Sunday, March 6, 2011

My Favorite WLS in 2011? Sleeve Gastrectomy!

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It is official now. My favorite weight loss surgery (WLS) now is the sleeve gastrectomy. Does it cause the most weight loss among all weight loss surgeries? No. Duodenal switch and gastric bypass would cause more weight loss. Is it the easiest operation? No. Probably the adjustable gastric band (Lap Band for instance) is easier to perform. However, the sleeve gastrectomy operation combines a unique set of advantages that, together, make it extremely appealing.

1. It is a true restrictive operation. It does not place an obstructive foreign body like the adjustable gastric band. All it does is, to make the stomach smaller, much smaller. We remove 60-80% of the stomach. And the part that we remove is the most expansible part.

2. Patients feel much less hungry in between meals. Doing so is of great help to the vast majority of morbidly obese patients. The mechanism could very well be due to removing the fundus of the stomach. That part of the stomach is the major source of Ghrelin, aka the "hunger hormone". In that particular aspect, it is more effective than the adjustable gastric band.

3. The weight loss after sleeve gastrectomy is reported to be 68% of the excess weight, which is comparable to gastric bypass. This is more than the average for the adjustable gastric band. Success is also more consistent after sleeve gastrectomy. But notice that we do not have long-term follow-up data for sleeve gastrectomy beyond 5-6 years. Having said so, the data thus far beat the weight loss data with the adjustable gastric banding.

4. The surgery is laparoscopic (so-called "minimally invasive") and does not involve implanting any prosthesis around the stomach. Furthermore, the small intestine (small bowel) is not touched. No division. No bypassing. Therefore, a whole set of potential complications (even though rare or uncommon) that are connected with gastric bypass become no issue.

5. For cash paying patients, sleeve gastrectomy is far less expensive than gastric bypass and even, in many institutions, Lap Band. As such, it is becoming the most appealing operation for weight loss among cash-paying patients.

6. Since there is no need for adjustments (as compared to the adjustable gastric band), sleeve gastrectomy is a relatively a low-maintenance type of weight loss surgery. 7. The recovery time is faster than gastric bypass.

So, all in all, sleeve gastrectomy is a nice balance between the gastric bypass and the adjustable gastric band. In our practice, it is now the most commonly requested (and performed) weight loss surgery. You may wonder, do we insert anything that looks like a sleeve in the stomach? No. Then why is it called "sleeve" gastrectomy? Well, someone looked at the final look of the stomach by the end of the operation, which is almost like a tube, and with some imagination called it a "sleeve".

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Wednesday, February 16, 2011

Weight Loss Surgery for BMI 30?

As you may know, the standard recommendation has been that bariatric surgery is indicated for BMI 35 or above, in the presence of at least 1-2 comorbidities. In the US, patients whose BMI is between 30 and less-than-35 have hard time being accepted for weight loss surgery and, by and large, have had no surgical option.

One bariatric surgery, adjustable gastric band placement, involves the placement of a device that is produced by Allergan (Lap Band). In an Allergan News Release, the U.S. Food and Drug Administration (FDA) approved the expanded use of the LAP-BAND® System, Allergan’s gastric band, for adults with obesity who have failed more conservative weight reduction alternatives, such as diet and exercise and pharmacotherapy, and have a Body Mass Index (BMI) of 30-40 and at least one obesity related comorbid condition. The LAP-BAND® System study, initiated by Allergan, Inc., is a prospective, single-arm, non-randomized, multi-center five year-study. The study was initiated in 2007, and included 149 patients. The criterion for success was at least 40% of patients achieving clinically meaningful weight loss at the 12-month time point, where clinically meaningful weight loss was defined as at least 30% Excess Weight Loss (EWL).

The 12-month results showed that almost 84% of the patients lost at least 30% of their excess weight at one-year. In terms of improvement in comorbid conditions of dyslipidemia, Type 2 diabetes, and hypertension, 22-33% of patients with those conditions, saw their conditions resolved after one year.

Comparing the Lap Band with non-surgical weight loss (which has very low success rates), and setting the threshold of "success" to the level of losing 30% excess weight, allowed those results to shine. However, if those were compared to sleeve gastrectomy (1-2 year average excess weight loss of 60-68%, and 5 year average loss of 50% excess weight) such a standard for success would not be met by the Lap Band. But the sleeve gastrectomy is a surgical procedure, not involving the implantation of a device. Therefore, there is no basis for FDA to have any saying about the sleeve gastrectomy or gastric bypass. It is safe to say that the improvement in comorbidities is, on the average, much better with the sleeve gastrectomy than the adjustable gastric band.

Will bariatric surgeons become more encouraged to apply the same BMI guideline of 30 for other bariatric surgeries (instead of 35) based on the FDA approval of the Lap Band? Would they be supported by the American Society of Bariatric Surgery if they do so? Will insurance companies change their coverage criteria based on that? So many questions. But it is a good start.