SLEEVE GASTRECTOMY (Sleeve)

INTRODUCTION

The Gastric Sleeve (sleeve gastrectomy) is one of the newer bariatric operations but has quickly gained popularity over the last 10 years. It is also known as the Vertical Sleeve Gastrectomy, Vertical Gastroplasty or Sleeve Gastroplasty, this procedure has become the most popular weight loss operation in the USA.  It is mostly a restrictive operation – it works by controlling how much food can be eaten at one time.   The operation also causes metabolic effects – which has great health benefits and improves weight loss even further.  The sleeve operation is the removal of more than 85% of your stomach.  The part that is removed is the most stretchable portion of the stomach.  The stomach is divided and stapled vertically, creating a tube or pipe-shaped stomach pouch.   The shape and length of the stomach causes serious restriction in the amount of food that can be eaten at one time.  The most dramatic metabolic impact the RYGB operation has, is on diabetes.  Even before any significant weight has been lost the diabetes has already improved and requires less medication to manage.

SLEEVE GASTRECTOMY: REDUCING STOMACH SIZE

The laparoscopic sleeve gastrectomy is a restrictive operation, which means it works mostly by reducing the size of the stomach and thus your ability to eat large amounts of food at one time. The stomach size is reduced by about 85%. The part of the stomach that stretches most to accommodate more food is the part that is removed. The surgery does not alter the normal digestive process. Food absorption and digestion remain the same. About six months after surgery, the patient is able to eat about 4 ounces of food per meal, three to four times per day.

The weight loss is projected to be 70% of the excess body weight, which is comparable to that of the Roux-en-Y gastric bypass. The weight loss is expected to occur over one to one and half years. Half of the expected weight loss is lost in the first six months after surgery.  Studies show patients typically lose the most weight 1-2 years after bariatric surgery and see substantial weight improvements in obesity-related conditions.

 

-        Patients may lose as much as 60% of excess weight six months after surgery, and 77% of excess weight as early as 12 months after surgery.

-        On average, five years after surgery, patients maintain 50% of their excess weight loss.

The sleeve gastrectomy surgery is the most performed weight loss operation (60%).  Its simplicity is likely its most attractive feature. It carries more risk than a Lap-Band operation, but less risk than a bypass operation. The risk mostly occurs because of cutting the stomach - the very long staple line and the new long and narrow stomach.  All staple lines can leak, get infected, and bleed. The sleeve behaves in many ways like the bypass operation in weight loss, diabetes control, and its beneficial side effects. The side effects help patients lose more weight than would have been expected from restriction alone.

The small stomach pouch is created by using stapling devices. Stapling devices cut and sew the stomach at the same time. A bougie (sizer) is inserted into the stomach to ensure the sleeve is not too small or too large each time. The bougie is a long, smooth-tipped, flexible rubber, solid filled tube that is used as a sizer.  The surgeon using the stapling device hugs the bougie while cutting the stomach. As a result, a perfect sleeve is created each time and approximately 85% of the stomach is removed. The lumen (diameter) of the new stomach is about the size of a nickel/quarter.

The operation restricts food intake very effectively, particularly during the first year, the time of maximum weight loss. Ultimately, a sleeve gastrectomy patient will be able to eat about half a cup of food per meal three times a day while experiencing prolonged satisfaction and fullness from that small amount of food. Portions, hunger, and cravings are controlled particularly well if the patient is compliant with the rules. This is a profound experience for many, being released from a prison of hunger. The average expected weight loss with the sleeve gastrectomy in the first year is comparable to that seen with the Roux-en-Y gastric bypass - about 70%. Many of our patients with proper education and good compliance to the rules can achieve even better weight loss.

Proceeding with weight loss surgery is a very personal and often difficult decision. Educating yourself about weight loss surgery is a very important first step.  If you are ready to meet with the surgeon, schedule a first visit appointment by calling the office at 913-322-7401 or request a new patient appointment via our website.

For those of you who may be traveling large distances to visit us, please inform our staff you are traveling so they can prepare you better and help you minimize the number of trips that may be required to get you ready for your weight loss operation.

AM I A SLEEVE GASTRECTOMY CANDIDATE?

To be a candidate for any type of weight loss surgery, the individual must be severely (BMI > 35) or morbidly (BMI > 40) obese.  If diabetes is present and it is not well controlled patients can qualify with a BMI > 30.   Morbid obesity is usually defined as being about 100 pounds over your ideal body weight. A better way of defining morbid obesity is by using the Body Mass Index (BMI).  BMI is a calculated number that takes weight and height into consideration. A person weighing 300 pounds who is 5ft tall will have a higher BMI than a person weighing 300 pounds but is 6 ft tall.

To determine if you qualify for the sleeve gastrectomy, you can start by entering your weight and height into a BMI calculator.

Insurance companies often will have additional criteria to qualify for weight loss surgery. Our office can help you determine what those are. Below you will find the basic criteria most insurance companies use to determine if patients qualify for weight loss surgery:

BMI ≥ 40            regardless of medical problems

BMI ≥ 35            usually with medical problems such as:

-       type II diabetes (T2DM),

-       hypertension,

-       sleep apnea and other respiratory disorders,

-       non-alcoholic fatty liver disease,

-       osteoarthritis,

-       lipid abnormalities,

-       gastrointestinal disorders, or

-       heart disease.

BMI > 30           If Diabetes type II is not well controlled.  Unfortunately most insurance companies are not yet covering for this criteria

In addition:

  • No endocrine causes of obesity (untreated hypothyroidism, etc.).

  • There is an acceptable operative risk (the procedure does not put the patient at undue risk).

  • The patient understands the surgery and its risks.

  • The patient does not have a drug or alcohol addiction.

  • The patient does not have uncontrolled psychological conditions.

  • The patient should have tried other attempts at weight-loss (diets, exercise, medications, counseling, etc.…..).

 

HOW DOES THE SLEEVE GASTRECTOMY WORK?

The sleeve gastrectomy maintains the principles of restriction with several metabolic effects. The long and very narrow new stomach restricts food intake and helps maintain satiety. The length and narrowness of the stomach limit how much food you can comfortably eat at any one time. The longer the pouch is full, the longer you experience satiety and no hunger. The restriction in food intake is similar to that experienced by a bypass patient, ultimately about 4 ounces of food 3 to 4 times per day. This is a profound experience for many, being released from a prison of hunger. The success in keeping the weight off strongly relies on patient education and compliance with the rules.

Sleeve gastrectomy surgery alone without permanent lifestyle and eating habit changes will not ensure long-term success. Proper education and compliance with the rules are key to any patient's success. The operation and its metabolic effects to a significant degree will force many patients to change their eating habits but we do not want patients to rely on that solely. The sleeve is only a tool. A tool to significantly help patients with the necessary work to reach their health and weight loss goals. Please explore our website for more information (videos, links, information..) about weight loss surgery.

WHAT CAN YOU EXPECT FROM THE SLEEVE GASTRECTOMY?

The medical and emotional benefits of the sleeve gastrectomy procedure begin almost immediately after surgery, and the cosmetic benefits follow their wake. Over time, the benefits of sleeve gastrectomy surgery may include:

-        Significant sustained weight loss

-        Portion control

-        Blood sugar levels that become completely normal or dramatically improved

-        Lower or normal blood pressure

-        Lower or normal cholesterol levels

-        Relief from sleep apnea, acid reflux, and urinary stress incontinence

-        Decreased joint pain and improved mobility

-        Increased energy and ability to exercise

-        Improved mood and self-esteem

-        Arrested progression of heart disease

-        Improvement of many lung conditions

-        Exercise endurance

-        Reduced need for medication

The co-morbidities of clinically severe obesity begin to resolve before complete weight loss occurs. These include better control or cure of diabetes; lowered or normalized blood pressure and cholesterol; relief from sleep apnea, severe acid reflux, and urinary stress incontinence; eased lower back, knee and hip pain. Patients also report enhanced mobility and increased stamina and endurance. Many conditions, such as evolving heart and pulmonary disease, have been arrested or its progression significantly slowed.

With the sleeve gastrectomy, patients lose around 70% of their excess weight within one to one and a half years. Half of that weight is lost in the first 6 months.

Example:

Patient Smith, John weight is 300 lbs, patient Smith, John ideal weight is 100 lbs, therefore patient Smith, John has 200 lbs of excess weight. If patient Smith, John chooses the sleeve gastrectomy that patient will lose about 140 lbs (70% x 200 lbs = 140lbs), 70 lbs of which the patient will likely loose in the first 6 months.

RISKS OF THE SLEEVE GASTRECTOMY

As with all surgery, there are risks. Patients considering surgery must weigh the risks and benefits of surgery against the severity of their obesity. The decision to proceed is based on the premise that the treatment should be less harmful than the disease being treated. Complications can occur as with any type of surgery.

Below is a list of some general and specific complications that are unique to the sleeve gastrectomy procedure:

-        Leakage from a staple line causing infection

-        Spleen injury, potentially requiring removal

-        Esophageal injury

-        Sleeve narrowing/stricture

-        Blood clots in legs

-        Pulmonary embolism (blood clot in the lung)

-        Inability to eat, or difficulty eating, certain foods

-        Development of gallstones or gallbladder disease

-        Inflammation of sleeve lining, sleeve ulcer

-        Weight gain (failure to lose satisfactory weight)

-        Instrumentation failure may or may not result in additional surgery

-        Pregnancy is not recommended during the first one and a half years of active weight loss

-        Other potential complications not included can also happen

-        Anemia, vitamin/mineral deficiency, protein malnutrition, temporary hair loss

Women are already at risk for osteoporosis particularly after menopause and should be aware of the potential for heightened potential bone calcium loss. All of the deficiencies mentioned above, however, can be easily prevented and managed through proper diet and vitamin supplements.

A chronic anemia due to Vitamin B12 deficiency may occur. The problem can usually be managed with Vitamin B12 supplements.

Advantages 

-        Technically simple and shorter surgery time

-        Can be performed in certain patients with high risk medical conditions

-        May be performed as the first step for patients with severe obesity

-        May be used as a bridge to gastric bypass or SADI-S procedures

-        Effective weight loss and improvement of obesity related conditions

-        Causes favorable changes in gut hormones that suppress hunger, reduce appetite and improve satiety 

Disadvantages 

-        Is a non-reversible procedure 

-        May worsen or cause new onset reflux and heart burn

-        Less impact on metabolism compared to bypass procedures

DECIDING ON THE SLEEVE GASTRECTOMY

The decision about which operation is best for you is a complicated one. The decision to proceed is based on the premise that the treatment should be less harmful than the disease being treated. Please read the obesity disease section of our website to learn more about obesity the disease, and the benefits weight loss surgery can offer to morbidly obese patients. Although the information presented throughout our website may be helpful, you will be able to learn substantially more about the benefits and risks of the sleeve gastrectomy operation during your visit with our bariatric surgeons.