Buscar en
Cirugía Española (English Edition)
Toda la web
Inicio Cirugía Española (English Edition) Sleeve Gastrectomy: Globalization and Its Controversies
Journal Information
Vol. 96. Issue 7.
Pages 393-394 (August - September 2018)
Download PDF
More article options
Vol. 96. Issue 7.
Pages 393-394 (August - September 2018)
DOI: 10.1016/j.cireng.2018.07.008
Full text access
Sleeve Gastrectomy: Globalization and Its Controversies
Gastrectomía vertical: globalización y sus controversias
Daniel del Castillo Déjardin
Corresponding author

Corresponding author.
, Fàtima Sabench Pereferrer
Hospital Universitario Sant Joan de Reus, Facultad de Medicina y Ciencias de la Salud, Universitat Rovira i Virgili, Reus, Tarragona, Spain
Article information
Full Text
Download PDF
Full Text

Currently, sleeve gastrectomy (SG) is a surgical technique of choice within the therapeutic algorithm of morbid obesity. In its beginnings, it represented the restrictive component within the technique of biliopancreatic diversion with duodenal switch, gaining prominence as the first surgical step in high-risk patients.1 Thanks to the good results of successive series, it is currently in first place in the global calculation of the almost 600,000 annual bariatric surgeries performed in the world (46%), surpassing Roux-en-Y gastrojejunal bypass (RYGB) according to the latest survey of the International Federation of Surgery of Obesity.2 In spite of everything, it is a technique that is not free of controversies due to the anatomical and functional changes it implies. Even its nomenclature underwent variations before arriving at the current “SG”. Currently, the scientific community is making an effort to standardize the ideal SG technique, which should respond to optimal weight loss results, the resolution of comorbidities and the reduction of complications. The latest consensus includes details, such as the preference to reinforce the staple line, or not making very narrow sleeves.3 But, it is analytical, randomized studies and systematic reviews that determine the degree of evidence for a technical option. Recently, prognostic factors have been identified for weight loss after SG; meanwhile preoperative BMI > 50kg/m2, the presence of comorbidities, age >50 years, and distance >5cm from the pylorus negatively influence the results.4

A publication titled 2014: The year of sleeve supremacy,5 which arose from the latest survey of the International Federation of Surgery of Obesity, praises the enormous versatility of this technique: in addition to being performed in only one surgery, it can also function as the initial step for almost all surgical bariatric options, including RYGB, gastric banding, vertical regastrectomy or SADI, as recent studies6 have shown, as well as biliopancreatic diversion with duodenal switch. It can be done in extreme ages, is less expensive and does not need long-term supplementation. But, with the “globalization” of SG, we are in danger of making erroneous indications and falling into the false myth that SG is the solution to all our problems (bariatric, at least). Therefore, comparing SG and RYGB results is a required exercise. In the short- and midterm, the evidence indicates that weight results are similar between both procedures7; but, after 5 years, the percentage of excess weight lost is significantly higher in RYGB, although not systematically in all series, with an average of 58% (included in an overly broad range [40–86%]).8 Regarding the resolution of comorbidities, the same pattern occurs: recent publications do not find differences between the two procedures, although others report their remission at lower percentages.9,10

From the functional standpoint, SG modulates the physiology through changes in gastric emptying. Several studies describe an increase in emptying speed afterwards, which seems to be linked to the distance between the beginning of the division and the pylorus.11 In this scenario, the gastric antrum becomes partly responsible for this response. Although the relationship between emptying and early incretin stimulation has not yet been demonstrated, improvements in plasma insulin levels have been determined in diabetic patients with an antrum resection 3cm from the pylorus compared to patients with resections at 8cm, suggesting that other factors may intervene in this change beyond the incretin profile.12 In addition, this distance can influence weight loss, especially in the short term, with a higher percentage of suboptimal results reported in distances >5cm, regardless of the remaining gastric volume.4,13 Beyond the antrum, recent studies determine that pyloric preservation can also be a determining factor in long-term glycemic control.14

SG also causes the physical loss of the main producer of ghrelin, which is classically attributed to the gastric fundus. However, the cellular distribution is not uniform, varies between sexes, does not correlate with plasma levels and there are other gastric and extragastric production areas whose role can influence the surgical strategy.15 Undoubtedly, more studies are needed in this regard.

While there is agreement on the advantages of the technique, issues remain that keep it from being used universally. Gastroesophageal reflux disease represents a real controversy and limitation for its surgical indication. After SG, the increase in pressure in the new sleeve leads to worsening of the existing GERD, but it can also favor its appearance de novo in previously asymptomatic patients.16 The evidence situates the incidence of de novo GERD between 0% and 34.9%, making it the most frequent complication of the technique. However, there are mechanisms that justify an improvement in symptoms thanks to the aforementioned increase in gastric emptying velocity, with a 20–56% decrease in prevalence.17 When faced with such contradictory results, it should be noted that clinical symptoms are not a reliable method of evaluation. Diagnostic and therapeutic algorithms (including a functional study of the lower esophageal sphincter) are essential, such as those recently proposed to correctly identify GERD and indicate the appropriate technique.16 Other frequent complications are staple-line leaks, staple-line bleeding, stenosis of the sleeve or volvulus. The latest data report the mean incidence of surgery-related complications at 8.7±7.5%, although if we exclude GERD, the leaks are 1.85±2.47% and bleeding 1.34±1.6%. Overall mortality is 0.32±1.13%10; recent analyses correlate greater mortality with distances <5cm from the pylorus.18

Questions still remain with uncertain answers, such as, which option is best for review surgery? Or, what will the long-term results be? Only critical study, constant updating, the surgeon's criteria and treatment based on the particular dimension of each patient are the principles to ensure success of the surgery, regardless of imposed globalization.

D.S. Hess, D.W. Hess.
Biliopancreatic diversion with a duodenal switch.
Obes Surg, 8 (1998), pp. 267-282
L. Angrisani, A. Santonicola, P. Iovino, A. Vitiello, N. Zundel, H. Buchwald, N. Scopinaro.
Bariatric surgery and endoluminal procedures: IFSO Worldwide Survey 2014.
Obes Surg, 27 (2017), pp. 2279-2289
M. Gagner, C. Hutchinson, R. Rosenthal.
Fifth International Consensus Conference: current status of sleeve gastrectomy.
Surg Obes Relat Dis, 12 (2016), pp. 750-756
R. Sanchez Santos, R. Corcelles, R. Vilallonga Puy, S. Delgado Rivilla, J.V. Ferrer, J. Foncillas Corvinos, et al.
Prognostic factors of weight loss after sleeve gastrectomy: multi centre study in Spain and Portugal.
L. Angrisani.
The year of the sleeve supremacy.
Obes Surg, 27 (2017), pp. 1626-1627
J.M. Balibrea, R. Vilallonga, M. Hidalgo, A. Ciudin, Ó. González, E. Caubet, et al.
Mid-term results and responsiveness predictors after two-step single-anastomosis duodeno-ileal bypass with sleeve gastrectomy.
Obes Surg, 27 (2017), pp. 1302-1308
R. Peterli, B.K. Wölnerhanssen, D. Vetter, P. Nett, M. Gass, Y. Borbély, et al.
Laparoscopic sleeve gastrectomy versus roux-y-gastric bypass for morbid obesity-3-year outcomes of the prospective randomized Swiss multicenter bypass or sleeve study (SM-BOSS).
Ann Surg, 265 (2017), pp. 466-473
Ž Juodeikis, G. Brimas.
Long-term results after sleeve gastrectomy: A systematic review.
Surg Obes Relat Dis, 13 (2017), pp. 693-699
P.R. Schauer, D.L. Bhatt, J.P. Kirwan, K. Wolski, A. Aminian, S.A. Brethauer, et al.
STAMPEDE investigators. Bariatric surgery versus intensive medical therapy for diabetes-5-Year Outcomes.
N Engl J Med, 376 (2017), pp. 641-651
S.H. Emile, H. Elfeki, K. Elalfy, E. Abdallah.
Laparoscopic sleeve gastrectomy then and now: an updated systematic review of the progress and short-term outcomes over the last 5 years.
Surg Laparosc Endosc Percutan Tech, 27 (2017), pp. 307-317
H. Bernstine, R. Tzioni-Yehoshua, D. Groshar, N. Beglaibter, S. Shikora, R.J. Rosenthal, et al.
Gastric emptying is not affected by sleeve gastrectomy—scintigraphic evaluation of gastric emptying after sleeve gastrectomy without removal of the gastric antrum.
Obes Surg, 19 (2009), pp. 293-298
M. Vives, A. Molina, M. Danús, E. Rebenaque, S. Blanco, M. París, et al.
Analysis of gastric physiology after laparoscopic sleeve gastrectomy (LSG) with or without antral preservation in relation to metabolic response: a randomised study.
Obes Surg, 27 (2017), pp. 2836-2844
F. Sabench, A. Molina, M. Vives, E. Raga, S. Blanco, F. Buils, et al.
Weight loss analysis according to different formulas after sleeve gastrectomy with or without antral preservation: a randomised study.
Obes Surg, 27 (2017), pp. 1254-1260
A.M. Ramos-Leví, A. Sánchez-Pernaute, C. Marcuello, M. Galindo, A.L. Calle-Pascual, A.J. Torres, et al.
Glucose variability after bariatric surgery: is prediction of diabetes remission possible?.
Obes Surg, 27 (2017), pp. 3341-3343
I. Kasacka, M. Arciszewski, I. Janiuk, W. Lebkowski.
Comparative evaluation of gastric ghrelin cells and levels of hormone in the serum of healthy women and men.
J Biol Regul Homeost Agents, 27 (2013), pp. 69-78
Y. Mandeville, R. Van Looveren, P.J. Vancoillie, X. Verbeke, K. Vandendriessche, P. Vuylsteke, et al.
Moderating the enthusiasm of sleeve gastrectomy: up to fifty percent of reflux symptoms after ten years in a consecutive series of one hundred laparoscopic sleeve gastrectomies.
Obes Surg, 27 (2017), pp. 1797-1803
J.E. Oor, D.J. Roks, Ç. Ünlü, E.J. Hazebroek.
Laparoscopic sleeve gastrectomy and gastroesophageal reflux disease: a systematic review and meta-analysis.
Am J Surg, 211 (2016), pp. 250-267
R. Sánchez-Santos, R. Corcelles Codina, R. Vilallonga Puy, S. Delgado Rivilla, J.V. Ferrer Valls, J. Foncillas Corvinos, et al.
Prognostic factors for morbimortality in sleeve gastrectomy the importance of the learning curve. A Spanish-Portuguese Multicenter Study.
Obes Surg, 26 (2016), pp. 2829-2836

Please cite this article as: del Castillo Déjardin D, Sabench Pereferrer F. Gastrectomía vertical: globalización y sus controversias. Cir Esp. 2018;96:393–394.

Copyright © 2018. AEC
Article options
es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos

es en pt
Política de cookies Cookies policy Política de cookies
Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el análisis de sus hábitos de navegación. Si continua navegando, consideramos que acepta su uso. Puede cambiar la configuración u obtener más información aquí. To improve our services and products, we use "cookies" (own or third parties authorized) to show advertising related to client preferences through the analyses of navigation customer behavior. Continuing navigation will be considered as acceptance of this use. You can change the settings or obtain more information by clicking here. Utilizamos cookies próprios e de terceiros para melhorar nossos serviços e mostrar publicidade relacionada às suas preferências, analisando seus hábitos de navegação. Se continuar a navegar, consideramos que aceita o seu uso. Você pode alterar a configuração ou obter mais informações aqui.