Dr, Myers, Could You Share More Details About the Gastric Sleeve Operation?

I recently was asked several questions about the details of performing a Gastric Sleeve procedure which is also called a vertical sleeve gastrectomy, (VSG), or just a sleeve gastrectomy. I relied by email but I think it would be of interest to others as well.

A Gastric Sleeve was first performed as a portion of a more complicated operation called a Duodenal Switch. This operation was modified and popularized by Dr. Douglas Hess from Bowling Green, Ohio. In this operation an intestinal bypass or switch was performed as well as reducing the size of the stomach with the formation of a tube of stomach formed along the inner curvature of the stomach wich we now call a gastric sleeve.

As our technology advanced bariatric surgeons began to perform the duodenal switch operation using less invasive techniques. Several small incisions were made to pass the instruments through and a laparoscope was used to visualize the inside of the abdomen.

However, a duodenal switch operation has higher risks and a higher mortality as well especially in excessively heavy patients. In an attempt to decrease these risks Dr. Micheal Ganger began to stage the two portions of the operation by doing the gastric sleeve portion of the operation at the time of the initial operation, allowing the patient to lose some weight before returning at a later time to perform the intestinal switch portion of the operation.

What he observed was that often the patient had lost so much weight from the first portion of the operation that they did not need to have the second phase of the operation.

Over time the Gastric Sleeve has been chosen as a primary bariatric operation even for patients who meet criteria for bariatric surgery but are not excessively heavy.
The operation has also been refined so that the diameter of the gastric sleeve has decreased in size and the operation has become even more successful. Now the volume of food a person can eat after a Gastric sleeve operation is about ¾ of a cup of food.

I will now share some technical aspects of the operation that I perform.
Different surgeons use different devices to size the diameter of the sleeve. Most surgeons probably use a bougie, (the French word for candle), which is a tapered dilator that is passed through the mouth after the patient is asleep. This is passed into the stomach and along the inner curve of the stomach so that the tube of stomach called the sleeve is tapered over the bougie. The size of the bougie varies but generally has decreased from a 60 French diameter which is nearly an inch in diameter to a 32 French which is about 1/3 of an inch in diameter.

I use a 9 mm gastroscope that is 32 French for a sizer instead of a boogie since it is easier to direct and to place and I can examine the inside of the sleeve for size and to make sure there is no bleeding or kinking after the sleeve has been completed. I leave a little space between the scope and the staple line to avoid kinking or twisting of the sleeve as well.

The rest of the stomach is removed by disconnecting the blood supply and any other connections to the portion of the stomach that is to be removed and using a linear stapling device to create a long staple line beginning about 5 cms, (2 inches), from the outlet of the stomach called the pylorus. I also taper the lower portion of the stomach which is called the antrum to make sure to stomach that is left is not too large. The staple line is then continued all the way up toward the inlet of the stomach called the gastro-esophageal junction being as careful as possible to leave a little amount of space so as not to staple onto the esophagus if possible.

This long staple line staples across the blood vessels that are necessary to keep the stomach left behind healthy. However, this means that there is some risk of bleeding from this staple line. To decrease the risk of bleeding along the staple line surgeons use one of a couple of techniques. Some surgeons oversew the staple line with a long running stitch. Others may suture selective points along the staple line. I have chosen to reinforce the staple line with buttress material that is made from bovine pericardium which is loaded onto the stapling device prior to inserting the stapler into the abdomen so there is no need for overseeing. This also reduces the actual operating tine to usually 1 hour or less.
In the usual patient the patient has three 5 mm incisions, (less than ¼ inch), and one 2 cm incision, (less tan an inch), and this slightly larger incision is usually hidden within the skin of the umbilicus or belly button.

I have been performing the Gastric Sleeve operation since October of 2007 and have performed over 100 of these operations. On the average our patients are losing over 70% of their excess weight at 1 year after surgery and they are very pleased with their outcomes.

I think we have learned something about bariatric surgery as well. All operations that are commonly used to help persons of size lose their excess weight reduced the size of the stomach. This is true for a gastric band, gastric bypass, gastric sleeve and a duodenal switch. Reduction in the size of the stomach is an important common theme. We have found that the amount of weight loss and the speed of that weight loss is very similar between the gastric bypass and the gastric sleeve.

My conclusion is that they both reduce the size of the stomach but have different ways of connecting the small gastric pouch to the rest of the gastrointestinal track. Except for the decreased absorption of vitanins and minerals I now believe there is very little difference in these two operations. I feel the intestinal bypass or duodenal switch part of these operations do not contribute as much as we once thought and the decreased size of the stomach is probably the most important part of these operations. The intestinal bypass or switch portion of bariatric operations contribute to the difficulty in absorbing vitamins and minerals without contributing all that much to the weight loss.