How much weight will I lose?

This is obviously a key question. Unfortunately, there is no long term data to give us a good answer. Preliminary data suggests that weight loss may be similar to that attained with Roux-en-Y gastric bypass.

Can the staples tear out?

No. Once you have recovered from the surgery, your body's own scar tissue heals the stomach tissue together, just as your skin stays healed long after sutures or staples are removed.

What are the staples made of?

Staples are made of titanium. You can have an MRI scan, and you can go through the detectors at the airport without any problems.

What is a Bougie, and what size do you use?

A bougie is a soft flexible rubber tube that comes in multiple sizes. They are designed to stretch esophageal strictures. We use them to calibrate the size of the gastric sleeve. The size indicates the circumference in millimeters. I use a Size 32 bougie, which translates to a diameter of about 10 millimeters or 0.4 inches. This is very thin, and explains why you can't eat very much! It is placed temporarily while performing the operation, then removed.

What is a leak test, and should I have one?

One of the most feared causes of complications after sleeve gastrectomy is a leak at the staple line. These leaks can be caused either by stapler malfunction, wrong choice of stapler size, or trying to staple tissue too thick to accomodate the stapler. There are several ways to test a staple line for defects. One is to submerge the finished sleeve under saline solution and inflate it with air from either a tube or an endoscope in the stomach. Another is to pump a dye called methylene blue into the stomach and see if it leaks out. These tests are done during the surgery. After surgery, we can test for leaks by giving contrast material (dye) by mouth and taking x-ray pictures to look for a leak. Each test has advantages and disadvantages, as well as significant false negative rates (the test is normal but there is still a leak). Another problem comes from the fact that many leaks don't even turn up until several days to a week after the surgery. Each surgeon has his own technique and philosophy on leak testing, as there is no clear consensus on the best way to check for leaks.

Why do I have to take vitamins?

The sleeve gastrectomy operation is purely restrictive, so you wouldn't think you would need to take vitamins if you are eating a healthy diet. On the other hand, by definition you are eating a hypo-caloric diet, one which will cause you to lose weight. Because of this, we worry that you won't get all the vitamins and minerals you need. This is the main reason we ask you to take vitamins after the surgery. In addition, the stomach secretes a substance called intrinsic factor, which is important in absorption of vitamin B-12. Since we are removing a large part of the stomach there is a chance that you won't be able to properly absorb this vitamin. For this reason it is a good idea to take supplemental vitamin B-12.

What are the advantages of the operation over gastric bypass?

There is no rerouting of the intestines, and no new connections need to be made. This makes it safer, easier, and faster to perform. The lack of rerouting eliminates the late risk of bowel obstruction from internal hernia that comes with the gastric bypas operation. Finally, the lack of rerouting also reduces the risk of vitamin and mineral deficiencies. Another advantage is that the operation is ideally suited for conversion to another procedure such as gastric bypass, duodenal switch, or even LapBand.

What are the disadvantages as compared to gastric bypass?

The main disadvantage is that we don't have long-term data to document that weight loss will be maintained. The sleeve may stretch out, resulting in weight regain. Another disadvantage is that the operation is not reversible, in that part of the stomach is removed and thrown away. It can never be replaced. (On the other hand, there should be no reason to want to put it back).

What are the advantages of the VSG over the LapBAND?

With the VSG there is no foreign body to break, slip, or erode. There is nothing to be adjusted. Reoperation rate for these complications is therefore eliminated. You don't need to worry about getting follow-up care if you move to another city.

Weight loss is faster and more reliable with the VSG. The feeling of fullness that you get from the VSG is much more satisfying than the feeling of obstruction or discomfort that you get with the LapBAND. Few patients vomit after the VSG, while many patients continue to have vomiting episodes long after they have their LapBANDs placed.

What are the disadvantages as compared to the LapBAND?

The LapBAND is reversible; the VSG is not. Unfortunately this turns out not to be much of an advantage of the LapBAND, as the only reason to remove a LapBAND is for complications.

If you have questions that have not been answered by this FAQ, please send them to me and I will try to answer them for you.

Here is an article published in Obesity Care News December 2008. It is complete and unedited.

The Gastric Sleeve: 'In-between' Procedure Gaining Popularity

Still Investigational, the Procedure Can Lead to Difficult-to-Repair Leaks

Laparoscopic adjustable gastric banding and Roux-en-Y gastric bypass are still favored by patients, surgeons and insurance, carriers in the United States, but the relatively straight‑forward sleeve gastrectomy, originally employed as the first step of a two-part proce­dure, is catching on as an effective and efficient in-between option.
"Many surgeons have started to look into this for many patients, and many patients seem to like the concept that there is no rearrangement of the small bowel anatomy," said Michel Gagner, MD, chief, Department of Surgery, Mount Sinai Medical Center, Miami Beach, Fla., and a clinical professor of surgery at Florida International University, Miami. Sleeve gastrectomy attracts patients who do not want a foreign body—such as a gastric band—as well as those leery of the anatomical rearrangement that occurs with the gastric bypass. Furthermore, as
a purely restrictive procedure, sleeve gastrectomy does not lead to micronutrient deficiencies that can be a problem in patients who undergo malabsorptive procedures.
"Both the long-term and short-term risks and complications are definitely less compared with bypass, and slightly more compared with the band," said Samuel Szomstein, MD, associate director, Bariatric and Metabolic Institute and Section of Minimally Invasive Surgery Cleveland Clinic, Weston, Fla., and clinical assistant professor of surgery, Nova Southeastern University Fort Lauderdale, Fla. "Weight-loss achievement is much more rapid and efficient than with the band, and slightly less than the bypass. That's why we like to call it the in-between procedure, because it falls in between those two."
According to Dr. Gagner, long-term complications with the sleeve are actually less than with the band, which has a reop­eration rate of 25% to 30% and a high explantation rate.
Although the rate of popularity in preference for the sleeve gastrectomy may be hindered somewhat in the United States by a lack of insurance coverage—at this time, there is still no code for the proce­dure—the operation is becoming more popular in countries where insurance is not an issue.
"We see in Asia—Taiwan, Japan, Thailand, India—they are starting to use the sleeve for lower BMI [body mass index] patients with type 2 diabetes," Dr. Gagner said. The sleeve is also popular in Mexico, some countries of South America and some European countries.
In the largest known sleeve series, Gregg Jossart, MD, and Paul Cirangle, MD, at California Pacific Medical Center, San Francisco, have found weight loss identical to that with gastric bypass.
Dr. Gagner said, "About 67% the first and second year, 60% the third year, and it drops to 50% the fourth year. The resolution of comorbidities is as good too, about 85% for type 2 diabetes," which some find surprising given that the duodenum and proximal small bowel remain intact after sleeve gastrectomy.
The operation, a vertical gastrectomy of the entire greater curvature of the stomach leaving a narrow tube, or sleeve, along the lesser curvature, originated as the first part of a duodenal switch in patients with a BMI of >60 kg/m2. In these high-risk patients, the first surgery allowed them to lose enough weight to reduce their risks enough to make the second surgery possible.
Because the procedure—performed laparoscopically with linear staples—is relatively simple, there is little room for variation in approach and technique. Results from a questionnaire filled out by surgeons at the First International Consensus Summit for Sleeve Gastrectomy in New York, in 2007, showed that most surgeons start stapling 5.5 cm from the pylorus. "Very few people go any closer to the pylorus. It seems to create more vomiting, dysphagia, pro­longed nausea," Dr. Gagner said. "By staying away from the antrum we seem to avoid some of those complications."
Surgeons do vary a bit in preference for size of the bougie-32 to 40 French—used to create the sleeve. Another varia­tion is in the choice of reinforcement if any—along the staple line in an attempt to reduce bleeding and leaks, the two common complications of the operation.
"Leaks that occur very close to the esophagus seem to be in the range of 1% to 2%, and lower leaks along the staple line occur less frequently, maybe 0.5%," Dr. Gagner said. Bleeding occurs in about 1% to 2% of patients. "We cannot make a claim that use of buttressing material reduces leaks, but there have been three or four publications showing that this mate­rial reduces bleeding."
To reinforce the staple line, some sur­geons use bovine pericardium; some, such as Dr. Szomstein, oversew with sutures. "We feel that this reinforcement is the most economic and efficient option," Dr. Szomstein said. "Some people don't use [any reinforcement] and it is still fine. There is no standard of care in that regard."
Although there is no clear-cut indica­tion for the sleeve, it may be suitable for most patients who meet National Institutes of Health criteria for any bariatric surgery. "Our preference is to use the sleeve in patients who have con­traindications for gastric bypass, such as patients who have intestinal conditions such as inflammatory bowel disease," Dr. Szomstein said.
Dr. Szomstein said he would consider sleeve gastrectomy for patients who have had previous extensive intestinal opera­tions or who may have such operations in the future; patients at higher risk for com­plications from bypass, such as smokers or those on anticoagulation therapy; and older and younger patients who want rapid weight loss without altered anatomy or the malnutrition risks associated with malabsorptive procedures.
The sleeve may not be a good choice for patients with a significant hiatal her­nia or a history of severe gastroesophageal reflux disease. "In those patients, it's important that you take care of that issue before or during the sleeve gastrectomy, because once you've done the sleeve gas­trectomy and you've resected that portion of the stomach, any further surgical ther­apy for reflux is not going to be possible," Dr. Szomstein said. He also cautioned against sleeve gastrectomy for patients with other gastric complications, such as a history of gastric cancer.
Dr. Gagner, however, pointed out that the sleeve is fairly popular in countries such as Chile and Japan where incidence of gastric cancer is high. "Doing a gastric bypass [in these patients] makes the fol­low-up of a gastric remnant virtually impossible, therefore a sleeve with or without duodenal switch is the way to go in these patients," he said.
Because few insurance companies cover sleeve gastrectomy, most patients will have to pay out of pocket for the proce­dure. "Because this is much less surgery than the bypass, you should accordingly bill the patient less for sleeve gastrecto­my," said Dr. Szomstein. At Cleveland Clinic, sleeve gastrectomy costs about $19,000, compared with approximately $29,000 for gastric bypass. Laparoscopic banding is less, about $17,000, but requires yearly adjustments that may "eventually be more expensive than the sleeve itself," Dr. Szomstein said.
For patients who lack bariatric coverage completely, sleeve gastrectomy may make good sense economically. At present, however, what the procedure shows in promise, it lacks in history—there is a lack of long-term data. "So far we have results up to two years, that includes studies that we have published at the Cleveland Clinic and there are very few other ones," Dr. Szomstein said. "The results are extremely good."
It is likely that weight regain will be the biggest problem, as it is with gastric bypass, due to stretching. "The gastric pouch of a gastric bypass stretches and the small bowel elongates," Dr. Gagner said. "In the gastric sleeve the stomach will stretch, so we'll see some weight regain occurring. But in my opinion, a sleeve gastrectomy that stretches will be easier to revise than a gastric bypass."
In the right hands, sleeve gastrectomy may indeed be a safe, well-tempered mid­dle ground between band and bypass, but not every surgeon is in support of the pro­cedure.
"We've entered a whole new arena where people who are trying to learn sleeve gastrectomies tend to do it on someone who has, say, a BMI of 36, someone who in my opinion has no busi­ness having a sleeve gastrectomy," said Jeffrey L. Lord, MD, director of MIS and bariatrics, Sacred Heart Institute of Surgical Weight Loss, Pensacola, Fla., chairman of the professional liability committee, the American Society for Metabolic and Bariatric Surgery.
Dr. Lord gives the example of a female patient with a BMI of 36 kg/m2 and minimal comorbidities whose insurance disqualifies her from any bariatric proce­dure. "She reads on the Web about the sleeve, which is cheaper than gastric bypass and doesn't require her to pay for adjustments down the line, like a band." The patient opts for the sleeve, has the procedure performed by an enthusiastic but inexperienced surgeon, and has a horrific complication: a leak at the esophageal gastric junction.
"My question to the world is, how do you fix a leak at the esophageal gastric junction on a sleeve gastrectomy? You don't have a gastric remnant that you could put a g-tube in, so you lose your bailout."
Dr. Lord has seen such complications firsthand—patients who have had sec­ ond operations that fail to fix the leak and who now suffer from pleural effu­sions, sepsis, wound infections, fistulas—"all the stigmata of a proximal gastric leak."
Although the percentage for leaks seems small, an average of 3% according to Dr. Lord, if 20,000 sleeve gastrectomies are performed—a conservative estimate—that means 600 a year. "And I've seen two in my small community," Dr. Lord said. "Both have gotten worse. Both have gotten VRE [vancomycin­-resistant enterococci] and it is a disaster to repair."
Lack of experience with the sleeve may be part of the problem, but it's not entire­ly so: Of Dr. Lord's two patients with complications, one was a surgeon's first sleeve, the other was a surgeon's 30th.
Of course, complications may occur with any procedure, but "99% of the bariatric surgeons out there have not dealt with a leaking sleeve," Dr. Lord said. "I foresee that we're on the edge of a major problem. I think it's worse than dealing with a leak on a gastric bypass, where you can put in drains and feed the patient through their gastric remnant, temporize it and allow the inflammation to go down. But if you can't get a sleeve to stop leaking, the inflammation will always be there and you're forced to go back and operate."
When a leak occurs, Dr. Gagner advocates using silicone-covered, endoluminal nitinol stents—a repair that demands endoscopic expertise. "They permit closing the leak and opening a distal stricture, which is often associated," he said. "The patient can eat or drink while the fistula closes."
Dr. Lord said there are limited patients who should receive a sleeve gastrectomy rather than another procedure: "In patients with recurring duodenal adenomas who refuse a foreign body implant, and you still have to gain access to the pylorus, it's an OK option." Perhaps, too, for the patient with a BMI of 60 kg/m2, a thick body wall habitus or a history of pancreatitis. "But to have someone with minimal comorbidities get a sleeve because it's a new 'gee-whiz' option? I think that's a bad choice. We don't even know what five- or 10-year data shows on it."
What data are available, Dr. Szomstein makes accessible to his patients considering the sleeve. "Technically, this is still under the investigational phase. In our center we have an IRB [institutional review board], we inform the patient that it is under investigation and that we have no long-term data on it."
As with any newer surgery, the sleeve should not be attempted by just anyone. "It is not only the surgery—the patients, the obese population, are highly complex and risky." The requirements for performing sleeve gastrectomy should be just as rigorous as for any other bariatric surgery. "These [surgeons] should be monitored, they should be proctored, and they should take specific courses before they are allowed to do this in their own practice," Dr. Szomstein said. "The surgeries should be done with a multidis­ciplinary approach, in centers of excellence specializing in care of the bariatric patient.”

 

 

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Mark A Pleatman MD
43494 Woodward Ave. #202
Bloomfield Hills, Michigan 48302