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Sleeve Gastrectomy: The New Kid on the Block

Maybe the title is a little misleading. Sleeve gastrectomy or vertical sleeve gastrectomy has been around for weight loss since 2001. Sleeve gastrectomy involves removing approximately 70% of the stomach and leaving the stomach in the shape of a banana. It was a procedure originally designed for people who weighed over 400 lbs and were considered too high risk to have a gastric bypass or duodenal switch because it would take a long time in the operating room to perform. So, taking out part of the stomach is a shorter operation, and the idea was that it would be safer to remove the stomach as a first stage of weight loss surgery. We hoped that the patients would lose at least 100 pounds, and then we would bring them back to surgery to bypass their intestines. What we found was interesting! When vertical sleeve gastrectomy patients were called to come back for the second stage of their weight loss operation, the intestinal bypass, they refused! Patients routinely lost over a hundred pounds and would not consider a second stage until their weight loss leveled off. So, that started all of us surgeons thinking, “What if sleeve gastrectomy could be a stand alone operation for weight loss, like gastric banding and gastric bypass?”

Sleeve gastrectomy started to increase around the country slowly. Our numbers have increased significantly since we got an insurance or CPT code for sleeve gastrectomy in January 2010. Most insurance companies cover sleeve gastrectomy if weight loss surgery is a covered procedure under your plan. So why is sleeve gastrectomy the new kid on the block? We finally have five year weight loss data for the sleeve so we can measure it up against the other weight loss procedures.

The weight loss for sleeve gastrectomy is somewhere between the results for gastric banding and gastric bypass. As we do more sleeve gastrectomies around the country and the world, different hormonal aspects of the operation are becoming clearer. Sleeve gastrectomy affects hunger because we remove the part of the stomach that makes ghrelin, a hormone that is elevated when people are hungry. We find that hunger in our sleeve patients is reduced and stays reduced long term. The operation also makes people eat a lot less because a lot of the stomach is removed. Most of the weight loss with sleeve occurs in the first year. The follow up with your surgeon and dietitian is crucial for ongoing success. There is another hormone, GLP 1, which is important in improving Type 2 Diabetes Mellitus. With sleeve gastrectomy, patients can expect a rise in this hormone with a resulting drop in their blood sugar and improvement or remission of their diabetes. With weight loss, Type 1 or adolescent diabetics will also see an improvement in their blood sugar and a reduction in their insulin usage.

Since sleeve gastrectomy involves removal of a large part of the stomach, there is potential for leaks to occur. A leak is when the staple line used to make the stomach smaller is not watertight. Other procedures may be necessary to control a leak. Leak rates for sleeve gastrectomy are approximately 1%. Weight regain is also possible with the sleeve and approximately 1/15 patients will require a reoperation for inadequate weight loss or weight regain. We are well versed with weight loss surgery and the possible complications as well as the best treatments of weight regain if it occurs since we see many patients including those that are operated at other institutions. Long-term with a sleeve, we do not expect to see complications like bowel obstruction that can happen with gastric bypass. We do encourage all weight loss surgery patients to take a multivitamin and return for the prescribed follow-up. Follow up is approximately 5-7 visits the first year and 2-3 the second year. We then see patients annually. We are in the process of getting a sleeve gastrectomy support group together to meet monthly. Support groups are a great way to stay on track on your weight loss journey.

Staying Motivated with New Year’s Weight Loss Goals

Holly F. Lofton, MD

January 1, 2013 undoubtedly enlightened us all with a new zealous attitude towards maintaining our health and achieving a normal BMI. However, as the cold weather and hustle of the city jolted us backed to reality, the fervor may have waned. So, take heed of these five unique pointers to help you reach those elusive goals.

1. Don’t expect to reach your target weight by the end of January.

Set realistic weekly and monthly goals so you can see small achievements while on the path to the new you. Make sure to write down your goals and verbalize them to a weight loss buddy or your spouse. This makes you more likely to stick to your plan.

2. Don’t do too much too soon. This can lead to burnout.

Work on adding one positive habit or extinguishing one negative habit per week. This strategy will allow you to feel as if you have accomplished some success before adding the next step. This type of behavior-building is proven to promote a long-term healthy lifestyle. For example:
week 1 - Have breakfast daily.
week 2 - Start packing lunch or meal replacement instead of eating out.
week 3 - Use the plate method (see figure) for dinner and limit ordering out to only once a week.

Consistency is critical if you want to make a habit stick. If you aim to complete the above tasks, do so every day for your first thirty days. Skipping the weekends will make it harder to form the habit. Activities you do once every few days are trickier to lock in as habits. This helps to establish a routine you can live with and that you can refer to as a guide when life stressors get you off track since we all slip once in a while.

3. Make your goal visible.

You are more likely to stay on track if you have a constant reminder of why you are working so hard. Hang your skinny jeans OUTSIDE of your closet and try them on once a week. Try marking your calendar down to the days you have until you galavant your new body on the beach for spring vacation. And of course, make weekly appointments with your nutrition specialist to get support and to monitor your blood pressure and waist circumference as they respond to your weight loss.

4. Keep your attitude positive.

If you think of your lifestyle change as a list of things you are NOT allowed to do, you will fail. Replace lost needs with a positive behavior. For example, when I wanted to cut down on the time I spent sedentary, I compensated by watching my favorite television shows while on the elliptical at the gym, but not on the couch. Try to replace unhealthy chips after dinner with a high protein snack like Greek yogurt; you will find yourself more satisfied.

Also, change your environment to support your new healthy lifestyle. Rid your home of high calorie holiday treats, pack your gym clothes at the same time you pack your lunch, and place reminders around your office and living space. Spending time with people who model the habits you want to mirror to increase your chances of success.

5. Be Imperfect.

Don’t expect all your attempts to change habits to be successful immediately. In my studies of psychology, I found the stages of change (see figure) to be one of the most relevant concepts. It includes contemplating, preparing for, and maintaining new behaviors but also EXPECTS “relapses”, or sliding backwards to the old behavior. When you slide back with your exercise routine or diet plan, just return to the new routine as soon as possible. Sliding backwards does not equal failure unless you never start to climb back up again. Try your best, but expect a few bumps along the way.

I wish you all the best of success in all of your endeavors in the New Year. NYU Langone Weight Management Program looks forward to making you healthier and keeping you on track!