Adjustable gastric banding limits food intake by placing a constricting ring completely around the stomach below the junction of the stomach and esophagus. While early bands were non-adjustable, those currently used incorporate an inflatable balloon within their lining to allow adjustment of the size of the stoma to regulate food intake. The small gastric pouch (the size of a golf ball) restricts the amount of food that can be consumed at a meal. Ingested food consumed passes through the digestive tract in the usual order, allowing it to be fully absorbed into the body. Today, gastric bands are placed through laparoscopic surgery, decreasing wound complication rates and time spent in hospital to less then one day (over 95% are done as outpatient surgery in our state-of-the-art facility), with patients returning to work within 7 days. Adjustment is undertaken without the need for surgery by adding or removing an appropriate material through a subcutaneous access port. As a restrictive procedure, gastric banding avoids the problems associated with malabsorptive techniques such as anemia, dumping and vitamin/mineral deficiencies.
Laparoscopic Gastric BypassThe Procedure
The laparoscopic RY gastric bypass is performed by introducing a laparoscope which is connected to a video camera, through small abdominal incisions, giving us a magnified view of the internal organs on a television monitor. The entire operation is performed "inside" the abdomen after gas has been inserted to expand it. Special stapling instruments are used to create a new small <10 ml stomach pouch. The remainder of the stomach is not removed (99%), but is completely stapled shut and divided from the new small stomach pouch. The outlet from this newly formed small stomach is connected to the small intestine so that food empties directly into the lower portion of the intestine bypassing the stomach. This is done by dividing the small intestine just beyond the ligament of Treitz for the purpose of bringing it up and constructing a connection with the newly formed stomach pouch. The other end is connected into the side of the remaining small intestine creating the "Y" shape that gives the technique its name. The result is an early sense of fullness, combined with a sense of satisfaction that reduces the desire to eat. The laparoscopic technique is identical to the open procedure. What is unique to our technique is the use of hand-sewing the gastrojejunostomy, as opposed to using stapling instruments. This allows for the creation of a very small gastric pouch. The end result on the outside is shown at left.
Laparoscopic Vertical Sleeve Gastrectomy
The Procedure
The best way to currently describe this weight loss surgery procedure is to present the following position statement from the AMERICAN SOCIETY FOR METABOLIC AND BARIATRIC SURGERY (edited for clarity for non surgeons).
The bariatric procedure commonly called "vertical sleeve gastrectomy (VSG) is a form of unbanded gastroplasty involving subtotal gastric resection for creation of a long lesser curve-based gastric conduit. This procedure may be viewed as the gastric component of the more established malabsorptive procedure of biliopancreatic diversion with duodenal switch (BPD/DS). The VSG 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 BPD/DS in complex or high risk patients including the super-super-obese patient (BMI > 60 kg/m2).
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 scientific literature describing short-term outcomes in 775 patients after sleeve gastrectomy. A single study provides data up to 3 years after the procedure and no follow-up beyond 3 years has been reported. 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 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 trial 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.
Long-term (> 5 yr) weight loss and comorbidity resolution data for sleeve gastrectomy has not been reported at this time. Weight 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 ASMBS.
Posts
![[Valid Atom 1.0]](valid-atom.png "Validate my Atom 1.0 feed")
