The gastric sleeve, also known as the sleeve gastrectomy or vertical sleeve gastrectomy, is currently the most popular weight loss surgery procedure in the United States, and there’s a good reason for this.
The procedure involves simply cutting away 70-80% of the stomach and does not require rerouting or bypassing the intestine. This makes it a straightforward procedure for the surgeon and reduces some inherent risks associated with a malabsorptive approach to weight loss.
Initially, the gastric sleeve was the first part of a two-part procedure known as the duodenal switch, also discussed here on our website. It was used to help patients lose some weight before the malabsorptive portion of the procedure, making the surgery safer as a result. As time passed, bariatric surgeons realized that the gastric sleeve alone offered significant weight loss benefits, eventually becoming a standalone procedure.
How the Gastric Sleeve Is Performed
The video below is an animated illustration of the gastric sleeve procedure:
As with all the procedures we perform at MASJax, sleeve gastrectomy is almost always performed minimally invasively or robotically. Minimally invasive surgery requires only five small incisions in the abdomen versus the single large incision necessary for traditional open surgery. The result is a shorter recovery with fewer complications, including less pain and blood loss, a shorter hospital stay, a lower risk of incisional hernias, and a reduced risk of infection. Robotically assisted surgery is an excellent option for patients who qualify; today, this is our primary tool
During sleeve surgery, the bariatric surgeon creates a small, sleeve-shaped, vertically oriented stomach that is only 20% of the size of the original stomach. This is achieved by cutting along the stomach’s greater curvature (outer portion). The part of the stomach that is cut away is removed from the abdomen entirely. The remaining pouch is larger than that created during gastric bypass about the size and shape of a banana or sleeve – hence the name.
Unlike the gastric bypass, which modifies both the stomach pouch and the small intestine lower down, the gastric sleeve only reduces the stomach’s size, lowering the likelihood of dumping syndrome and minimizing vitamin and mineral deficiencies after surgery.
The procedure is performed under general anesthesia in a hospital setting and takes approximately 35-50 minutes. Patients remain in the hospital overnight for observation. They can usually return to work within three weeks with reduced physical exertion, and full recovery requires approximately six weeks.
Who Qualifies for Gastric Sleeve
Sleeve gastrectomy requires a BMI of 35 or over with at least one obesity-related comorbidity (such as hypertension, diabetes, sleep apnea, hyperlipidemia, etc.) or a BMI of 40 or above, regardless of comorbidities.
We are, however, moving toward making this procedure available to lower BMI patients. A recent ASMBS and IFSO guideline update suggested that bariatric surgery should be considered in patients with a BMI of 30 or more with certain comorbidities or 35 or more, regardless of comorbidities. In those of Asian descent, bariatric surgery should be considered at a BMI as low as 27.5. While this is an exciting update to guidelines in place since 1991, it may still take some time for federal and insurance policies to catch up. So, for patients who do not qualify according to their insurance criteria, we’ll need to consider cash payment.
The sleeve may also be appropriate for some patients who have yet to achieve their expected results after a gastric band. Bands can be converted to a sleeve by removing the band and performing a standard gastric sleeve during a single anesthesia event. Conversions and revisions come with a higher surgical risk that will be discussed during consultation.
Life After Gastric Sleeve
The gastric sleeve has shown excess body weight loss potential and disease improvement/resolution rates similar to the gastric bypass while avoiding many risks. Because the pyloric sphincter (the valve between the stomach and small intestine) is kept intact during the surgery, patients are less likely to suffer from dumping syndrome, for example.
Patients diligent with their postoperative care can expect excess body weight loss greater than 65% and an improvement or resolution of most obesity-related conditions. One notable exception is that some patients who undergo a gastric sleeve will develop or worsen their acid reflux. This is often mitigated by repairing a hiatal hernia during surgery if present.
Most patients will experience an added hormonal benefit of the gastric sleeve in the form of fewer hunger pangs after surgery. This is because the excised portion of the stomach includes the fundus, the main production center of ghrelin, a hunger hormone, which is also removed from the body. However, it is worth knowing that ghrelin production may increase in the years after bariatric surgery as the small intestine compensates. Patients must develop and reinforce healthy eating habits while receiving this hormonal benefit.
Potential Risks and Concerns of Gastric Sleeve
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- Much like gastric bypass patients, gastric sleeve patients will have to supplement their diet with multivitamins and other vitamins as necessary. However, the risk of nutritional deficiencies is much lower than with a combination of restrictive and malabsorptive procedures.
- The most severe, but fortunately uncommon, the risk is a leak along the staple line made during surgery. Our surgeons have a great deal of experience with this complication and take steps both during and after surgery to help ensure a leak does not occur.
- As with any surgical procedure, there are inherent risks, including infection, blood loss, and pain. Please speak to your surgeon about these and other risks.
- Due to the significant restriction provided by the smaller stomach, gastric sleeve patients will not be able to eat as much. Occasional overindulgences can cause temporary stretching of the pouch. However, consistently overeating and ignoring postoperative instructions can make the stretching irreversible, leading to a lack of weight loss or weight regain.
The Ideal Gastric Sleeve Patient
If you’ve researched bariatric surgery, you’ll notice several possible procedures to choose from. In fact, many procedures are available overseas that still need to be approved in the United States. However, the gastric sleeve is a tried-and-true procedure, ideal for many bariatric patients. To understand whether you are an ideal patient for gastric sleeve surgery, it’s best to watch our online seminar and schedule an appointment with one of our bariatric surgeons. In the meantime, you can use the following as a rough guide.
BMI: the gastric sleeve is typically best for patients on the lower end of the BMI qualification scale. Once patients cross into the 50 and 60 BMI range, a duodenal switch may be more appropriate.
Reflux: patients with significant acid reflux will be cautioned to avoid the gastric sleeve as it could worsen the condition. This is because the pressure within the gastric pouch increases after surgery. Typically, this pressure is released upwards rather than downwards, causing reflux. A gastric bypass generally is more appropriate in these patients.
Type 2 diabetes: patients suffering from poorly controlled or uncontrolled type 2 diabetes will likely see significant improvement with a gastric sleeve. However, gastric bypass truly is the gold standard for these patients. The gastric bypass often puts type two diabetes into remission within days of surgery, even before any significant weight loss has been achieved.
Cash Pay: for patients considering cash pay, the gastric sleeve is usually the most cost-effective procedure. Of course, the considerations above still apply, and we will not perform a sleeve on patients who are not good candidates. However, the cost of the sleeve can be up to half that of a bypass or duodenal switch.
