In this informative article we will discuss the main features of the gastric sleeve procedure, letting you know the advantages and disadvantages of it so you can make an informed decision about whether this procedure is for you or not.
In our previous article we analyzed in the same way the gastric bypass procedure Why do we analyze these two procedures? The answer is simple: based on statistical figures, worldwide, gastric bypass along with sleeve gastrectomy are the two most common bariatric surgical procedures performed due to their proper balance in terms of risks/ benefits.
Before we start talking in depth about this topic we would like to remind you that in our practice we carry out much more frequently gastric sleeve surgeries than any other procedure for various reasons, several of which we deal with in this article Gastric sleeve procedure: how it works, pros and cons
According to statistics presented at the International Congress on Obesity Surgery and Metabolic Diseases, the IFSO (International Federation for the Surgery of Obesity and Metabolic Disorders) in Montreal in August 2014, in first place and for the first time in the history of bariatric surgery , the gastric sleeve surgery was the bariatric procedure more frequently performed in the whole world displacing the gastric bypass to second place.
The reasons for this new trend may be many, there are several factors contributing to this, however there are no hard statistics to explain it, so here in our role as obesity surgery blog and experts in gastric sleeve surgery we will focus on expressing our opinion on both procedures with the aim of you as a bariatric patient or potential bariatric patient, know the most outstanding qualities of these great bariatric procedures that are here to stay unlike others appearing in less than a decade they are forgotten because of their complexity, high complication rate and/or their ineffectiveness.
History of the gastric sleeve
This procedure is known by different names: sleeve gastrectomy, gastric sleeve, vertical sleeve gastrectomy, VSG, etc.
The gastric sleeve was "born" as part of the armamentarium available in bariatric surgery. Without seeking to go into details that have no relevance for you as a patient we explain the following:
Gastric sleeve surgery is a bariatric procedure that has been performed “relatively” for a short period time compared to other procedures, we say relatively because already more than 10 years have passed since the first laparoscopic gastric sleeve procedure was performed.
Arguably it was discovered "by accident" during the resection of a portion of the stomach (such as the gastric sleeve) while a more aggressive procedure known as duodenal switch was being performed.
Dr. Michel Gagner when seeing that patients with high BMI’s were at high risk during surgery to try to make the duodenal switch in a single surgical step, decided to opt for surgery in two steps: resecting (cutting) the stomach as a first step and leaving for a second surgical step the intestinal bypass or switch to complete the procedure on a further moment.
But after several months from the first step of the procedure, it was noted that patients treated in this way achieved good weight loss with the sole resection of the stomach, so this way it became available as a single and separate bariatric procedure from the duodenal switch. Over the years very satisfactory results were obtained in regards of the excess weight loss, loss that was maintained through the passage of years and there is when the gastric sleeve was adopted as a bariatric procedure, since then its technique has been perfected giving even better results in the recent years.
On what does gastric sleeve surgery consist?
This is a procedure which in theory may seem simple and safe, but like most things in the world of bariatric surgery it does require experience and detailed knowledge of the technique to give the best possible results and to reduce the chances of postoperative complications.
The gastric sleeve surgery involves the removal of a portion of the stomach to reduce its capacity. After several studies and statistics it has been determined that the best results are obtained when about 70% of the stomach is removed, that portion of the stomach is extracted from the body and does not remain in the patient as in the gastric bypass.
The resection of 70% of the stomach is done vertically producing a tubular stomach, leaving it with the shape of the sleeve of a jacket, hence the name of the procedure. Gastric capacity is reduced significantly passing approximately (varies from person to person) from 1 to 1.5 quarts to only 3 to 4 ounces in capacity, which thus significantly reduces the space that the patient has for food intake.
Also, the fact of cutting the stomach and removing it from the body achieves a very considerable reduction of ghrelin hormone production, also known as the "hunger hormone" which is a neuropeptide released by cells in the stomach when it is empty. This hormone when released, causes a stimulus in the brain that lets the person know that is hungry and causes the very well known sensation of "emptiness" in the stomach, increases gastric acid secretion and motility in preparation for food intake.
When the stomach is stretched by the presence of food, the production and release of ghrelin stops, reducing appetite stimulation, which is why gastric sleeve surgery gives the results obtained in relation to weight loss, not only restricting the amount of food the patient can eat but also reducing the sensation of appetite or prolonging the feeling of fullness for longer periods of time.
How does the Gastric Sleeve work
The way it works was described in previous paragraphs; the truth is that the explanation of how the gastric sleeve and other bariatric procedures work can be extremely complex if we involve the endocrine and gastrointestinal effects so in order to make the information suitable for every reader we will focus on the basics.
In bariatric surgery as a treatment option for morbid obesity, there are various procedures that can be "pure or mixed", whether they only reduce gastric capacity (restrictive) or besides this they produce impaired absorption of ingested food (malabsorption).
Gastric sleeve is a pure restrictive procedure, in which the size of the stomach is reduced, which in turn decreases its capacity and causes decreased production of ghrelin hormone.
This procedure achieves a significant weight loss as it helps the patient to ingest a smaller amounts of food and the food they eat is sufficient to cause fullness sensation for a longer period time.
Why do we consider gastric sleeve as a "smart" procedure?
One of the most frequently asked questions about the gastric sleeve by our patients when they are considering surgery as a treatment to their obesity problem is: how do you know how much stomach to cut for my case?
The answer is relatively simple. Unlike what many patients believe the size of the stomach before surgery does not seem to go hand in hand with the degree of obesity that they suffer. But we do have noticed that the length from the start to the end of the stomach is in close relation with the build and height of the patient.
To operate on a patient that measures 6’2”, we use a calibration tube (bougie) to use it as a pattern to know how much stomach is left in place. It will not be the same amount of stomach that stays in a patient that is 5’0” even when we use the exact same size of bougie because the patient who is taller has almost as a rule more length from the beginning to the end of the stomach compared with the 5’0” patient whose stomach is shorter.
If we haven’t explained yet properly, we put it this way, imagine the length of the arm of the people in question, almost as a commonsense rule the patient's arm that measures 6’2” will be considerably longer than the arm of the patient that measures 5”0”, the same happens with the stomach’s length of this people, the taller one will have more remnant stomach than the one that is shorter.
That is why even if we use the same diameter for the calibration tube (bougie) it is almost impossible to think that we will exceed or we'll stay "short" with the amount of stomach that we leave to the patient as this is determined based on their height, build and own needs.
We have never seen a postoperative gastric sleeve patient who has lost more weight than they needed to lose, but we have seen the opposite though, patients who have not lost all the weight that they should or could lose, but remembering what was discussed in previous articles, this is not because the procedure is ineffective but in relation to the fact that the patient did not follow the surgeon’s indications and did not complied with the dietary and behavioral changes to achieve proper weight loss and maintenance of such loss.
This situation can occur with every existing bariatric procedure today. No infallible bariatric procedure exists, so we remind and insist our patients that change is not only physical (with surgery) but behavioral and mental, which depends to the them and only them. The great thing about weight loss surgery is that even if the patient is not focusing and making his/her best effort after surgery, the procedure makes them lose weight considerably during the first months or even first year so this is usually enough stimulus for anyone to get in the right track with their relationship with food.
The gastric sleeve, the most frequently performed bariatric procedure worldwide
Although gastric bypass is considered the "gold standard" of bariatric surgery, and is considered the benchmark used to compare to any other procedure that has been devised, discovered or developed over the last 4 decades, the gastric bypass is a more complex surgery that lends itself to countless variations in its technique which makes the standardization of such technique more difficult and therefore the results.
This also applies to any other method of weight loss. Despite the previous sentence, gastric sleeve surgery is a much simpler procedure in the sense that there are not many variants making it a little easier to standardize the technique. Allowing us bariatric surgeons to have more consistent and stable results worldwide, it is one of the reasons why I believe it is currently the most frequently performed procedure worldwide, in addition to the excellent results obtained in patients with not very high body mass indexes (BMI of 50 or less) in addition to the low rate of complications in the short, medium and long term.
Gastric Sleeve Results/Advantages
- Weight Loss is similar to gastric bypass
- It is a pure restrictive procedure making it difficult to develop nutritional deficiencies to the patient.
- It is a short duration procedure in experienced hands.
- No risk of anastomotic ulcers like in the gastric bypass.
- No risk of internal hernias like in the bypass.
- There is no need for frequent periodic reviews.
- It is a "smart" procedure (see above).
- Low risk of developing anemia.
- Lower risk of hair loss and total recovery of hair in majority of cases
- Low percentage of growth of the gastric remnant and therefore less likely to regain the lost weight.
- In case it is required it can be considered as a first step for a second bariatric surgery in patients with very high BMI (above 50).
- The "ashy" skin appearance in not developed.
- Adequate control of diabetes.
- Adequate control of high blood pressure and other obesity related diseases.
- Extensive experience in certain bariatric groups, it has been performed for over a decade.
- Greater possibility to standardize the surgical technique.
- Lower risk of venous thrombosis due to the shorter duration of the procedure.
- Much lower risk of complications in the medium and long term.
- Low rate of complications in the short term.
- Low mortality rate.
- Extensive experience in the results in the short and medium term.
Sleeve Gastrectomy Disadvantages
- It is not recommended for patients with chronic gastroesophageal reflux.
- Possibility of reflux "de novo" after surgery (though, in over 75% of cases is temporary).
- Gastric leak is a complication of difficult management and resolution.
As you will see, after analyzing the pros and cons of gastric sleeve surgery and delve into how it works, there are many reasons to believe that the gastric sleeve is an excellent choice as a weight loss surgical treatment. The disadvantages are few and the advantages are many when compared with other methods; however, every case must be analyzed individually, there is no better decision being taken than the one made by a knowledgeable patient and guided by his/her bariatric surgeon.
Your turn, tell us what you think of this procedure, if you plan on having it one, which are your concerns?
Written by: Gabriel Rosales
Dr. Gabriel Rosales is a highly skilled, board certified surgeon in constant pursuit of learning the latest innovations in the weight loss surgery field to give his patients the best care possible.