Sleeve Gastrectomy update 2016 by Gregg Jossart, MD, FACS, FASMBS

The sleeve gastrectomy is appealing to many individuals considering weight loss surgery, but have been hesitant to proceed due to concerns about banding and bypass problems. In 2015, the sleeve gastrectomy became the most common weight loss procedure worldwide.  It is over 50% of operation in the United States.

History

The Sleeve Gastrectomy (SG) has been performed (with the duodenal switch) since the 1980s.  The earliest forms of this procedure (without the duodenal switch) were conceived by Dr. Jamieson in Australia(Long Vertical Gastroplasty, Obesity Surgery 1993)- and by Dr. Johnston in England in 1996 (Magenstrasse and Mill operation- Obesity Surgery 2003). In 1997, Dr. Gary Anthone refined the Duodenal Switch procedure to just the SG in a patient with special indications. In 2001, Dr Gagner, in New York, offered the Laparoscopic SG to a high risk patient who could not safely undergo a Duodenal Switch.

In 2007, Dr. Jossart in San Francisco co-published the largest series at that time of over 200 patients with results comparable to other stapling procedures and superior to adjustable gastric banding.  He currently does more than 160 sleeve gastrectomies per year.  It is now the most common weight loss operation and is being offered to low BMI and low risk patients as well as very high risk patients as a safer option than other procedures.

Anatomy

This procedure generates weight loss through gastric restriction (reduced stomach volume) and possibly by hormonal mechanisms. The stomach is restricted by stapling and dividing it vertically and removing more than 85% of it.  This part of the procedure is not reversible. The stomach that remains is shaped like a banana and measures 1 ounce.  Some surgeons create pouches larger than one ounce.  The nerves to the stomach remain intact with the idea of preserving the functions of the stomach while reducing the volume.  The valve at the top of the stomach(Lower esophageal sphincter) and at the bottom of the stomach(pylorus) remain intact.

Alternative to a Roux en Y Gastric Bypass and gastric banding.

The Sleeve Gastrectomy is a reasonable alternative to a Roux en Y Gastric Bypass for a number of reasons.  The sleeve gastrectomy patients generally do not have ulcers or intestinal blockages.  Dumping is rare or minimal.  Diarrhea and vitamin deficienies are also minimal.  The sleeve gastrectomy can later be modified to a gastric bypass or a duodenal switch could be added on if diabetes did not resolve or weight loss was inadequate. To date, the weight loss outcomes and diabetes resolution are similar between the two operations and superior to a banding procedure.

Patients rarely choose gastric banding in 2016 because all insurance companies approve the sleeve gastrectomy.  Prior to 2010, insurance companies did approve the sleeve gastrectomy so patients had to choose between the gastric bypass and gastric banding.  Now, they can avoid the gastric band foreign body problems(erosion, slippage, obstruction) and the bypass problems by selecting a sleeve gastrectomy.

Special indications to choose a Sleeve Gastrectomy

Those who have other medical problems that prevent them from having weight loss surgery such as anemia, Crohn’s disease, extensive prior surgery, severe asthma requiring frequent steroid use, and other complex medical conditions.  People who need to take anti-inflammatory medications(ibuprofen) may also want to consider the Sleeve Gastrectomy as they tend not to have ulcers.

Limitations of a Sleeve Gastrectomy

• Sleeve gastrectomy patients have the potential for inadequate weight loss or weight regain.  This is true for all procedures but the SG does not have an intestinal bypass which may help maintain weight loss.
• The sleeve is generally good for a weight loss of 75-125 pounds.  It is difficult to lose more with any operation.  Diet and exercise play a critical role in the final outcome.  Soft calories such as chips and ice cream, etc will lead to inadequate weight loss-gauranteed!  As Dr. Jamieson summarized in 1993, Given good motivation, a good technical operation and good education, patients can achieve weight loss comparable to that from more invasive and dangerous procedures.
• Heartburn/Acid reflux is controversial and is technique related.  Patients who have a simultaneous repair of their reflux anatomy(hiatal hernia) and a sleeve gastrectomy often have resolution of their heartburn.  Some could have worsening symptoms and require a gastric bypass.
• Staple line leaks can happen with any stapling procedure and are rare with the sleeve gastrectomy in experienced hands.  Reports are often as high as 1-2% of patients but should be only 1 in 1000.

Summary of Dr. Jossart’s experience

Dr. Jossart has been offering the sleeve gastrectomy since 2002 in San Francisco(California Pacific Medical Center) and since 2005 in San Jose(Good Samaritan Medical Center). He has Center of Excellence or Center of Medical Experience status with all of the insurance companies.  He emphasizes patient dietary education, exercise and support group attendance as critically important in achieving and maintaining a healthy weight.