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:

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.

Diets for Gastric Sleeve Patients Designed By Dr. Joya

NOTE:  IF YOU ARE A SMOKER: YOU MUST ALSO DO THE FOLLOWING:

Quit Smoking Immediately and Do the above mentioned Balloon exercises.

POST SURGERY DIETARY INSTRUCTIONS from Dr. Joya

The following 6 rules are very important eating habits:

1. Only eat small quantities: The capacity of the stomach has changed. Also the amount of food intake has to change. Nevertheless it is not always easy to stop eating at the right time. What do we mean, if we say small quantities? For example one slice of bread for breakfast or 2 potatoes and a small piece of fish for lunch.

2.      Chew well and swallow food only completely mashed: You need more time for chewing and also not all food is possible to chew well. The list of “unsuitable food” will show you the products which are usually not easy to chew.

3.      Never eat and drink at the same time: The reduced capacity of the stomach will no longer permit to take in both: liquid and food at the same time. The usual amount of beverage, 2-3 litre liquid per day, are desirable. It´s better to drink between or before meals.

4.      Do not lay down or rest after eating: because in a horizontal position reflux is more likely. The food also remains longer in the prestomach and leads to a very uncomfortable accumulation of mucus.

5.      Eat five times a day: This is important, because if you only eat 2-3 times a day, it is not possible to have a great variety of food. Consequently, as you can only eat small amounts, you do not get enough proteins, minerals and vitamins. In addition, when eating 5 times daily, it is less likely that you are overpowered by sudden hunger attacks where you probably forget the new eating habits.

6.      Watch for beverages rich in calories: In our experience, many people take in a lot of their calories with soft drinks, hot chocolate and milk shakes. This is also possible after the operation, so consider this before drinking high calorie liquids. The type of liquid should be varied and include tea or coffee, diluted fruit- or vegetable juice, light drink with artificial sugar, low fat variants of butter milk, mineral water without gas.