Expert: Karla K. - 3/8/2010

Question
my doctor told me she would do a sleeve or a roex-y on me both would work. But she really wanted to do a sleeve. she never would answer me when i asked why the sleeve as to the y.i have researched but can't really find out much. i have a BMI of 49 what is the major differance in the two.

Answer
John:

With a BMI of 49, you owe it to yourself to explore the Duodenal Switch.  In a few studies, it's shown to be more effective in those with a BMI over 50, and with a BMI of 49--you're nearly there.  http://www.ncbi.nlm.nih.gov/pubmed/19937190

My guess is that your surgeon hasn't recommended it because she does not do the operation.  You can find a list of docs who do at duodenalswitch.com  or dsfacts.com

That actually may be one reason she's recommending the Sleeve over the Roux-en-Y.  She may view your sleeve as a first stage procedure which would allow you to easily convert to a DS if your weight loss wasn't sufficient.  

But now, back to your question.  The Gastric Sleeve or Vertical Sleeve Gastrectomy is a restrictive-only operation, although some call it a restrictive plus hormonal. The hormonal part has to do with reducing the production of ghrelin--a hormone which influences hunger.  For some people, the reduction is dramatic--and they have to remind themselves to eat.  For others, it is less--but still noticeable.  Basically, your surgeon will be removing 90% or so of your existing stomach (mainly the fundus) and leaving behind a thin tube.  You'll still have the pyloric valve which regulates the rate at which food empties into your small intestines--so are unlikely to get dumping syndrome, which is more common with a RNY.  So far, weight loss percentages with the Sleeve are around 59-60% of your Excess Weight Loss.  There have been very few 5 year results reported.  One report shows a 5 year result of 55% EWL.  http://www.ncbi.nlm.nih.gov/pubmed/20094819  Some lose more, some lose less.  One of the advantages of the sleeve, is that for most, it leaves you with a normal functioning stomach and thus a very high quality of life.  As with any bariatric surgery, you'll still need to have annual bloodwork for life--as you'll be more prone to Vitamin B12, folic acid, Vitamin D, and parathyroid hormone issues.  Post-op, your surgeon will put you on a vitamin regime--usually at least a multivitamin, plus supplemental sublingual B12 and vitamin D.  You're more prone to B12 issues as the portion of your stomach which produces the majority of the intrinsic factor is removed--and it is necessary for B12 absorption.  If sublingual B12 does not work for you, you may eventually need injections.  You should be able to eat normally, but a lot less than you eat now.  Your stomach will stretch over time.  If you are unhappy with your weight loss, it's considered an easy revision to a duodenal switch, as the sleeve is the first part of a DS.  If you do have a SG, please be sure that your surgeon uses a small (32F) bougie (tube to size the sleeve)--as this has shown to lead to better weight loss.

The Roux-en-Y has been around for a long time and is well-liked by many surgeons.  Your surgeon will create a pouch in your stomach, but usually the remnant stomach is left behind.  Some people do not like this fact because it leaves them with a "blind" stomach.  Others prefer it, because they hate the thought of part of their stomach being removed permanently.  A hole is made in the pouch and a portion of your small intestine is brought up to directly connect with the hole.  Because there is no valve there regulating the rate at which food leaves the pouch, you may experience dumping syndrome when you eat refined carbs/sugars.  Some people like the dumping syndrome, as it serves as a deterrent from eating sweets and such.  Others hate it, because it can be quite uncomfortable.  Not everybody experiences dumping syndrome, and it has been known to disappear as time goes on.  Some people attribute that, along with a stretched pouch, to eventual weight gain.  The RNY is a restrictive plus malabsorptive operation.  Because the food you are eating bypasses a portion of your small intestine, not as many calories (or nutrients) are absorbed--and this aids weight loss.  It also means that you will also need to commit to bloodwork for life.  You'll be on supplements for life, similar to the VSG, but a little bit more extensive.  A 2010 study of Vets found a 5 year EWL of 59% as well...comparable to the VSG.  http://www.ncbi.nlm.nih.gov/pubmed/20049654   I've seen some results slightly better than that, but not by much.

I think if you are choosing between the VSG and RNY, then the VSG is likely to provide you with similar results, higher quality of life, and less operative risk than a RNY.  However, I do think you should also look at the Duodenal Switch based on your BMI.  You might also want to hang out on the Revision Board and Duodenal Switch Boards at ObesityHelp.  The VSG and Main (RNY) boards are good too, but please try and talk with people who are at least 3+ years out--as otherwise, you'll end up with people in the honeymoon phase of their weight loss surgery experience.  Weight regain usually doesn't start until around 2-3 years post-op.

Whatever you do, please make sure that you use an experienced surgeon.

Good luck,
Karla