second most commonly procedure performed worldwide. The reason for its popularity was related to the procedure’s advantages including preservation of pylorus and therefore less risk for dumping syndrome, no malabsorption, no foreign object, no adjustments, and weight loss comparable to gastric bypass, and the feasibility of the 2nd procedure, if needed.

Significant new scientific evidence published over the last four years prompted the ASMBS, the America Association of Clinical Endocrinologists, and the Obesity Society to change its guidance in April 2013 to reclassify sleeve gastrectomy as a proven surgical option, rather than an investigational one.

The sleeve gastrectomy is a partial gastrectomy in which the majority of the greater curvature of the stomach is removed. The stomach is divided and stapled vertically, removing approximately 75 to 80%. This creates a tube or banana-shaped pouch which restricts the amount of food that can be consumed and absorbed by the body. One criticism of the sleeve gastrectomy was the durability of the operation as one theorized that, over time, the SG could expand and patients would lose their restriction. We have found this to be untrue, due to the absence of the fundus.

The sleeve works by several mechanisms. First, the new stomach pouch holds a smaller volume than the normal stomach. This helps to reduce the amount of food and calories consumed. The greater impact seems to be the effect the surgery has on the gut hormones that impact hunger satisfy and blood sugar control. Ghrelin levels decrease (a gut hormone found in the stomach) and GLP-1 and PYY levels increase, promoting less hunger while insulin resistance improves and aids glycemic control.

Once patients learn more about bariatric surgery, many are choosing sleeve gastrectomy. They come to the conclusion that sleeve is “not as drastic” as gastric bypass and has better long term hunger control than the band. Patients generally achieve approximately a 60% excess weight loss at the 2 year mark. The weight loss is comparable to the bypass and patients consider sleeve less invasive than bypass as there is not rerouting of the intestines. Today, our patients are choosing sleeve gastrectomy over band and bypass.

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