Gastric Sleeve-
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The bariatric procedure commonly called "sleeve (vertical) gastrectomy” is a form of unbanded gastroplasty involving subtotal gastric resection for creation of a long lesser curve-based gastric conduit (Figure 1). This procedure may be viewed as a modification of the widely-accepted bariatric procedure of vertical banded gastroplasty and is the gastric component of the more established malabsorptive procedure of biliopancreatic diversion (BPD) with duodenal switch. Sleeve gastrectomy is a resectional form of the Magenstrasse and Mill procedure, an unbanded long lesser curve gastroplasty without resection (Figure 2), after which durable 5 year weight loss has been reported in the morbidly obese at 5 years.1 The mechanism of weight loss and resultant comorbidity improvement seen following sleeve gastrectomy may be related to gastric restriction or to neurohumoral changes observed following the procedure due to the gastric resection or some other unidentified factor(s).
There are currently 15 published reports in the peer-reviewed literature describing short-term outcomes in 775 patients after sleeve gastrectomy. 2-16 A single study provides data up to 3 years after the procedure and no follow-up beyond 3 years has been reported. 7 The reports describe surgical treatment of patients with preoperative body mass index ranging from 35 to 69 kg/m2 and excess weight loss ranging from 33% to 83%.
Comorbidity resolution 12 to 24 months after sleeve gastrectomy has been reported in 345 patients 3-6 demonstrating resolution rates of diabetes, hypertension, hyperlipidemia, and sleep apnea after sleeve gastrectomy are comparable to results of other restrictive procedures.
Similar to other forms of gastroplasty, perioperative risk for sleeve gastrectomy appears to be relatively low, even in high risk patients. Published complication rates range from zero to 24% with an overall reported mortality rate of 0.39%. Only a single prospective randomized trial7 is published which compares sleeve gastrectomy to a more widely accepted bariatric procedure. In that trial, sleeve gastrectomy was found to be at least as effective and durable as adjustable gastric banding at one and three years following surgery.
The sleeve gastrectomy procedure has been utilized as a first-stage bariatric procedure to reduce surgical risk in high-risk patients by induction of weight loss and this may be its most useful application at the present time. Sleeve gastrectomy appears to be a technically easier and/or faster laparoscopic procedure than Roux-en Y gastric bypass or malabsorptive procedures in complex or high risk patients including the super-super-obese patient (BMI > 60 kg/m2). From a technical standpoint, there appears to be no consensus regarding the optimal dilator size that should be utilized to create the lesser curve conduit with various reports recommending diameters between 32 and 60Fr. It has been suggested that dilation of the unbanded gastric sleeve conduit may provide a mechanism of long-term weight loss failure.
Long-term (> 5 yr) weight loss and co-morbidity resolution data for sleeve gastrectomy have not been reported at this time. Weights regain or a desire for further weight loss in a super-super-obese patient may require the procedure to be revised to a gastric bypass or biliopancreatic diversion with duodenal switch. Detailed informed consent including information about the possibility of long-term weight regain and the potential need for subsequent conversion to another procedure is suggested before the sleeve gastrectomy is planned for an individual patient. Decisions to perform this procedure should also be in compliance with ethical guidelines published by the ASMBS17.
The ASMBS recognizes performance of sleeve gastrectomy may be an option for carefully selected patients undergoing bariatric surgical treatment, particularly those who are high risk or super-super-obese, and that the concept of staged bariatric surgery may have value as a risk reduction strategy in high-risk patient populations. It is suggested that surgeons performing sleeve gastrectomy prospectively collect and report outcome data for this procedure in the scientific literature. In addition, it is suggested that surgeons performing sleeve gastrectomy inform patients regarding the lack of published evidence for sustained weight loss beyond 3 years and provide them with information regarding alternative procedures with published long-term (≥ 5 years) data confirming sustained weight loss and comorbidity resolution based upon available literature at this time.
