Following up on our review of the bariatric surgical procedures currently available let's take a closer look at sleeve gastrectomy or The Sleeve, or VSG.
In the vernacular language of weight loss surgery wearing a sleeve has nothing to do with a piece of clothing that covers the arm; wearing a sleeve describes a relatively new surgical procedure that is fast gaining favor for the treatment of morbid obesity. The procedure involves removing a portion of the stomach and the formation of a tubular stomach sleeve different in shape and function from the more common gastric bypass pouch. This procedure restricts food intake but is not considered malabsorptive which often results in dumping syndrome and vitamin deficiency in gastric bypass patients. It is believed that the sleeve procedure also reduces the amount of ghrelin and other hormones that are released providing a hormonal advantage to reducing caloric intake.
According to Dr. Gregg H. Jossart, Director of Minimally Invasive Surgery at California Pacific Medical Center, the sleeve gastrectomy is an evolution of prior procedures that has its roots in the earliest bariatric weight loss surgery procedures. The first open sleeve gastrectomy was performed in March 1988 as part of what is now called the duodenal switch procedure. By 2001 the open sleeve gastrecomy was increasingly used for treating super morbidly obese patients who were deemed too high risk for other metabolic weight loss surgeries such as gastric bypass or the duodenal switch. Doctors were seeing patients achieve a weight loss of 40 to 50 percent excess weight. Once the super morbidly obese patient achieved this initial weight loss they could undergo a "second stage" procedure, most likely the Roux-en-Y gastric bypass surgery, which brought continued weight loss.
In the meantime advances were being made in laparoscopic gastric surgeries that were reducing risk to patients and decreasing hospital stays while improving the rate of recovery from surgery. Minimally invasive laparoscopic procedures are performed by surgeons inserting cameras and instruments through small incisions using images displayed on high resolution monitors for magnification of the surgical elements.
Super-morbidly obese patients, those with a BMI greater than 58, are not always suited to laparoscopic bariatric surgical procedures due to the depth of adipose tissue. But techniques were developed by 2003 that made a laparoscopic approach to the sleeve feasible. A small study of super morbidly obese patients undergoing the laparoscopic sleeve gastrectomy indicated an average excessive weight loss of 33 percent. These patients were then able to safely undergo the second stage Roux-en-Y gastric bypass surgery, also laparoscopically.
By 2009 several study groups at different stages post-surgery were all reporting favorable weight loss with the laparoscopic sleeve gastrectomy. The results were so favorable in fact, results in weight loss were comparable to both gastric bypass and adjustable gastric banding. These results quickly popularized the procedure for patients seeking surgical intervention for the metabolic disorder of morbid obesity.
Todays laparoscopic sleeve gastrectomy, which evolved from an open duodenal switch to open sleeve gastrectomy, is fast becoming the favored procedure for super-morbidly obese patients as the first stage operation before Roux-en-Y. For patients of lower BMI the sleeve procedure is effective as a single treatment for weight loss and presents another surgical option to the better known gastric bypass or adjustable gastric band (lap-band) surgeries. Bariatric surgeons are happily reporting that the long-term safety of the sleeve procedure is definite as the risk of marginal ulcer or small intestinal obstruction does not exist as it does with gastric bypass.
However, surgeons are seeking to resolve two main issues with the gastric sleeve. The first is a standardized pouch volume. It is believed a smaller pouch volume of 30-40cc will affect a more durable weight loss, but with this smaller volume comes problems. Jossart said, "Unfortunately this smaller volume increases the chance of staple line bleeding or splitting, especially near the gastroesophageal junction. Proper management of the staple line will ultimately optimize the safety of this procedure."
As with all surgical procedures it is critical to have the surgery performed by a board-certified surgeon who is familiar with the anatomy, surgical procedure, and postoperative management of the patient.
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