The gastric sleeve is the most commonly performed bariatric surgery in the United States and represents one of the most popular surgeries worldwide. The benefit of the gastric sleeve revolves around its simplicity; approximately 80-85% of the stomach is cut away and removed from the abdomen. This provides restriction, limiting how much food a patient can eat. In addition, however, the sleeve has a hormonal component that reduces hunger in most patients. Because the fundus of the stomach is removed, the main production center of ghrelin, the hunger hormone, is also eliminated. The result is that patients may lose 60%, 70%, or even more of their excess body weight and maintain that weight loss for a significant amount of time – potentially for the rest of their lives.
With an increase in excess weight and obesity across the United States, there has been a commensurate uptick in chronic reflux, also known as gastroesophageal reflux disease or GERD. GERD is distinct from the occasional reflux (GER) we all get as it is more consistent and persistent. GERD can be loosely defined as having a reflux episode more than a few times a week for several weeks.
Dr. Jacobs’ 5 Key Points
- In modern-day surgery, laparoscopy is the gold standard of care.
- Abdominal surgeries can be done laparoscopically or robotically. They are both minimally invasive techniques. The difference is in one (robotically), the surgeon sits in a console away from the patient in a non-sterile field, and in the other (laparoscopically) the surgeon is hands on at the patient’s side in the sterile field and operates.
- Robotic surgery and traditional laparoscopy are similar in safety and efficacy – the method depends on surgeon preference. In Bariatrics, robotic surgery has NOT shown a benefit to patients, and the robot is significantly more expensive than the standard laparoscopic equipment. The robot costs over $2 million plus a maintenance fee of hundreds of thousands of dollars yearly and more expensive instrumentation.
- I have had one leak in primary bariatric surgeries (gastric sleeves, gastric bypasses) in the last 14 years and two leaks in revisional surgeries during that same period of time.
- Performing bariatric surgery in an accredited Center of Excellence is also mandatory in my view. If a complication were to occur, this is where you would want to be.
Dr. Jacobs’ 4 Key Points
- Fatty liver disease is prevalent (about 66%) in patients with excess weight and obesity.
- While most primary care physicians discuss cholesterol and blood pressure regularly, fatty liver disease represents an underappreciated but very real and potentially chronic problem for patients carrying excess weight.
- Bariatric surgery is an effective way to improve or eliminate fatty liver disease.
- The number one cause of cirrhosis today is fatty liver due to obesity.
As bariatric surgeons, we see the liver in every procedure we perform.
Dr. Jacobs’ 5 Key Points
- I encourage patients to lose weight. How it’s done doesn’t matter, as long as it’s safe. If you don’t want surgery, these medications can help you lose significant body weight and can improve cardiovascular and metabolic disease risk as a result. That’s great!! Be aware, high BMI (very obese) patients, may not lose enough weight on these meds.
- If you’ve had bariatric surgery and have regained weight, these medications may reboot your surgery and help you lose what you have gained. Weight loss medications and bariatric surgery can work hand-in-hand.
- When you stop taking these medications, studies show you regain the weight. It’s a long term commitment. This is why, if you don’t want to take lifelong meds (especially adolescents and young adults who need to be on meds for many many years), will benefit more from surgery. Some people may want to take these meds intermittently, we don’t know enough about that yet.
- If these medications don’t work for you, consider bariatric surgery (still the gold standard). Being obese or overweight is not good. Surgery is very safe and effective.
- These drugs are generally well tolerated but look out for pancreatitis, gastroparesis (paralysis of your stomach), severe constipation, nausea and vomiting, and unusual behaviors, including ideations of self-harm.
Which revisional procedure to perform depends on the individual scenario. But before proceeding with how to treat recidivism and/or reflux, one word of caution. These surgeries are technically more demanding, and only surgeons with extensive bariatric experience should be performing these surgeries.
I am proud to note that in the last 14 years, we have not had a staple line leak from these surgeries, encompassing approximately 30% of my practice.