With thanks to Dr Milton Owens & Rancho Speciality hospital California

The procedure was originally conceived of in England and has been further developed and utilized in the U.S, Germany and Belgium. The technique is an improvement over earlier gastroplasty procedures which included placement of foreign bodies, and left the excess stomach intact. It was originally used for very high BMI patients (~ 500 lbs.) to try to reduce the overall risk of surgery. It was then followed by a second surgery when the patient had lost enough weight to safely go through a second procedure like the Gastric Bypass.
The new procedure was started in England about 5 years ago as a stand alone procedure for patients of BMI’s of 35-45. It proved to be quite safe and effective even at 5 years post op.

U.S. studies have been very impressive; in one study of almost 100 very high risk, very high BMI patients there were no deaths, and only 1 leak, and 1 pulmonary embolus.

Dr. Owens has used this procedure for high risk, high BMI patients with good results. It can be considered by patients who are:

Concerned about bowel obstructions and leaks that may occur with Gastric Bypass due to the re-arrangement of the anatomy required.
Concerned about the dietary changes and vitamin supplements required by Gastric Bypass
Concerned about the foreign body introduced with the Lap Band placement
Concerned about the need for follow up, fills required with the Lap Band
It should also be considered for patients weighing over 500 lbs, patients with existing anemia, Crohn’s disease, or other conditions that make them too high risk for Bypass procedures.

Dr Owens is the first surgeon in Southern California to offer Sleeve Gastrectomy. His expertise in Sleeve Gastrectomy offers our patients another option to help them receive the best weight loss procedure for their individual needs. Vertical Sleeve Gastrectomy procedure also called Sleeve Gastrectomy, vertical gastroplasty, Greater Curvature Gastrectomy, Parietal Gastrectomy, Gastric Reduction and Sleeve Gastroplasty is performed by approximately 18 surgeons worldwide.

Choosing the Sleeve:

 • Those who are concerned about the potential long term side effects of an intestinal bypass such as bowel obstruction, ulcers, anemia, osteoporosis, protein deficiency and vitamin deficiency.
• Those who are considering a LapBand but are concerned about a foreign body or the need for fills and more frequent follow up.
• Those who have other medical problems that prevent them from having weight loss surgery such as anemia, Crohn’s disease, extensive prior surgery, and other complex medical conditions.
• Those taking anti-inflammatory medications that may need to be avoided after gastric bypass due to increased risk of ulcers. Advantages of the Sleeve:
• Stomach holds less but tends to function normally so most food items can be consumed in small amounts
• Thought to eliminate the portion of the stomach that produces the hormones that stimulates hunger (Ghrelin).
• No dumping syndrome
• Minimizes the chance of an ulcer occurring.
• Very effective as a first stage procedure for high BMI patients (BMI >55 kg/m2).
• Limited results appear promising as a single stage procedure for low BMI patients (BMI 35-45 kg/m2).

Extract from study paper published in Obesity Surgery. 2007 Jul
 Andrew A Gumbs , Michel Gagner , Gregory Dakin , Alfons Pomp 

The rising prevalence of morbid obesity and the increased incidence of super-obese patients (BMI >50 kg/m2) seeking surgical treatments has led to the search for surgical techniques that provide adequate EWL with the least possible morbidity. Sleeve gastrectomy (SG) was initially added as a modification to the biliopancreatic diversion (BPD) and then combined with a duodenal switch (DS) in 1988. It was first performed laparoscopically in 1999 as part of a DS and subsequently done alone as a staged procedure in 2000. With the revelation that patients experienced weight loss after SG, interest in using this procedure as a bridge to more definitive surgical treatment has risen. Benefits of SG include the low rate of complications, the avoidance of foreign material, the maintenance of normal gastro-intestinal continuity, the absence of malabsorption and the ability to convert to multiple other operations. Reduction of the ghrelin-producing stomach mass may account for its superiority to other gastric restrictive procedures. SG should be in the armamentarium of all bariatric surgeons. Nonetheless, long-term studies are necessary to see if it is a durable procedure in the treatment of morbid obesity. 

Surgical videos on WeBSurg

You can watch a Sleeve Gastrectomy on the Web. This video demonstrates a routine case of laparoscopic sleeve gastrectomy for morbid obesity. This is usually the first stage of a two-stage procedure. The surgeon starts at the mid portion of crow’s foot about 7 cm from the pylorus and mobilizes all the greater curvature vessels and attachments using bipolar cautery. After full mobilization of the greater curvature up to the angle of His, the gastric sleeve is constructed using a linear stapler. A bougie is used to calibrate the diameter of the gastric sleeve. The specimen is removed from an enlarged trocar site. The surgeon in this case placed a drain.
To watch the procedure visit http://www.websurg.com/ref/Laparoscopic_sleeve_gastrectomy-vd01en1853.htm 

History
The Vertical Sleeve Gastrectomy procedure (also called Vertical Gastrectomy, Sleeve Gastrectomy, Greater Curvature Gastrectomy, Parietal Gastrectomy, Gastric Reduction, Logitudinal Gastrectomy and even Vertical Gastroplasty) is performed by approximately 20 surgeons worldwide.  This forum is titled “VSG forum� to include the two most common terms for the procedure(vertical and sleeve).   The earliest forms of this procedure were conceived of by Dr. Jamieson in Australia(Long Vertical Gastroplasty, Obesity Surgery 1993)- and  by Dr. Johnston in England in 1996 (Magenstrasse and Mill operation- Obesity Surgery 2003).  Dr Gagner in New York, refined the operation to include gastrectomy(removal of stomach) and offered it to high risk patients in 2001.  Several surgeons worldwide have adopted the procedure and have offered it to low BMI and low risk patients as an alternative to laparoscopic banding of the stomach.

It generates weight loss by restricting the amount of food (and therefore calories) that can be eaten by removing 85% or more of the stomach without bypassing the intestines or causing any gastrointestinal malabsorption.  It is a purely restrictive operation.  It is currently indicated as an alternative to the Lap-Band® procedure for low weight individuals and as a safe option for higher weight individuals.

full article http://www.obesityhelp.com/forums/vsg/cmsID,8874/mode,content/a,cms/

Studies of stomach-surgery patients offer the strongest evidence yet that shedding pounds can extend life.
Obese people are significantly less likely to die if they undergo stomach surgery to lose weight, according to two new studies that offer the first convincing evidence that the health gains of losing weight translate into living longer.
The research, involving 20,000 obese people in the United States and Sweden, found that those who underwent surgery had a 30 percent to 40 percent lower risk of dying over the next seven to 10 years compared with those who went without the operations.
Previous research has shown that losing weight cuts the risk of diabetes, heart disease, cancer, and other major ailments and suggested that might lead to an increase in longevity. But the new studies offer the strongest evidence to date in answer to one of the most important and contentious questions about one of the western world’s biggest health problems: Does weight loss result in not only healthier lives but also longer ones?
“The question as to whether intentional weight loss improves life span has been answered,” wrote George Bray of the Pennington Biomedical Research Center in Baton Rouge, La., in a commentary accompanying the reports in today’s New England Journal of Medicine.
“The answer appears to be a resounding yes.”

“Morbid obesity is a disease. Bariatric surgery is the only efficient treatment of morbid obesity. It is a matter of life and death. The results of this major scientific study will, I hope, contribute to eliminate the preconceived ideas against morbidly obese persons and bariatric surgery”, says Jennifer Schultz, cofounder of the Coalition against Morbid Obesity . “This study effectively shows the beneficial impact of bariatric surgery on the health and survival of morbidly obese people.”
Morbid obesity is the starting point for different types of diseases that are often fatal, such as arterial hypertension, Type 2 diabetes, or heart disease. An individual’s obesity level can be evaluated by means of the body mass index (BMI), which is calculated by dividing the person’s weight by his or her height squared (Kg/m(2)). Morbid obesity corresponds to a BMI higher than or equal to 40, or higher than or equal to 35 if accompanied by comorbidities.
According to the World Health Organization (WHO), bariatric surgery is considered to be the only effective treatment for morbid obesity. Bariatric surgery includes a series of techniques that are based on two intervention principles: Restriction and Malabsorbtion. Restrictive procedures include Gastric Banding (the lap band) and the relatively new technique of Vertical Sleeve Gastrectomy, which is producing some very encouraging results. Malabsorptive procedures include Gastric Bypass and Duodenal Switch.

There are two Metabolic Hormones Controlling Appetite, Leptin and Grehlin

Leptin:
Discovered in 1994, signals the brain that the body has had enough to eat.
The earliest-discovered of these hormones, and the first hormone ever shown to have a direct role in appetite and weight control. The hormone is secreted in fatty tissue and released into the bloodstream.  However, as the amount of fatty tissue in the body increases, the body begins to “resist� the leptin.  Obese people often have extremely high levels of leptin circulating in the blood.  However, the brain “ignores� the leptin because  it has become desensitized to it.  For this reason, injecting leptin into obese people to “curb� their appetite has been shown to be ineffective.  Also, if obese people reduce fatty tissue by losing weight, it is not clear whether the brain ever recovers its normal sensitivity to leptin.

Conclusion:
Once someone becomes obese and leptin-resistent,  automatic self-regulating appetite
control is no longer possible.

Grehlin:
Discovered in 1999, signals the brain to increase feelings of hunger.
Discussion:
Ghrelin is the only major metabolic hormone not secreted in fatty tissue– it is secreted in the lining of the stomach.  In obese people, Ghrelin levels tend to be high, increasing the apparent feeling of hunger.  Also, Ghrelin levels apparently fail to “cycle� up and down over a 24 hour period, as occurs with thinner people.

Gastric Bypass Surgery and Sleeve Gastrectomy: These types of surgery block part of the stomach, reducing the area of stomach lining being actually used.  Because there is less stomach lining, there is less ghrelin being secreted too, resulting in reduced hunger.

Anti-Obesity Vaccine– controlling ghrelin:  Scripps Research Institute reported in August 2006 that it had broken through with the first anti-obesity vaccine.  Still at a very early stage, Scripps scientists injected mature male rats with a vaccine which acted against ghrelin.  The vaccine stimulates the body to produce antibodies which attack or block the ghrelin being secreted.
This finding may be especially important to stop what is commonly known as “yo-yo dieting,� the cycle of repeated loss and regain of weight experienced by many dieters.

These findings may mark a turning point in the treatment of obesity by using the body’s own immune system to combat chronic obesity by the use of targeted antibodies.

No human trials have yet been reported.

By Angela Parker Indystar.com 15/08/07
If you’re thinking those laugh lines aren’t so funny anymore or that surgery might be the only way to shed dangerous extra pounds, here’s a tip: Having realistic expectations and determination are requirements for successful cosmetic or bariatric surgery.
 
For cosmetic surgery patients, realistic expectations are like best friends who tell the truth even when it hurts. Expecting surgery to turn a Phyllis Diller into a Julia Roberts is just not realistic — but expecting to look like a younger version of yourself is totally achievable. Dr. Catherine P. Winslow, FACS, Winslow Facial Plastic Surgery, recommends looking at photographs from 10 years ago to get an idea of what surgery can accomplish.

“Anti-aging surgery is designed to take the years off, not alter the way you look,� Winslow said. “If patients have good expectations, they are going to be pleased with the results. If they have inappropriate expectations, they are going to be unhappy no matter what you do.�

Extensive presurgery counseling with a surgeon or psychologist helps ensure patients have the proper perspective, and it can reveal unhealthy attitudes that would make them poor surgery candidates.

After surgery, patients might experience mild depression early in the healing process. Though they know to expect some swelling, seeing their faces in that condition can be disconcerting.

“A lot of hand-holding is involved in getting patients to the point where they are happy with the results,� Winslow said.

For bariatric surgery patients, determination is the critical element. It’s a mistake to think surgery alone is a cure for obesity. After the initial dramatic weight loss, patients must be determined to keep the pounds off for a lifetime.

“We can deliver a lot of skill and advice and performance. But if the recipient is not going to be a team player, then no matter how good our work is, it’s not going to work out,� said Dr. Samer G. Mattar, medical director, Clarian Bariatric Center.

Ironically, patients must start losing weight six months before surgery. Bariatric surgery risks are about the same as with gall bladder surgery, but obese patients can reduce their risk by changing their diets and shrinking their enlarged livers. This enables the surgeon to maneuver more easily behind it to work on the stomach.

Patients who are unwilling to make this effort likely won’t have the determination to make their surgery a lifelong success.

“The only patient who is not suitable is the patient who is not willing to see me in preparation for surgery,� said Ruthanne M. Hilbrich, RD, nutrition coordinator, Clarian Bariatric Center. “They have to shrink that liver, and if they are not willing to, I postpone their surgery.�

Laura Donnelly, Health Correspondent, Sunday Telegraph 12/08/07
Almost 700,000 people are so fat that they need drastic surgery to tackle their weight problems, the Government’s health watchdog has found.

Despite the scale of the obesity crisis, primary care trusts (PCTs), fearful that the £3 billion cost of the operations would cripple the NHS, are restricting surgery to the most desperate cases. Last year, fewer than 5,000 such operations were performed.

Analysis of the guidance drawn up by the National Institute for Health and Clinical Excellence (Nice) reveals that 688,000 people in England, classified as “morbidly obese”, are entitled to be fitted with gastric bands or to have stomach stapling operations to reduce the amount of food they consume.

Nice says that anyone with a body mass index (BMI) above 40 should be offered surgery if other attempts to lose weight fail after six months, and those with a BMI above 50 should go under the knife immediately. A BMI of 40 equates to a man of 5ft 9in weighing 19 stone and a woman of 5ft 4in weighing almost 17 stone.

However, obesity experts claim that PCTs are ignoring the guidelines and, because they cannot afford to pay for thousands of operations – which cost about £6,000 each – are imposing stricter restrictions of their own.

Critics said the figures were an indictment of the Government’s failure to tackle Britain’s obesity epidemic, which has seen the number of obese people soar by 40 per cent in the past decade. One Briton in four is now classed as obese.

Andrew Lansley, the shadow health secretary, said: “This is an illustration of the Government’s failure to tackle the problem. It shouldn’t be about waiting until someone becomes a hopeless case.”

Obesity experts said that cash-strapped PCTs were desperate to avoid the costs of operating on the obese.

David Hewin, a surgeon at Gloucestershire Royal Hospital, said: “The numbers involved are huge, so PCTs are coming up with much more stringent criteria and moving the goalposts. Some are only offering surgery to patients who have other medical problems, such as type two diabetes, and some only to patients with a BMI over 50.”

Janet Edmond, director of the British Obesity Surgery Patient Association, said budgetary concerns were being exacerbated by a shortage of the specialists required to perform the procedures. “At the moment this is being funded in small numbers,” she said. “I would love to see a lot more patients getting access to surgery but realistically it cannot be done overnight. The resources are just not there.”
 

By Carolyn Johnson – ABC7 San Francisco
Is This A New Weight Loss Solution?
In May we followed a patient through a relatively new stomach reduction procedure, a Gastric Sleeve, and the patient was told to expect dramatic changes within the first three months. We wanted to see if the promises held true, so we went along for his three months checkup. Gregg Jossart, M.D., California Pacific Medical Center: “He’s a tall man, so he’ll probably lose about 70 to 80 pounds in the first ninety days, and his diabetes will probably be cured two to three months from now, and his blood pressure should be dramatically improved and that should be cured as well.”                                                                                                                                                          Bold predictions from Dr. Gregg Jossart, chief of minimally invasive surgery at California Pacific Medical Center.                                           Patient Scott Coffelt weighed in at 340 pounds the day of surgery. With small incisions, similar to those used for gastric banding or the “lap band”, doctors separated Scott’s stomach from the surrounding tissue and stapled off the majority of it, leaving just a tiny pouch. The rest of his stomach, removed for good along with the part that produces the hormone ghrelin, believed responsible for stimulating appetite. Unlike a gastric bypass, the intestines were not re-routed.                                                                                                                                                                Dr. Jossart: “You’ve lost 65 pounds in about 90 days.”                                                                                                                                       And with that weight loss came great gains.                                                                                                                                                          Scott Coffelt, stomach reduction patient: “I haven’t taken any medication since the day after surgery. Nothing for diabetes, high blood pressure, cholesterol, any of that. all the pills are gone.”

More http://abclocal.go.com/kgo/story?section=edell&id=5556228

By EMMA MORTON -The SUN
August 03, 2007
 
FAT Brits who want to lose weight should just eat less, a top doctor claimed last night.                                                                                        Obesity is now “over-medicalisedâ€�, said British Medical Association chief, Dr Hamish Meldrum. He said too many adults use pills and surgery to try to slim – instead of cutting out junk food.

Dr Meldrum said: “People use fancy labels that suggest things are a medical problem. It is preferable for people to change their eating habits.�

Weight-loss surgery — like gastric bands — has risen six-fold in ten years, with 1,000 Brits having the op each year.

Slimming pill sales are also up with more than £48million a year spent on tablets.

COSMETIC BLISS WOULD WELCOME COMMENTS ON THIS ITEM

Here is some information from NICE (National Institute for Clinical Excellence) which puts the above comment into perspective, we think.  If the morbid obesity epidemic was able to be solved by the simple expedient of eating less, there would be no problem:

According to NICE, in 1998, an estimated 0.6% of men and 1.9% of women in England and Wales had a BMI of 40 or more. This represents 124,000 men and 412,700 women or 2500 people for a typical primary care trust population of 200,000. The prevalence of obesity is rising as the average BMI increases. Between 1994 and 1998 the average BMI increased by 0.44 for men and 0.57 for women.

“ NICE recommend that weight loss surgery may be offered if the patient fulfils all the following criteria:

Obesity surgery should be considered only for people who have been receiving intensive management in a specialised hospital obesity clinic .
individuals should be aged 18 years or over.
there should be evidence that all appropriate and available non-surgical measures have been adequately tried but have failed to maintain weight loss.
there should be no specific clinical or psychological contra-indications to this type of surgery.
individuals should be generally fit for anaesthesia and surgery.
individuals should understand the need for long-term follow-up.
Surgery should normally be reserved for those with a BMI of 40 or more but NICE accept that it may be offered to those with a BMI in excess of 35 if they have associated morbidities that may benefit from weight reduction.”

Because of underfunding care for the obese in the NHS, we wonder if there are sufficient resources available to treat EVEN A FRACTION OF THOSE PATIENTS WHO MEET THESE CRITERIA