The Sleeve Gastrectomy (VSG) is a new procedure that
induces weight loss by restricting food intake. With this procedure,
Dr. Joya removes approximately 80-85 percent of the stomach
laparoscopically so that the stomach takes the shape of a tube or
"sleeve." This procedure is usually performed on superobese or high
risk patients with the intention of performing another surgery at a
later time. This surgery may also be done on regular patients (BMI
of 30+) who desire a lower risk procedure than the RNY Bypass while
getting similar results. The second procedure a gastric bypass can
then be done if necessary for the superobese to reach goal.
The vertical sleeve gastrectomy
or the gastric sleeve,
is a restrictive form of weight loss surgery in which approximately
85% of the stomach is removed leaving a cylindrical or sleeve shaped
stomach with a capacity ranging from about 60 to 150 cc, depending
upon the surgeon performing the procedure. Unlike many other forms
of stomach stapling
surgery, the outlet valve and the nerves to the stomach remain
intact and, while the stomach is drastically reduced in size, its
function is preserved. Again, unlike other forms of surgery such as
the Roux-en-Y gastric bypass, the vertical sleeve gastrectomy is not
reversible.
Because the new stomach continues to
function normally there are far fewer restrictions on the foods
which patients can consume after surgery, albeit that the quantity
of food eaten will be considerably reduced. This is seen by many
patients as being one of the great advantages of the vertical
gastrectomy, as is the fact that the removal of the majority of the
stomach also results in the virtual elimination of hormones produced
within the stomach which stimulate hunger.
Perhaps the greatest advantage of the
gastric sleeve lies in the fact that it does not
involve any bypass of the intestinal tract and patients do not
therefore suffer the complications of intestinal bypass such as
intestinal obstruction, anemia, osteoporosis, vitamin deficiency and
protein deficiency. It also makes it a suitable form of surgery for
patients who are already suffering from anemia, Crohn’s disease and
a variety of other conditions that would place them at high risk for
surgery involving intestinal bypass.
Finally, it is one of the few forms
of weight loss surgery in Mexico which can be performed laparoscopically in
patients who are extremely overweight or who have a BMI of 30+.
Perhaps the main disadvantage of the
vertical sleeve gastrectomy is that it does not always produce the
weight loss which people would wish for and, in the longer term, can
result in weight regain. This is indeed true of any form of purely
restrictive weight loss surgery, but is perhaps especially true in
the case of the vertical gastrectomy.
Because the procedure requires
stomach stapling
patients do run the risk of leakage and of other complications
directly related to stapling of
the stomach. In addition, as with any
surgery, patients run the risk of additional complications such as
post-operative bleeding, small bowel obstruction, pneumonia and even
death. The risk of encountering any of these complications is
however extremely small and varies from about 0.5 and 1%. Having
said this, the risk of death from this form of surgery at about
0.25% is extremely small.
As a general rule the gastric
sleeve is best suited to individuals who are either extremely
overweight or who are looking to have weight loss surgery with a BMI
of 30+. In the case of the former the vertical sleeve gastrectomy
would normally form the first of a two-part plan of weight loss,
with further bariatric surgery being performed once the patient’s
weight has fallen sufficiently to allow for other forms of weight
loss surgery to come in to play. In the case of the latter, it is
designed as a standalone surgery.
Expected Weight Loss
This combined approach has tremendously decreased the risk of weight
loss surgery for specific groups of patients, even when the risk of
the two surgeries is added. Most patients can expect to lose 60 to
80% of their excess body weight over a 12 - 24 month period with the
gastric sleeve alone. Most non superobese patients may not even
need the second procedure to achieve their goal weight. The timing
of the second procedure will vary according to the degree of weight
loss, typically 6 - 18 months after completion of the first surgery.
HOW THE SURGERY IS DONE:span>
Dissection
The stomach is lifted and the surgeon starts the devascularisation
of the greater curvature with the help of the Ultracision _ device.
Once the lesser sac has been entered, dissection is continued in a
cephalad direction and the lower pole of the spleen is quickly
reached.
At the level of the spleen’s lower pole, the peritoneal sheets are
farther apart and the tissue in between is thicker and harbors
tortuous vessels (the short gastrics) which must be coagulated
separately, by using small bites of the Ultracision.
Eventually the dissection reaches the root of the left pillar of the
hiatus.
When the upper pole of the fundus has been freed, the surgeon can
lift the stomach anteriorly and to the right very much like turning
a page of a book
Care should be taken not to damage the left gastric vessels which in
an obese patient are always closer (lower) than one would
anticipate. Once the stomach has been freed, division can be
performed.
Linear Gastrectomy
(sleeve resection)
The linear stapler-cutter device, blue load is introduced in and
oriented so that the tip of the devascularised stomach lies between
the jaws; the tip of the instrument is oriented towards and just to
the left of the visible endings of the lesser curvature vessels. The
greater curvature is pulled laterally and the device is fired.
Hence a pyramid shaped portion of stomach is partially detached from
the stomach body and only attached to it at its base.
Before further firing, a 32 French plastic tube is introduced perorally by the anesthetist and advanced into the stomach. The
stapler is reopened without firing and repositioned so that it
LOOSELY pushes the nasogastric tube against the lesser curvature .
Hence the diameter of the tube will be at least 32 French. The
instrument is fired, reloaded and the maneuver repeated.
Finally, after some five or six firings of the stapler, the greater
curvature is completely detached from he stomach. It is pulled out
of the patient’s abdominal wall, through the trocar hole in the left
upper quadrant.
The gastric suture line is secured by the placement of Medium Large
clips over the entire length. Alternatively a running suture of
polypropylene 2/0 can be sewn in reinforcement of the staple line.
After a final check for bleeding, the abdomen is rinsed and a
Penrose drain is introduced. No nasogatric tube is left inside the
stomach. The patient is taken to the recovery room and from there
back to the room.
Postoperative
management.
The patient is allowed to leave the hospital as soon as a few days
after the surgery. This is usually on the third post operative day.
The drain can be removed then. The patient is restricted to a clear
liquid diet for 1 week, a semi-liquid diet for 1 week, followed by a
pureed diet for another 3 weeks. If there are no problems, the
patient is advanced to a regular diet. Sweets, alcohol and
carbonated drinks should be banned. Exercising is encouraged from
the second post operative week on.
Vertical Gastrectomy: How it Works
This procedure generates weight loss
solely through gastric restriction (reduced stomach volume). The
stomach is restricted by 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 from 2-5
ounces (60-150cc) depending on the surgeon performing the procedure.
The nerves to the stomach and the outlet valve (pylorus) remain
intact with the idea of preserving the functions of the stomach
while reducing the volume. By comparison, in a Roux-en-Y gastric
bypass, the stomach is divided, not removed, and the pylorus is
excluded. The Roux-en-Y gastric bypass stomach can be reconnected
(reversed) if necessary. Note that there is no intestinal bypass
with this procedure, only stomach reduction.
Advantages of the Vertical
Gastrectomy Weight Loss Surgery
- The stomach is reduced in volume
but tends to function normally so most food items can be consumed,
albeit in small amounts.
-
Eliminates the portion of the
stomach that produces the hormones that stimulates hunger (Ghrelin).
- No dumping syndrome because the
pylorus is preserved.
- Minimizes the chance of an ulcer
occurring.
- By avoiding the intestinal bypass,
the chance of intestinal obstruction (blockage), anemia,
osteoporosis, protein deficiency and vitamin deficiency are almost
eliminated.
-
Very effective as a first stage
procedure for high BMI patients (BMI>55 kg/m2).
-
Limited results appear promising as
a single stage procedure for low BMI patients (BMI 30-45 kg/m2).
-
Appealing option for people with
existing anemia, Crohn's disease and numerous other conditions
that make them too high risk for intestinal bypass procedures.
-
Can be done laparoscopically in
patients weighing over 500 pounds.
Disadvantages of the Vertical
Gastrectomy Weight Loss Surgery
- Potential for inadequate weight
loss or weight regain. While this is true for all procedures, it
is theoretically more possible with procedures that do not have an
intestinal bypass.
- Higher BMI patients will most
likely need to have a second stage procedure later to help lose
the rest of the weight. Two stages may ultimately be safer and
more effective than one operation for high BMI patients. This is
an active point of discussion for bariatric surgeons.
- Soft calories such as ice cream,
milk shakes, etc can be absorbed and may slow weight loss.
- This procedure does involve stomach
stapling and therefore leaks and other complications related to
stapling may occur.
- Because the stomach is removed, it
is not reversible. It can be converted to almost any other weight
loss procedure.
- Considered investigational by some
surgeons and insurance companies.
Vertical Gastrectomy: Risks and
Complications
As with any surgery, there can be
complications. This list can include:
-
Deep vein thrombophlebitis 0.5%
- Non-fatal pulmonary embolus 0.5%
- Pneumonia 0.2%
- Acute respiratory distress syndrome
0.25%
- Splenectomy 0.5%
- Gastric leak and fistula 1.0%
- Postoperative bleeding 0.5%
- Small bowel obstruction 0.0%
- Death 0.25%
Post-Op Dietary Plan for Vertical
Gastrectomy Weight-Loss Surgery Patients
As with all surgical weight-loss
programs, it is imperative that
gastric sleeve patients adhere to a strict
postoperative diet. Once goal weight is achieved, usually 1-2 years
after surgery, most patients can consume about 1000-1200 calories
per day.
Long-Term Weight-Loss Results
On average, patients who undergo Vertical Gastrectomy surgery
experience a 60-80% loss of excess weight.
