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. Increasing satiety, however, and modulating the central regulatory mechanisms for weight loss are not simply the result of gastric volume reduction. As a result, most of these gastroplasties failed to achieve permanent weight loss and only one survived: Sleeve Gastrectomy. Sleeve gastrectomy is a metabolic procedure that in addition to mechanical restriction, it alters gastrointestinal hormone secretion that affect organs like the pancreas, liver and brain. The end result is decreased hunger and increased satiety. Unlike gastric plication and endoscopic sleeve gastrectomy (better called endoscopic gastric plication), sleeve gastrectomy increases gastric emptying. Increased gastric emptying is the one common mechanism of action to all successful metabolic procedures for weight loss like gastric bypass.

Magenstrasse or stomach road is a fast emptying pathway of gastric liquids from the postprandial stomach. Soluble ingested simple carbohydrates like fructose and sucrose dissolve in gastric liquid and are “dumped” into the duodenum to stimulate the secretion of a number of neuro-hormonal signals like GLP-1 and PYY. These neuroendocrine signals stimulate carbohydrate metabolism and control satiety and body weight. They play an important role in the pathophysiology of obesity and type-2 diabetes. A number of gastric procedures enhance the Magenstrasse emptying pathway including Nissen fundoplication, Magenstrasse and Mill gastroplasty also known as reversible gastric sleeve) and sleeve gastrectomy. All three procedures are associated with increased gastric emptying and increased GLP-1 and PYY.

Along those lines, I developed sleeve gastrotomy hoping to increase gastric emptying while preserving most of the stomach tissue for food digestion, acid production, vitamin absorption. Magenstrasse emptying pathway is generated by well-coordinated gastric fundus and antrum contractions. The aim behind sleeve gastrotomy is to potentiate these contractile waves to restore the Magenstrasse emptying pathway. If this theory can be proven, sleeve gastrotomy would be the best gastroplasty for weight loss.

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