Gastric sleeve surgery is a restrictive bariatric procedure. Stomach volume is greatly reduced resulting in small meal consumption. Weight loss, however, is not related to stomach volume reduction. Gastric sleeve induced weight loss is a physiologic result of altered gastrointestinal neuro-hormonal signals secondary to increased gastro-intestinal motility. These signals affect certain parts of the brain favoring weight loss. Gastric sleeve patients experience decreased appetite, and increased satiety with small meals. Carbohydrate digestion, absorption and metabolism improve leading to normalized blood sugar levels and weight loss. Gastric sleeve surgery patients who maintain a healthy lifestyle enjoy a lifelong weight reduction.

Patients who fail to adopt healthy eating habits tend to overeat and stretch the gastric sleeve lumen. Patient with a dilated gastric sleeve present to their bariatric surgeon with weight regain, increased appetite, and increased meal size. A contrast study typically reveals uniform dilation of the gastric sleeve lumen. Preferential dilation of gastric sleeve lumen at the fundus level indicates functional narrowing at the incisura angularis. In such cases, there is poor initial weight loss and increased incidence of acid reflux.

For patients with a uniform gastric sleeve dilation we start with lifestyle changes and education on healthy eating habits. If patients are compliant, we proceed with gastric re-sleeve or conversion to gastric bypass or duodenal switch. The more weight regain the patient has experienced the less likely the re-sleeve will succeed in weight loss. Patients who have regained all their excess weight loss and more are advised to proceed with sleeve conversion to gastric bypass or duodenal switch. Conversion of dilated gastric sleeve to duodenal switch has the highest success rate.

Patient with a dilated gastric fundus and narrowed incisura angularis are better served with conversion to gastric bypass. A narrowed incisura angularis is associated with severe GERD and gastric bypass is the only solution to alleviate GERD symptoms in this situation.