Laparoscopic Sleeve Gastrectomy (LSG)

What is Laparoscopic Sleeve Gastrectomy ?

As patients begin investigating surgical weight-loss options, one of the first questions to arise is “what procedure is best for me?” The answer to this question must come after thorough research regarding the risk and benefits of each procedure and an evaluation to determine the individual patient’s risk for undergoing surgery.

About 80 percent of the bariatric procedures performed in the United States are gastric bypass procedures. The other 20 percent are comprised of restrictive procedures, such as the laparoscopic adjustable gastric band. The laparoscopic sleeve gastrectomy (LSG), a relative newcomer to bariatric surgery, is growing in popularity.

The sleeve gastrectomy originated as the restrictive part of the duodenal switch operation. In the last several years, though, it has been used by some surgeons as a staging procedure prior to a gastric bypass or duodenal switch in very high risk patients. It has also been used as a primary, stand-alone procedure by some surgeons.

How is Sleeve Gastrectomy Performed?

The majority of sleeve gastrectomies performed today are completed laparoscopically. This involves making five or six small incisions in the abdomen and performing the procedure using a video camera (laparoscope) and long instruments that are placed through these small incisions.

During the sleeve gastrectomy, about 75 percent of the stomach is removed leaving a narrowgastric tube or “sleeve” (pictured right). No intestines are removed or bypassed during the sleeve gastrectomy. This procedure takes one to two hours to complete. This short operative time is an important advantage for patients with severe heart or lung disease.

Sleeve Gastrectomy May be Performed for the Following Reasons

  • Body Mass Index is greater than 60
  • Severe comorbidities (cardiac, pulmonary, liver disease)
  • Advanced age
  • Inflammatory bowel disease (Crohn’s disease)
  • Need to continue specific medications (anti-inflammatory medicines, transplant medications)
  • Need for continued surveillance of the stomach (that couldn’t be evaluated after a gastric bypass)
  • Severely enlarged liver found during the operation
  • Severe adhesions (scarring) to the bowel found during the operation
  • Any combination of the above that significantly increases the patient’s risk

How Does the Sleeve Gastrectomy Cause Weight-Loss?

Sleeve gastrectomy is a restrictive procedure. It greatly reduces the size of the stomach and limits the amount of food that can be eaten at one time. It does not cause decreased absorption of nutrients or bypass the intestines. After this surgery, patients feel full after eating very small amounts of food. Sleeve gastrectomy may also cause a decrease in appetite. In addition to reducing the size of the stomach, the procedure reduces the amount of the “hunger hormone,” ghrelin, produced by the stomach.1 The duration of this effect is not clear yet, but most patients have significantly decreased hunger after the operation.

Who Should Have a Sleeve Gastrectomy?

This operation has been used successfully for many different types of bariatric patients.2 Since it is a relatively new procedure, there is no data regarding weight-loss, complications or weight regain beyond three years. At the Cleveland Clinic, we use this procedure as part of a staged approach for high-risk patients. Patients who have a very high body mass index (BMI) or severe heart or lung disease may benefit from a shorter, lower risk operation such as the sleeve gastrectomy as a first stage procedure. Sometimes, the decision to proceed with the sleeve gastrectomy is made in the operating room due to an excessively large liver or extensive scar tissue to the intestines that make gastric bypass impossible.

In patients who undergo LSG as a first stage procedure, the second stage (gastric bypass) is performed 12 to 18 months later after significant weight-loss has occurred, the liver has decreased in size and the risk of anesthesia is much lower. Though this approach involves two procedures, we believe it a safe and effective strategy for selected high-risk patients.
LSG is also being used as a primary weight-loss procedure in lower BMI patients. Because this is a more recent application of this procedure, it is currently being performed as part of an investigational protocol for this lower BMI patient group.

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