Sleeve Gastrectomy: from the origin to the present, towards the future

Dr. Gagner tells the history of sleeve gastrectomy (SG), first described as “greater curvature gastrectomy” or “pariental cell gastrectomy”. Laparoscopic sleeve gastrectomy has been the gold standard technique since the 1990s. Long-term main problems of SG are: weight regain, GERD/Barrett’s and type-2 Diabetes re-appearance. Dr. Gagner goes through the main randomized studies, showing long-term results regarding excess of weight loss (EWL) after SG compared to Roux-en-Y gastric bypass (RYGB). Some reviews comparing SG versus RYGB show no differences 5 years later. However, it is important to point out that some of the first SG were performed with a less accurate technique and might have poorer results. Superobese patients treated with SG have been described to achieve 50% EWL 9 years after. Some series report over 50% EWL at 8 years for patients with BMI initially under 50. SG converted to RYGB has the same EWL over years. The reason for the conversion is either reflux or weight regain. Causes of this second surgery, according to Dr. Gagner, might be the use of a Bougie of 48Fr instead of 36Fr, an inadequate fundus dissection, or no hiatal hernia repair performed in the first procedure. Interestingly, if these results are taken under an intention-to-treat analyses more EWL is achieved after SG compared to RYGB, up to 62.5% at 11 years. Regarding type-2 diabetes, the same results have been described when comparing SG and RYGB. Long-term results 10 years after RYGB show 55% EWL, 29% GERD, 51% diabetes remission. Dr. Gagner talks about the role of the duodenal switch (DS), since some series report a complete remission of diabetes of 63% at 5 years versus 37% for RYBG. DS can be considered an option for a second surgery after SG. Long-term results show a 92% resolution of diabetes in these cases, as well as the lowest percentage of body fat and good rates of patient satisfaction. Reflux after SG is one of the most challenging scenarios in bariatric surgery. Techniques such as the LINX system, RF to increase the sphincter, cardiopexy or funduplication are being currently considered. To summarize, SG and RYGB have similar long-term results. Patients with RYGB seem to develop less symptomatic GERD. Revisional options are more frequent after SG. SG is a good option as a first step, leaving other techniques such as re-sleeve, RYGB or DS in selected patients depending on comorbidities as a second step if needed.