Gastric sleeve surgery, also known as Gastric Sleeve Resection or Vertical Sleeve Gastrectomy (VSG), is one of the newer types of bariatric surgery. This surgery can also be referred to as sleeve gastrectomy, vertical sleeve gastrectomy, tube gastrectomy and laparoscopic sleeve gastrectomy.
It is restrictive type of weight loss surgery that permanently reduces the size of the stomach. It promotes weight loss by limiting food intake and lessening the sensation of hunger; it does not involve intestinal rerouting or food malabsorption.
This bariatric procedure does not replace the need for following a healthy diet and regular physical activity; in fact, patients seeking major weight loss through gastric bypass will need to commit themselves to regular diet and exercise afterwards so that they can achieve long-lasting, successful results.
Weight Loss Alternatives
Though it’s the most commonly used, gastric bypass is just one kind of weight-loss surgery. Other types include:
Roux-en-Y Gastric Bypass
This variant is the most commonly employed gastric bypass technique, and is by far the most commonly performed bariatric procedure in the United States. It is the operation which is least likely to result in nutritional difficulties. The small bowel is divided about 45 cm (18 in) below the lower stomach outlet, and is re-arranged into a Y-configuration, to enable outflow of food from the small upper stomach pouch, via a “Roux limb”. In the proximal version, the Y-intersection is formed near the upper (proximal) end of the small bowel. The Roux limb is constructed with a length of 80 to 150 cm (31 to 59 in), preserving most of the small bowel for absorption of nutrients. The patient experiences very rapid onset of a sense of stomach-fullness, followed by a feeling of growing satiety, or “indifference” to food, shortly after the start of a meal.
Duodenal Switch (DS)
procedure, also known as Biliopancreatic Diversion with Duodenal Switch (BPD-DS) or Gastric Reduction Duodenal Switch (GRDS), is a weight loss surgery procedure that is composed of a restrictive and a malabsorptive aspect.
One of the most effective weight loss procedures for the super obese is the Duodenal Switch. The Duodenal Switch includes a restrictive component but is primarily a malabsorptive weight loss procedure. With Duodenal Switch weight loss surgery, the size of the stomach is reduced to limit food intake and the small intestine is “switched” around to alter the digestion process and limit food (calorie) absorption. This bariatric operation has greatly improved the health and quality of life for many seriously obese individuals by helping them achieve and maintain significant long-term weight loss.
Adjustable Gastric Banding
The surgeon uses an inflatable band to partition the stomach into two parts. He or she then wraps the band around the upper part of your stomach and pulls it tight, like a belt, creating a tiny channel between the two pouches. The band keeps the opening from expanding and is designed to stay in place indefinitely. But it can be adjusted or surgically removed if necessary. Most surgeons perform this operation using a laparoscope.
Vertical Banded Gastroplasty
This operation divides the stomach into two parts — limiting space for food and forcing you to eat less. There is no bypass. Using a surgical stapler, the surgeon divides your stomach into upper and lower sections. The upper pouch is small and empties into the lower pouch — the rest of your stomach. Partly because it doesn’t lead to adequate long-term weight loss, surgeons use it less commonly than gastric bypass.
In this procedure, a portion of your stomach is removed. The remaining pouch is connected directly to your small intestine, but completely bypasses your duodenum and jejunum where most nutrient absorption takes place. This weight-loss surgery offers sustained weight loss, but it presents a greater risk of malnutrition and vitamin deficiencies and requires close monitoring.
Candidates for Gastric Sleeve
No reliable statistics exist yet for how many of these procedures have been done. The current scientific literature supports use of sleeve gastrectomy as a primary bariatric procedure. This means that the indications for the sleeve are the same as other covered procedures such as gastric bypass or adjustable gastric banding. The National Institutes of Health (NIH) requires a body mass index (BMI) greater than 40. This is the equivalent of being about 100 pounds overweight for men and 80 pounds overweight for women. People with BMIs between 35 and 39 may also be candidates for weight loss surgery if they have obesity-related illnesses such as diabetes, high blood pressure or high cholesterol. A BMI takes height and weight into account to measure body fatness. A BMI of 30 or higher in adults is considered obese.
Gastric sleeve surgery also may be appropriate for people who can’t return as often for the follow-up visits required by gastric banding procedures such as Lap Band surgery or Realize Band surgery.
- Underweight = <18.5
- Normal weight = 18.5-24.9
- Overweight = 25-29.9
- Obesity = BMI of 30+
Generally, gastric bypass surgery is reserved for people who are unable to achieve or maintain a healthy weight through diet and exercise, are severely overweight, and who have health problems as a result. Gastric bypass may be considered if:
Once the surgeon fully assesses the patient, the best-suited technique will be discussed before a personalized surgical plan is developed.
Prepare for Vertical Sleeve Gastrectomy
Before gastric sleeve resection or any bariatric surgery, you must quit smoking, as smoking increases the risk for infections, pneumonia, blood clots, slow healing and other life-threatening complications after surgery. Ideally, you should permanently quit smoking, but even if you don’t you must quit for at least one month before and one month after bariatric surgery.
Some surgeons require patients to go on special diets in the week(s) before the procedure.
Patient Considerations for Gastric Sleeve Surgery:
- Safer option for individuals with BMI greater than 60 to undergo two-stage process of gastric sleeve followed up with duodenal switch or gastric bypass after partial weight loss
- Option for patients concerned about long-term side effects of weight loss surgery that involves rerouting and bypassing a portion of the small intestine, such as intestinal obstruction, ulcers, anemia, osteoporosis, protein deficiency, and vitamin deficiency
- Restrictive weight loss option for patients who are not comfortable having a medical device implanted into their body as with the LAP-BAND or REALIZE Band
- Surgical weight loss option for patients with health problems or complex medical issues that may prevent them from having other types of weight loss surgery, such as anemia, Crohn’s disease, anti-inflammatory drug use, or extensive prior surgery
- Revision option for gastric band patients experiencing problems with their band but who do not want to convert to a bypass type of operation
Medical Evaluation for Gastric Sleeve Resection
A team of health professionals — usually including a doctor, dietitian, psychologist and surgeon — will evaluate whether gastric bypass surgery is appropriate for you. The evaluation essentially determines if the health benefits outweigh the potentially serious risks of this major procedure. Even if you meet the criteria for gastric bypass surgery, you will still need to be evaluated to see if you’re psychologically and medically ready to undergo the procedure.
Your Nutrition and Weight History
The team reviews your weight trends, diet attempts, eating habits, exercise regimen, stress level, time constraints, motivation and other factors.
Your Medical Condition
Some health problems increase the risks associated with having surgery or may be worsened by surgery, such as blood clots, liver disease, heart problems, kidney stones and nutritional deficiencies. The team will evaluate what medications you take, how much alcohol you drink and whether you smoke. You also will have a thorough physical exam and laboratory testing.
Your Psychological Status
Certain mental health conditions may contribute to obesity or make it more difficult for you to maintain the health benefits of gastric bypass surgery. These may include binge-eating disorder, substance abuse, depression, anxiety disorders and issues related to childhood sexual abuse. While these may not prevent you from having gastric bypass surgery, your doctors may want to postpone surgery to ensure that any condition is appropriately treated and managed.
The team will also assess your willingness and ability to follow through with recommendations made by your health care team and to carry out prescribed changes in your diet and exercise routine.
Although there’s no specific age limit for gastric bypass surgery, the risks increase if you’re over age 65. The surgery remains controversial in people under age 18.
Advantages of Gastric Sleeve Weight Loss Surgery
- Promotes weight loss by restricting amount of food that can be eaten at any one time
Reduces hunger since it removes the part of the stomach that produces the hunger stimulating hormone ghrelin
- Digestion occurs normally as the digestive system is not altered
- Does not cause malabsorption or nutritional deficiencies as it does not involve rerouting or bypassing the small intestine
- Less chance of developing ulcers than with gastric bypass surgery
- Dumping syndrome not likely to occur as the stomach outlet (pyloric valve) remains intact, unlike gastric bypass surgery
- Less complicated procedure than gastric bypass or duodenal switch surgery
- Can usually be performed laparoscopically on extremely obese patients
- Does not require a gastric band being implanted into the body
- Does not require adjustments or fills as with a LAP-BAND or REALIZE Band
- Safer than a combined restrictive/malabsorptive weight loss surgery for patients who have many health problems
- May be converted to gastric bypass or duodenal switch if necessary for additional weight loss
- Expected excess weight loss for stand-alone procedure is 60 to 70% at two years
Sleeve Gastrectomy Surgery Overview
Gastric sleeve surgery is performed under general anesthesia and takes about one to two hours. Afterward you will probably stay in the hospital for one or two days; recovery from gastric sleeve surgery may last a few weeks.
During this procedure a bariatric surgeon removes about 85 percent of the stomach so that it takes the shape of a tube or sleeve. This operation is performed laparoscopically, meaning that the surgeon makes small incisions as opposed to one large incision. He or she inserts a viewing tube with a small camera (laparoscope) and other tiny instruments into these small incisions to remove part of the stomach. The tube-shaped stomach that is left is sealed closed with staples.
In some cases, gastric sleeve surgery may be followed by a gastric bypass surgery or duodenal switch surgery after a person has lost a significant amount of weight. Called a “staged” approach to weight loss surgery, this makes the second procedure less risky than it would have been had it been the first and only procedure. The timing of the second surgery varies according to the degree of weight loss. It usually occurs within six to 18 months after the initial surgery.
The cutaway part of the stomach is removed from the body and not left in place as with gastric bypass surgery, therefore the stomach reduction is permanent and the gastric sleeve procedure is not reversible. Overall, it is a less complicated operation than either gastric bypass or duodenal switch surgery, since the pyloric valve and small intestine are left intact. Also, the gastric sleeve does not involve implanting a medical device into the body in order to restrict eating as with adjustable gastric banding surgery.
Plastic Surgery After Massive Weight Loss
Although the full extent of weight loss may not occur until after a second procedure has been performed, such as gastric bypass, it is important to know that plastic surgery after massive weight loss may be necessary to remove excess skin and fat and create a more shapely body profile. Arm lift surgery and body lift are common post-bariatric procedures.
Gastric Sleeve Results
Most patients who have gastric sleeve surgery lose 50% to 80% of their excess body weight over the first six months to one year after having the weight loss surgery. Studies have shown that after the gastric sleeve resection procedure people show improvement in diabetes, high blood pressure, high cholesterol and sleep apnea within one to two years. These improvements are comparable with those seen after other weight loss surgeries.
As this is a relatively new procedure, limited data is available on long-term weight loss (beyond five years after surgery) or overall health improvements.
In addition to dramatic weight loss, gastric bypass surgery may improve or resolve the following conditions associated with obesity:
- Type 2 diabetes
- High blood cholesterol
- High blood pressure
- Obstructive sleep apnea
- Gastroesophageal reflux disease (GERD)
The improvements observed in type 2 diabetes, high blood pressure and high blood cholesterol may significantly decrease the risk of cardiovascular events in individuals who have undergone gastric bypass surgery compared with those treated through other means. Gastric bypass surgery has also shown to improve mobility and quality of life for people who are severely overweight.
Recovery Bariatric Surgery
The abdomen is often swollen and sore for several days. Your surgeon may prescribe pain medication for the discomfort. Some scarring may occur, but this can be covered with clothing.
Diet After Surgery
The gastric sleeve procedure will help a person control their hunger and limit the amount of food they can eat at any one time. As with all surgical weight loss programs, however, weight loss ultimately depends on adopting a new lifestyle, healthy diet, and regular exercise. The surgery itself does not require many food restrictions as the stomach continues to function normally, but for weight loss to occur high-calorie and high-fat foods and drinks must be avoided and daily calories must be limited. Many bariatric surgeons recommend eating five small, healthy meals a day with no snacking in-between meals.
Following surgery, patients will need to follow a liquid diet for about two weeks while the body heals. The diet will slowly progress from soft to solid foods. At about 4 to 6 weeks after surgery, most patients will usually be able to eat a regular solid diet. During the first 1 to 2 years after surgery, when most weight loss is expected to occur, the diet is limited to 600 to 800 calories a day. Once goal weight is achieved, most patients are able to eat about 1000 to 1200 calories a day.
Gastric Sleeve Post Operative Care
Following surgery, you will need to become re-accustomed to eating solid foods. Normally this starts with two weeks on a liquid-only diet, two weeks of semi-solid, pureed foods and then solids.
Following recovery, certain lifestyle changes and follow-up care occur; people who have gastric sleeve surgery must:
- Exercise regularly.
- Learn behavior modification techniques.
- Follow very specific dietary instructions for the rest of their lives, including eating very slowly, consuming only small quantities of food at a time, chewing thoroughly and swallowing food only when it is mashed, and not eating and drinking at the same time.
Possible Gastric Bypass Risks
As with any major surgery, gastric bypass carries risks such as bleeding, infection and an adverse reaction to the anesthesia.
Risks and Complications of Gastric Sleeve Surgery:
- Leaking of the sleeve. The operation requires stapling inside the stomach, and there is always a chance that the staples won’t hold, resulting in a leak. The leaking stomach acids frequently lead to infection of surrounding tissues and other serious problems that may require another operation or a drainage tube.
- Blood clots
- Weight may be regained over time, because the stomach can stretch.
Since this procedure is relatively new, long-term risks and benefits are not known. However, it does have several advantages over gastric banding and other surgical procedures.
Disadvantages of Gastric Sleeve
- As it is a purely restrictive weight loss procedure, inadequate weight loss or weight regain is more likely than with a procedure involving intestinal bypass
- With time, new smaller stomach pouch may stretch (also occurs with gastric bypass surgery)
- Although the gastric sleeve helps control hunger and limit amount of food that can be eaten at any one time, weight loss will not occur without a healthy, low-calorie diet and regular exercise (same as with other purely restrictive procedures such as LAP-BAND and REALIZE Band)
- If performed as the first part of a two-stage process, a second malabsorptive weight loss surgery such as the duodenal switch will need to be performed at a later time
- The surgery is not reversible as a portion of the stomach is permanently removed
- Leaks or bleeding may occur along the stomach stapling edge
- Procedure may not be covered by some insurance companies
- All surgery and anesthesia involves some level of risk including bleeding, blood clots, infection, pneumonia, or complications
- Lack of published data for long-term weight loss results