The Sleeve Gastrectomy generates weight loss by restricting the amount of food that can be eaten without any bypass of the intestines or malabsorption of food because the continuity of the stomach remains intact. In addition to avoiding foreign bodies such as the lap band, the other advantage over other procedures is that the excess stomach volume is removed. This helps patients control their hunger. Some insurance companies cover this procedure but most do not.
High BMI patients (BMI > 50-60):
In America and Germany, this procedure was first performed laparoscopically in very high BMI patients to try to reduce the overall risk of weight loss surgery. The Vertical Gastrectomy is a reasonable solution to this problem. It can usually be done laparoscopically in patients weighing over 500 pounds. The stomach restriction allows these patients to lose more than 100 pounds and in many patients more than 200 pounds. This weight loss can lead to significant improvement in health and effectively “downstages” a patient to a lower risk group. Once the patients BMI is lower (35-40) they can return to the operating room for the second stage of the procedure, which can either be the Duodenal Switch, Roux-en-Y gastric bypass or even a LapBand®.
Low BMI patients (BMI 35-60 Kg/M2):
This procedure also started in England over five years ago as a stand alone weight loss procedure for anyone with a BMI greater than 35 Kg/M2 and proved to be effective even at five years. However, ten percent of patients failed to achieve a BMI below 35 at five years and most of them tended to be heavier patients that would expect to go through a second stage as noted above. Low BMI individuals who should consider this procedure include:
- Those who are concerned about the potential long term side effects of an intestinal bypass such as intestinal obstruction, ulcers, anemia, osteoporosis, protein deficiency and vitamin deficiency
- Those who are considering a LapBand® but are concerned about a foreign body
- Those who have other medical problems that prevent them from having weight loss surgery such as anemia, Crohn’s disease, extensive prior surgery, and other complex medical conditions
- Those who take anti-inflammatory medications, however these medications usually should be avoided after a gastric bypass because the risk of ulcer is higher
How it Works
The procedure generates weight loss solely through gastric restriction, or reduced stomach volume. The stomach is restricted by dividing it vertically and removing more than 85%. This part of the procedure is not reversible. The remaining stomach is shaped like a banana and measures from two to five ounces, depending on the surgeon performing the procedure. The nerves to the stomach and the outlet valve (pylorus) remain intact to preserve the functions of the stomach while reducing the volume. By comparison, in a Roux-en-Y gastric bypass, the stomach is divided, not removed, and the pylorus is excluded. The Roux-en-Y gastric bypass stomach can be reconnected (reversed) if necessary.
Sleeve gastrectomy has these potential advantages.
- The stomach is reduced in volume but continues to function normally so most food items can be consumed in small amounts.
- Eliminates the portion of the stomach that produces the hormones that stimulates hunger.
- There is no dumping syndrome because the pylorus is preserved.
- Minimizes the chance of an ulcer occurring.
- By avoiding the intestinal bypass, the chance of intestinal obstruction, anemia, osteoporosis, protein deficiency and vitamin deficiency are almost eliminated.
- The procedure has been show to be very effective as a first stage procedure for high BMI patients and results appear promising as a single stage procedure for low BMI patients.
- The procedure may also be an appealing option for people with existing anemia, Crohn’s disease and numerous other conditions that make them too high risk for intestinal bypass procedures.
- This procedure can be done laparoscopically in patients weighing over 500 pounds.
Sleeve gastrectomy has these potential disadvantages:
- There is a potential for inadequate weight loss or weight regain. While this is true for all procedures, it is theoretically more possible with procedures that do not have an intestinal bypass.
- Higher BMI patients will most likely need to have a second stage procedure later to help lose the rest of the weight.
Risks and Complications
Wound infections can occur after all types of surgery. When independent evaluators look at surgical wounds they find about five percent of patients get wound infections. These can be minor or major. Major infections can include fever, hot skin around a wound site, leakage from the wound, and redness of the area. These infections may require antibiotics or surgery. It is important to tell your doctor if you think you have an infection. The most common site for an infection after laparoscopic Roux-en-Y gastric bypass is the biggest incision on the left side.
As the connection forming your new small stomach heals, it forms scar tissue, which naturally tends to shrink over time, making the opening smaller. This is called a stricture or a stenosis. Usually, the passage of food through an anastamosis will keep it stretched open, but if the inflammation and healing process outpaces the stretching process, scarring may make the opening so small that even liquids can no longer pass through it. The solution is a procedure called gastroendoscopy, and stretching of the connection by inflating a balloon inside it. Sometimes this manipulation may have to be performed more than once to achieve lasting correction. Even more rarely stents or repeat operations are required.
Many blood vessels must be cut, to divide the stomach and to move the bowel. Any of these may later begin bleeding, either into the abdomen (intra-abdominal hemorrhage), or into the bowel itself (gastrointestinal hemorrhage). Transfusions may be needed, and re-operation is sometimes necessary. Use of blood thinners, to prevent venous thromboembolic disease, may actually increase the risk of hemorrhage slightly.
Infection can occur after surgery. Effective short-term use of antibiotics, diligent respiratory therapy, and encouragement of activity within a few hours after surgery, can reduce the risks of infections.
Abdominal surgery always results in some scarring of the bowel, called adhesions. No matter what surgery you have on the bowel there is a one to two percent lifetime risk of adhesions forming and blocking the bowel. When a patient’s bowels become blocked, the patient generally has severe abdominal pain and eventually vomiting. Vomiting is always abnormal after surgery. The treatment for bowel obstruction is surgery.
Any injury, such as a surgical operation, causes the body to increase the coagulation of the blood. There is an increased probability of formation of clots in the veins of the legs, or sometimes the pelvis, in the morbidly obese patient. A clot which breaks free and floats to the lungs is called a pulmonary embolism, a very dangerous occurrence. Commonly, blood thinners are administered before surgery, to reduce the probability of this type of complication. The best way to prevent this life threatening complication is to walk after surgery.
An anastamosis is a surgical connection between two parts of the stomach. The surgeon attempts to create a water-tight connection by connecting the two with either staples or sutures, either of which actually makes a hole in the bowel wall. The surgeon will rely on the healing power of the body, and its ability to create a seal like a self-sealing tire. If that seal fails to form, fluid from within the gastrointestinal tract can leak into the sterile abdominal cavity and give rise to infection and abscess formation. Leakage of an anastamosis has been reported in bariatric procedures. Sometimes leakage can be treated with antibiotics, and sometimes it will require immediate re-operation.
Almost any of the above complications can result in death. The best way to avoid the most common causes of death after gastric bypass surgery is to walk frequently and to report any problems to your surgeon.