Capital Surgical Associates

What is vertical sleeve gastrectomy (VSG)?

A vertical sleeve gastrectomy (VSG) is a minimally invasive procedure that reduces the size of your stomach to three or four ounces. Not only does this procedure limit the food you can eat, it also causes the levels of a hunger hormone called ghrelin to drop which reduces your appetite. Patients who have this type of surgery typically lose 25% of their starting body weight.

What is involved with the VSG procedure?

The part of the stomach that easily stretches to hold large meals is removed, leaving an approximately ½” x 8” long-sleeve shaped stomach. The removed section is also the part of the stomach that creates the hunger-driving hormone, ghrelin, which results in a marked decrease in ghrelin production and hunger after surgery. While part of the stomach is removed, it does not include intestinal rerouting.

VSG is performed robotically or laparoscopically and requires four to five small incisions into the abdominal wall.

Depending on individual patient factors, many patients can return home on the day of their surgery. Occasionally, patients will spend 1 night in the hospital postoperatively. Patients usually return to normal activity in two weeks after surgery, and have no restrictions after 2 months.

Who is a candidate for VSG?

• Most insurance plans will cover sleeve gastrectomy surgery for patients with a body mass index (BMI) of 40 or more or a BMI of 35 – 39 who also suffer from a condition related to their weight
• Individuals who weigh 100 lbs. or more over their ideal weight
• Surgery is recommended by many professional societies for patients with a BMI of 30 – 35, although most insurance plans will not cover the cost of surgery if a patient’s BMI is less than 35

Who is not a candidate:

• Individuals under the age of 18
• Individuals who are pregnant or may become pregnant within one year after a VSG due to the inability to intake adequate nutrition to support a developing fetus
• Individuals who are unable to tolerate general anesthesia due to other health conditions
• Individuals unwilling or unable to adopt the postoperative nutritional guidelines

Advantages of VSG include:

• Surgical: The safest, fastest, and mostly outpatient operation performed. VSG carries the lowest risk of developing nutritional deficiencies
• Weight loss: With reduced hunger and restricted portions, weight loss is rapid with patients initially losing two to three pounds per week. Weight loss usually slows by six months, and most people lose the weight within one year. Patients maintain on average a total weight loss of 25% of their starting weight.
• Health benefits: Improvement or complete resolution of numerous weight-related diseases, such as high blood pressure, obstructive sleep apnea, type 2 diabetes, hyperlipidemia, plus more. There are typically no risks of developing anemia or bone disease such as osteoporosis

Possible disadvantages of VSG:

• A few percent less weight loss than gastric bypass on average
• Gastroesophageal reflux may develop in a small percentage of patients postoperatively
• Patients may have some hair thinning during the rapid weight loss period but can expect hair growth with protein supplementation and once they achieve the weight management stage
• Since this procedure includes removing part of the stomach, it is irreversible. The sleeve can only be adjusted with an additional surgical procedure

Dietary requirements and restrictions:

As with all surgical weight loss programs, it is essential that patients adhere to a strict postoperative diet including:

• Weeks 1 to 3 after surgery: Liquid protein diet
• Weeks 4 to 7: Soft protein-based diet
• Week 8 until weight goal is achieved: High-protein and low carbohydrate solid diet
• Once weight goal is achieved, most patients consume a normal healthy diet with the appropriate number of macronutrients for their height and build to maintain their new, healthy, weight
• Vitamins: A daily bariatric-specific multivitamin should be taken postoperatively. An individual patient’s vitamin regimen will be tailored to them when we test vitamin levels in the months after surgery

What is Roux-en-Y gastric bypass?

A Roux-en-Y gastric bypass, or simply referred to as gastric bypass, is a surgery that creates a new one- to two- ounce stomach and connects a part of the small intestine to it. It is the second most commonly performed type of bariatric surgery, with sleeve gastrectomy being the most common. This procedure helps patients to feel full with a smaller meal and also increases the levels of naturally produced hormones to help patients who suffer from diabetes to have normal blood sugar levels.

What is involved with Roux-en-Y gastric bypass?

A one- to two-ounce pouch at the top portion of the stomach is created by stapling it off from the old stomach. Portions of the small intestine are re-rerouted in a “Y” shape. The outlet from the newly formed pouch and the small intestine are sewn together which reduces and allows stomach acid to leave quickly, reducing heartburn symptoms and bypassing the old stomach and first part of the small intestine, contributing to a rapid improvement in type 2 diabetes. Gastric bypass surgery also increases a feeling of fullness much quicker during meals.

Roux-en-Y gastric bypass is performed robotically or laparoscopically requiring five to six small incisions and rerouting of the intestines.

Depending on individual patient factors, many patients can return home on the day of their surgery. Occasionally, patients will spend one night in the hospital postoperatively. Patients usually return to normal activity in two weeks after surgery and have no activity restrictions after two months.

Who is a candidate?

• Most insurance plans will cover Roux-en-Y gastric bypass surgery for patients with a body mass index (BMI) of 40 or more or a BMI of 35 – 39 who also suffer from a condition related to their weight
• Individuals who weigh 100 lbs. or more over their ideal weight
• Surgery is recommended by many professional societies for patients with a BMI of 30 – 35, although most insurance plans will not cover the cost of surgery if a patient’s BMI is less than 35
• Roux-en-Y gastric bypass may be an option as a second or revision operation for someone who has had a different bariatric surgery in the past and desires to lose more weight

Who is not a candidate?

• Individuals under the age of 18
• Individuals who are pregnant or may become pregnant within one year after a gastric bypass due to the inability to intake adequate nutrition to support a developing fetus
• Individuals who are unable to tolerate general anesthesia due to other health conditions
• Individuals unwilling or unable to adopt the postoperative nutritional guidelines and take vitamin supplementation

Advantages of Roux-en-Y gastric bypass include:

• Weight loss: With reduced hunger and restricted portions, weight loss is rapid with patients initially losing two to three pounds per week. Weight loss usually slows by six months, and most people lose the weight within one year. Patients maintain on average a total weight loss of 25-30% of their starting weight.
• Health benefits: In addition to having the particular advantage of resolving type 2 diabetes and heartburn in people who suffer from those conditions, after gastric bypass surgery, patient's see improvement or complete resolution of numerous weight-related diseases such as high blood pressure, obstructive sleep apnea, hyperlipidemia and more.

Possible disadvantages:

With proper diet and vitamin supplements, some of the deficiencies below can be managed:

• Vitamin and nutrient absorption are altered and some medicines may not be well tolerated after the procedure.
• Because the duodenum is bypassed, lower absorption of iron can result in iron-deficiency anemia. This is particularly a concern for patients who experience chronic blood loss due to various health conditions. For this reason, gastric bypass patients take an iron supplement postoperatively.

• Bypassing the duodenum can cause lower calcium and vitamin D absorption, which may result in lower bone mineral density in some patients. For this reason, gastric bypass patients take supplemental calcium and vitamin-D postoperatively
• Patients may have some hair thinning during the rapid weight loss period but can expect hair growth with protein supplementation and once they achieve the weight management stage

• The dumping syndrome may occur if patients with a gastric bypass consume concentrated carbohydrates and sweets

Dietary requirements and restrictions:

As with all surgical weight loss programs, it is essential that patients adhere to a strict postoperative diet including:

• Weeks 1 to 3 after surgery: Liquid protein diet
• Weeks 4 to 7: Soft protein-based diet
• Week 8 until weight goal is achieved: High-protein and low carbohydrate solid diet
• Once weight goal is achieved, most patients consume a normal healthy diet with the appropriate number of macronutrients for their height and build to maintain their new, healthy, weight
• Vitamins: Two daily multivitamins, B12, calcium, iron, and vitamin D should be taken indefinitely to maintain adequate micronutrient levels
• Patients should not consume too much sugar, carbohydrates, or large amounts of food to avoid dumping syndrome which results in the rapid emptying of stomach contents into the small intestine. While typically not a serious risk to your health, the results can be extremely unpleasant causing nausea, diarrhea, weakness, sweating, or fainting