Laparoscopic Sleeve Gastrectomy

The Laparoscopic Sleeve Gastrectomy is a restrictive form of weight loss surgery in which approximately 2/3 of the stomach is removed leaving a cylindrical or sleeve shaped stomach with a capacity ranging of about 100 to 150 cc, depending on the surgeon performing the procedure. Weight loss is generated by restricting the amount of food (and therefore calories) that can be eating without bypassing the intestines or causing any gastrointestinal malabsorption. Also known as the Vertical Sleeve Gastrectomy, it is a purely restrictive operation.

Historically, the vertical sleeve has been performed as the “first stage” of the Duodenal Switch procedure for many years. In 2001 and 2002 it was first performed as a stand-alone procedure laparoscopically. In 2001 a study was performed with 40 Gastric Sleeve patients. In a 2002 series, more than 700 procedures were performed with no deaths, no conversions to open and a leak rate less than 1%. Weight loss results between the two studies were between 57 and 81% between 2 and 3 years out.

Why the Procedure Works

Besides restricting the amount of food a patient can take in, the procedure actually removes the portion of the stomach which is responsible for secreting Ghrelin, which is a hormone that is responsible for appetite and hunger. By removing this portion of the stomach rather than leaving it in place, the level of Ghrelin is reduced to near zero, actually causing a loss of or a reduction in appetite (Obesity Surgery, 15, 1024-1025, 2005.) Currently, it is not known if Ghrelin levels may increase again over time, though patients do report that some hunger and cravings do slowly return. One study demonstrated that the cravings in a Sleeve patient three years after surgery are less than LapBand patients and this probably accounts for the increased percentage of overall weight loss of sleeve over bands.

Also, the portion of the stomach that is removed in the vertical sleeve is the portion that stretches the most. The portion that remains is least likely to expand over time and as a long, narrow tube it creates resistance to food. As you know, resistance is greatest the smaller the diameter and the longer the distance. So not only is appetite decreased, but very small amounts of food generate early and lasting satiety (fullness.)

Advantages of the Laparoscopic Sleeve Gastrectomy

Without intestinal bypass, the risk of malabsorptive complications such as vitamin and mineral deficiencies and protein deficiencies is minimal.
Minimizes the possibility of patient developing ulcers.
The pyloris is preserved so “dumping syndrome” does not occur or is minimal.
Can be easily modified to another procedure should weight loss be inadequate or weight regain occur.

Current data available, while limited, shows weight loss as nearly comparable to the Gastric Bypass and superior to the LapBand.
Even though the stomach is smaller and the intake of food is less, the stomach still functions normally.

No foreign object is placed in the body, no need for “fills” or adjustments.
Provides a solution for patients with conditions which place them at an unacceptable high risk from other forms of bariatric surgery, i.e. Crohn’s disease, anemia, previous LapBand surgery, prior Nissen Fundoplication, large hiatal hernia (also appropriate for bypass,) current vitamin and mineral deficiencies, autoimmune diseases, etc.

Disadvantages of the Sleeve Gastrectomy

As this form of surgery does not provide any form of “bypass” the patient may not experience the degree of weight loss they were expecting.
Patients can slow weight loss if they do not follow strict dietary guidelines following surgery. (True for all forms of weight loss surgery)
Complications may occur following stomach stapling.
The procedure is not reversible. Part of the stomach is permanently removed. Other weight loss surgeries can be performed in addition to it, but there is no mechanism to remove, like the Band.

Risks and Complications of the Laparoscopic Sleeve Gastrectomy

Weight regain requiring reoperation
Gastric leakage and fistula 1%
Deep Vein Thrombosis 0.5%
Non-fatal pulmonary embolus 0.5%
Post-operative bleeding 0.5%
Pneumonia 0.2%
Death 0.25%