Sleeve Gastrectomy

Sleeve Gastrectomy Variations

Every surgeon performs the sleeve gastrectomy with specific nuances in technique. We have evaluated many of these variations either through personal experience or observation or discussion with other surgeons using similar or different techniques.​

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When originally performed by Dr. Elariny in 2000, the sleeve was performed by creating the tubular stomach tightly over a 60 French bougie. When the sleeve started to gain popularity, many surgeons began using a 30-40 French bougie for pouch creation indicating that they would remain at least 1 cm or more away from the bougie during stapling in order to avoid creating too small of a tubular sleeve. There has been much success with this approach; however there have been many reported complications with the sleeve created in this manner. For example, when a bougie that is too small is used (e.g. a 30 French size), the staple line may inadvertently swing towards the bougie in one or more places along the staple line creating stricture(s). One very tight stricture can lead to unwanted restriction of food passage in unplanned locations and result in nausea and vomiting that could become permanent and require balloon dilation or revision. Worse than this, if 2 or more sites of unwanted strictures occur, this can lead to "high pressure zones" between the strictures which increases the risk of leak and may result in chronic pain.  Finally, using a smaller bougie and "staying away from it" encourages the formation of larger than desired and unknown size sleeve tube. This can result in poor weight loss effect.  For these reasons, the avoidance of bougie size less than 50 French for creation of the sleeve gastrectomy is safer. We use a 50 French bougie for the creation of a straight sleeve and several measures are implemented to be sure that the resection is complete. First, the use of Reglan or other medications that can stimulate gastric wall contraction is avoided before and during surgery. The anesthesia team must be made aware of this goal. If the stomach is contracted during stapling, the end result sleeve will be larger than desired. Second, the stomach is minimally manipulated during devascularization and no bougie is placed until the stomach is ready for immediate transection and stapling. Third, the bougie is passed carefully and rapidly to the pylorus and the stomach is stretched firmly by pulling the greater curvature away (to the patient's left side), pressing the lesser curvature against the bougie and the staple reload on the other side of the bougie to create a tight sleeve around the bougie. Another key element in this process is to make sure there is an equal amount of anterior and posterior stomach wall on either side of the staple line so that the sleeve is smooth and straight. Finally it is very important to de-fat and devascularize the greater curvature all the way down to the pylorus, but not beyond it or onto it, so that it remains well vascularized for function, but visible for placement of the first firing of the stapler. Although it is technically easier and fastidious to stay 4-7 cm above the pylorus for the first staple firing, and it also avoids stapling through the thickest part of the antrum of the stomach, this results in a future problem for the patient: 1) a large antral storage sac, and 2) an increased acid production capacity. For these reasons, we begin 1-2 cm close to the pylorus for the first firing of the sleeve.

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For the Banded sleeve, the restriction of food passage is desired at a higher point than the dynamic pylorus. Building on the experience of the Ed Mason VBG of the 1970's where the banding occurred 7 cm from the GE Junction, and similar to the location of restriction created with a gastric bypass also 7 cm from the GE junction (usually between the 2nd and third left gastric vascular branch on the lesser curvature), restriction for a sleeve is also positioned 7 cm from the GE junction and below at least two vascular branches. For this case, the sleeve itself is made over a 60 French bougie instead of a 50 French bougie and the restriction point at 7 cm, is created over a 40 French bougie. The restriction point has been reliably created with Marlex mesh in approximately 700 patients with over 10 years of follow-up. The Marlex is fashioned with a height of 1 cm and preparatory length of 10 or more cm and stapled down to a tight position over a 40 French bougie. Several iterations of this technique were used before it was perfected and warrant discussion. First the question of resecting a small segment of the staple line at 6.5-7.5 cm from the GE junction - yes or no. In this iteration the 40 French bougie is passed into the existing sleeve and a 1 cm half circle/ellipse of the staple line is excised to create a waist line. Alternatively, with the 40 French bougie in place, the staple line at 6.5-7.5 cm from the GE junction can be imbricated inward (over sewn) tightly over the 40 bougie. Once the waist line is created (via stapling or over sew) the mesh can then be placed. A lesser curvature perigastric tunnel is then created and the mesh passed through this anterior to posterior and then again with the 40 French bougie in place, the two leaflets of the mesh are stapled together with firm pull on the mesh to maintain compression circumferentially around the sleeve. The bougie is then pulled back and the mesh should be checked with the tip of a Maryland Grasper to be certain that the mesh is not compressive on the gastric wall in the absence of the bougie. This step is thought to be one main reason why in over 700 banded sleeves, and >20 years of follow-up, we have never had a single case of erosion. This is in contradistinction to the erosion rates seen with the original Ed Mason VBG where erosion was common. The hypothesis as to why mesh erosion is not seen in this technique of banded sleeve; as compared to the original VBG procedure is 5-fold. 1) In the VBG, the band was cut to length prior to placement, so this leads to failure to individualize band length to specific patient characteristics - specifically the thickness of the patient's stomach and the peculiarities of thickness that may be attributable to the dissection performed surgically. 2) Although the band does wrap around the lesser curvature circumferentially 360 degrees in both the VBG and the Banded, sleeve, only in the VBG does there exist a 360 degree circumferential exposure of the staple-line side of the band to stapled stomach tissue. In the banded sleeve, there is only one sided linear (not circumferential circular) exposure of the band to stapled stomach surface. 3) Care is taken in creation of the banded sleeve to avoid compression of the stomach serosa by the band as described above, by placing the band with a 40-french bougie in place and than assuring space between the band and serosa after fixating the band. 4) the size of the banded opening is 40 French (larger than the VBG), making it less likely that excess restriction is contributing to frequent vomiting or retching than can encourage erosion. 5) the band over sleeve is not directly sutured or stapled to the stomach wall, and is only stapled to itself, and so it exists like a ring exists over a finger, and is not physically surgically fixated at any point to the sleeve, instead, it is held in place by existing vascular pedicles on the lesser curve, and it's circumferential surface area.

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Other variations: The banded sleeve has been performed using a flat polypropylene sheet in early procedures (n=10). No erosions occurred, but 20% required removal (n=2) due to excessive nausea and vomiting. During removal, in both these patients, it was noted that a firm capsule formed around the flat band creating a cylindrical capsule ring in the horizontal plane around the linear vertical plane of the band. This capsule contained significant fluid, which is thought to be contributing to undesired restriction and variable undesired restriction. For these reasons, the Marlex mesh was the preferred mesh. There were a few patients who were reticent to have Marlex mesh implanted and wanted biologic material, and in those cases, dependent on facility availability, UBM, bovine pericardium, and AlloDerm have been used without untoward effects. In early banded sleeve procedures, we were worried about erosion and so in several early patients we placed a tubular “slip” or flap of omentum between the gastric staple line and the mesh band. This was eventually discovered not to reduce erosion risk as the erosion rate remained zero without the omental flap. However, we noticed that as patients with the flap lost significant weight, the experienced a reduced sense of restriction. As such we continued to offer this procedure with the omental flap using a 34 French bougie to tighten the mesh around the sleeve and omentum. This has afforded 7 such patients with what we consider self-adjusting restriction. As the patient loses weight, the omental flap thins and allows for less restriction, and if weight gain occurs, the flap enlarges and creates increased restriction. We have not obtained MRI or imaging evidence to prove this clinical theory based on patient experiences, but we have determined that EBWL in these patients exceeds that of patients without banded sleeve gastrectomy, but have not been able to statistically differentiate between different types of banding. Anecdotally, satisfaction with the “self-adjusting” band is higher.