Sleeve Gastrectomy for BMI less than 35: Is it Worth it?

Sleeve Gastrectomy for BMI less than 35: Is it Worth it?

“Determining the health benefits of sleeve gastrectomy in patients with body mass index, BMI less than 35” is a new article published in Surgery for Obesity and Related Diseases journal. The authors compare the outcomes of sleeve gastrectomy in 1073 patients with low BMI to 44511 patients with BMI more than 35 (mean BMI 46.7).

Statistical analysis shows comparable rates of hypertension, diabetes and hyperlipidemia medication discontinuation. Low-BMI patients were more likely to achieve a healthy BMI (less than 25). The authors conclude that despite being older and with higher rates of metabolic disease, low-BMI sleeve gastrectomy patients benefited from bariatric surgery. Furthermore, low-BMI sleeve gastrectomy patients were more likely to achieve a healthy weight. Therefore, abolishing the BMI threshold for sleeve gastrectomy should be considered.

I wholeheartedly agree with these conclusions. Sleeve gastrectomy is currently one of the safest general surgeries we perform with very high success rate. Why wait to lose weight? Bariatric surgery is currently the most effective treatment for type 2 diabetes. Denying low-BMI patients with metabolic disease a safe and effective procedure like sleeve gastrectomy is not reasonable. BMI is a statistical tool established more than 50 years ago by insurance companies to predict mortality in a population. BMI, however, is not a personalized measure of one’s health. A diabetic low-BMI patient is at higher risk for cardio-vascular disease then a non-diabetic high-BMI patient. Eliminating diabetes at a lower BMI and younger age should be the norm rather than the exception. Sleeve gastrectomy is a powerful tool to safely control and cure metabolic disease. It is time to update our guidelines.

Gastric Bypass, Gastroparesis Houston

Gastric bypass, Gastroparesis, Sleeve Gastrectomy

Question from Tonya in Clear Lake:

“A bariatric surgeon told me I might be a candidate for RYGB, but it depends on my transit times for the smart pill. If I have gastroparesis with delayed gastric and large intestinal transit but normal small intestine am I a good candidate for gastric bypass surgery?”

Dear Tonya,

My experience is limited to gastroparesis and delayed gastric emptying. For patients with severe gastroparesis, I prefer a modified sleeve gastrectomy over gastric bypass to improve gastric emptying and effectively resolve gastroparesis related symptoms. Sleeve gastrectomy improves both gastric and intestinal emptying. Therefore, I predict that a modified sleeve gastrectomy improves intestinal motility too. I am not sure about the effect of gastric surgery on colon emptying. I am also not sure about the clinical significance of small bowel transit time in the setting of gastroparesis.

For patients with delayed gastric emptying but normal small intestine motility, will gastric bypass surgery be equally effective to modified sleeve gastrectomy in alleviating gastroparesis related symptoms? This is a very interesting question and I am not sure if we have an answer. Gastroparesis is a heterogeneous disorder with many different subtypes. Unlike longitudinal gastrectomy or modified sleeve gastrectomy, gastric bypass or resection does not address the underlying pathophysiology of gastroparesis. For this reason, most gastroparesis patients do not respond to either gastric bypass or gastric resection.

To summarize, in my own personal and limited experience, modified sleeve gastrectomy is the best treatment for severe refractory gastroparesis independent of small bowel transit time. There may be a role for gastric bypass surgery in gastroparesis patients with “normal” small bowel motility, but I am not aware of studies to support such an approach.

Duodeno-gastric Bile Reflux after Sleeve Gastrectomy

We have previously discussed the pathophysiology associated with bile reflux from duodenum into gastric sleeve lumen ending into distal esophagus in the setting of hiatal hernia. At Houston Weight loss Surgery Center, we have made the observation of increased incidence of bile gastritis in gastric sleeve patients with hiatal hernia and distal esophagitis. Continue reading “Duodeno-gastric Bile Reflux after Sleeve Gastrectomy”

Is Sleeve Gastrectomy the Best Gastroplasty for Weight Loss?

Over the past 50 years a number of gastroplasties have been developed to treat obesity. From the first horizontal gastroplasty to the latest endoscopic sleeve gastrectomy, bariatric surgeons in Houston and all over the world attempted to reduce stomach volume in hopes of restricting food intake and promoting weight loss. Continue reading “Is Sleeve Gastrectomy the Best Gastroplasty for Weight Loss?”

Gastric Bypass and Sleeve Gastrectomy Revision Surgery

I read with great interest the study published in Surgery for Obesity and Related Diseases by DeMaria et al. It is a retrospective review of 96 gastric bypass patients who underwent conversion of to distal gastric bypass between 2010 and 2016. The Roux or alimentary limb is cut at the jejuno-jejunostomy and transposed distally leaving a common channel between 150 to 200 cm in length. Continue reading “Gastric Bypass and Sleeve Gastrectomy Revision Surgery”

Gastric Bypass Long-term Complications

Gastric Bypass Long-term Complications

I am a 64 y/o female, 20 years post roux-en-y gastric bypass. I have GERD, a “small” hiatal hernia, Barrett’s esophagus, nighttime bile regurgitation, and bilious vomiting after any decent sized meal. I continue to get worse each year. My GI doctor does not believe it is possible for a gastric bypass patient to have GERD. He believes I simply misunderstand the meaning of GERD. I am so frustrated and miserable. Where should I go from here? Continue reading “Gastric Bypass Long-term Complications”

Gastric Bypass Surgery Is Not a Good Option for Gastroparesis

I was asked to review a study titled “Laparoscopic Treatment of Gastroparesis: A Single Center” submitted for publication in SOARD (Surgery for Obesity and Related Diseases). It is a single center, retrospective study. The charts of 93 patients with either idiopathic or diabetic gastroparesis were reviewed over a period extending from 2003 till 2014. Most patients were treated with gastric electric stimulator implantation. 15 patients underwent Roux-en-Y gastric bypass surgery.

The authors showed that gastric bypass surgery unlike gastric electric stimulation is not associated with statistically significant improvement in vomiting and pain. They also showed that 40% of operated patients continued to use an antiemetic and or pro-kinetic medication after either gastric bypass or gastric electric stimulation. 18% of patients required reoperation. Most of those patients underwent gastric electric stimulator removal. The authors conclude that surgery is feasible and effective for gastroparesis treatment. Although both procedures have some degree of efficacy, Gastric Electric Stimulation seems to provide improvement of more gastroparesis symptoms.

Gastroparesis incidence is rising and we still don’t have a good understanding of its pathophysiology. Most importantly, there is no established effective treatment guidelines for gastroparesis. Many gastroparesis patients are left untreated or poorly treated with symptoms that significantly diminish their quality of life and overall health.

Randomized, prospective controlled studies have clearly shown that gastric electric stimulation showed no symptom improvement in gastroparesis patients. RYGB is not well studied for gastroparesis treatment. In my personal experience, I have seen no improvement of gastroparesis symptoms following RYGB especially in severe and medically refractory cases.

I disagree with the author’s conclusion stating that gastric bypass and electric stimulation are effective surgical solutions for gastroparesis. According to this study, gastric bypass did not alleviate vomiting and pain and gastric electric stimulation, GES, showed symptom improvement in around 60% of patients. GES and gastric bypass procedures have therefore limited efficacy in gastroparesis management.

I think it is very important for general and bariatric surgeons to understand that gastric bypass surgery is not a good option for medically refractory gastroparesis cases. I have developed a procedure for treatment of gastroparesis, few years ago, based on published reports showing improved gastric emptying following gastric sleeve surgery. A longitudinal gastrectomy or modified sleeve gastrectomy that preserves the gastric antrum (stomach pump) and leaves some gastric fundus (especially for the malnourished patients) has been amazingly effective for gastroparesis treatment in my private practice. I have used this approach in around 10 patients with great results. These patients had complete resolution of all gastroparesis related symptoms including nausea, vomiting and abdominal pain. Any outcome short of complete symptom resolution should not be labeled as “effective”.

Resecting the greater curvature while preserving the gastric antrum has a real potential for being a breakthrough treatment for this poorly understood disorder. Prospective randomized studies evaluating the modified sleeve gastrectomy for gastroparesis treatment are needed to help us improve our care of this medical condition.

Jimmy’s Success Story Could be Yours in 2017

Jimmy is a 50-year-old male who has been struggling with excess weight for the past 25 years of his life. 15 years ago, he underwent a purely restrictive procedure called Molina band in Houston, TX. Through an open approach, the weight loss surgeon at the time, placed a Gore-Tex band around the upper stomach creating a small gastric pouch with a narrow opening. The mechanical restriction allowed Jimmy to lose some of his excess weight. However, within few years and as it is expected with purely restrictive procedures he gained back around 100 pounds. Furthermore, he developed significant narrowing of the gastric pouch opening leading to gradual worsening of acid reflux, food regurgitation, inability to tolerate solid diet and daily vomiting. Over the past 10 years, Jimmy has been living on a puree diet including ice cream.

When Jimmy presented to my office, it was obvious that he had gastric pouch outlet obstruction. He underwent an upper endoscopy that confirmed the diagnosis and was immediately scheduled for revision surgery. The procedure we agreed upon was conversion of Molina band to Roux-en-Y gastric bypass. Jimmy underwent the surgery with no complications and had an uneventful recovery in a very short period. His heartburn and food regurgitation have resolved. His diet choices include now fruits, vegetables and lean proteins. He felt more energetic and was started to exercise daily. Jimmy likes weight lifting and one year after surgery he lost 110 pounds while building an impressive body physique.

Jimmy is the perfect example of a star bariatric patient. He used the gastric bypass procedure as a tool to overcome excess weight, sleep apnea, acid reflux and hypertension. He followed Houston Weight Loss Surgery Center recommendations and adopted a healthy lifestyle that allowed him to achieve the goals he has always wanted: live a healthy, happy and disease free life. If you or someone you know is interested in losing their excess weight and gain back their health give us a call. Our team of weight loss experts are happy to assist you.