Sleeve Gastrectomy Surgery

Sleeve gastrectomy — also called "vertical sleeve gastrectomy" or simply "the sleeve" — is a restrictive-type weight-loss procedure that dramatically reduces the overall capacity of the stomach.

First performed in 1988, the sleeve did not become widely popular until around 2010–2011. It is now performed throughout the world and enjoys a reputation as a safe, effective weight-management option.

Dr. Fitzer performs sleeve gastrectomies laparoscopically, meaning the incisions used are very small. Keeping the incisions small speeds recovery and reduces surgical risks related to wound healing. In most cases the procedure takes 35–75 minutes. You can watch Dr. Fitzer perform a sleeve on our YouTube channel.

How the Procedure Works

During the procedure, Dr. Fitzer removes approximately 75–80% of the stomach to create a long, narrow stomach "sleeve" that connects the end of the esophagus to the beginning of the intestine. It looks like this:

This narrow tube holds far less food than the larger, bag-like stomach did. Patients feel full on much smaller portions and, as a result, eat significantly less. Studies have also shown that sleeve surgery decreases the release of ghrelin, a hunger hormone secreted by the stomach. Ghrelin reduction helps to suppress hunger, control cravings, and leave patients feeling more satisfied.

The small intestine is not involved in sleeve surgery, so nutrient absorption is not impacted at all. The risk of nutritional deficiencies is therefore lower than with procedures that do involve manipulation of the small bowel. Unlike the gastric bypass or the adjustable band, sleeve gastrectomy is not reversible, since the excess stomach is removed during surgery.

Outcomes

Weight loss with the sleeve is generally better than with the LAP-BAND but not as substantial as with gastric bypass. Excess weight lost averages over 70% from year one through year nine among Virginia Bariatric patients. Below is a graph depicting Virginia Bariatric's actual sleeve patient weight loss data:

The large national databases of bariatric surgery patient outcomes (like the MBSAQIP, for instance) show that for patients several years out from sleeve surgery, the average weight loss with the sleeve is somewhat lower than at Virginia Bariatric, around 60%.

The low average weight loss seen in the databases reflects the fact that there are two different types of surgeons that tend to perform them. The first type is the professional bariatric surgeon. Professional bariatric surgeons have one or more years of formal, specialized training in performing bariatric operations, and their practices tend to focus exclusively on that kind of surgery. Dr. Fitzer falls into this category: He completed a year-long bariatric surgery fellowship at the University of Missouri, and close to 100% of his annual case load has consisted of bariatric procedures since he entered clinical practice in 2006.

Professional bariatric surgeons can be relied upon to perform a proper stomach reduction. Here are a few examples of imaging studies from Dr. Fitzer’s own sleeve patients (identifying information removed):

The second type of sleeve surgeon is the general surgeon who has chosen to dabble in sleeve surgery, which I refer to as the “amateur sleeve surgeon.” For amateur sleeve surgeons, the sleeves they do usually comprise a relatively small percentage of their total case volume, sometime in the single digits. (The rest of the time, they do other things: breast surgery, hernia repair, etc.) Surgeons without bariatric training or experience tend to do very different sleeve operations than the professionals. The stomach usually ends up getting a modest “trim” instead of a proper volume reduction. Here are a few examples of patients with amateur sleeves who came to me for revisional surgery:

An over-large sleeve won’t have normal restrictive function, and the weight-loss outcome usually suffers. If you’ve met somebody who had crummy weight loss after a sleeve and/or near-total weight regain, odds are that they had an amateur sleeve. Fortunately, they can be repaired without much difficulty. See Revisions.

For More Information

There is a good bit more to be said about the sleeve. If you are interested in learning more about it right now, a good option is to watch Dr. Fitzer's bariatric webinar on YouTube. A consultation with Dr. Fitzer is also a fast way to learn more.