The advent of the gastric sleeve as an insurance-approved procedure for weight loss surgery took place in early 2010. Garden State Bariatrics has offered the gastric sleeve since its approval in 2010 and considers it one of the newest, best tools out there for long term permanent weight loss.
In this fascinating segment Dr. Basil Yurcisin, discusses the gastric sleeve procedure for weight loss and how it is certainly one of our specialties.
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The Gastric Sleeve
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Learn more about Basil Yurcisin, MD
Basil Yurcisin, MD
Dr. Basil Yurcisin is a bariatric and general surgeon. He trained at one of the world’s top fellowship programs in bariatrics and minimally invasive surgery- Duke University Medical Center. In 2010, Dr. Yurcisin joined Garden State Bariatrics, and became a partner in 2017. He is a Fellow of the American Society for Metabolic and Bariatric Surgery (ASMBS) and a Fellow of the American College of Surgeons (ACS). Not only is he an incredibly talented bariatric surgeon, Dr. Yurcisin is compassionate, funny and dedicated to the lifelong success of his patients.Learn more about Basil Yurcisin, MD
Transcription:
ill Klaproth: What is the gastric sleeve and is it right for you? We’re going to find out as we chat with Dr. Basil Yurcisin. He is a bariatric and general surgeon and a partner at Garden State Bariatrics and Wellness Center.
Let's jump right into this. What is the gastric sleeve? Can you explain that to us?
Dr. Basil Yurcisin: Essentially, we take a stomach and we take a portion of the stomach away surgically and we leave you with a sleeve of stomach left over. A normal human stomach is approximately 32 ounces and we take that stomach down to about a 10-ounce stomach that's the shape of a sleeve and that's what it is. We take a portion of the stomach away and we leave a sleeve-shaped stomach remaining.
Bill: What you do then is you take a portion of the stomach away. Do you take that out?
Dr. Yurcisin: It’s surgically removed. We do the operations traditionally laparoscopically, which means with small or keyhole type incisions, and we are able to remove the portion of the stomach that we've taken off the stomach out of the abdomen through one of the larger of those incisions.
Bill: That’s amazing. How does that work with a smaller stomach? The person feels full faster so they don’t eat as much?
Dr. Yurcisin: That’s definitely one of the mechanisms by which we believe the sleeve works. There's still some research being done in this field, but a couple of the most excepted mechanisms are what you just outlined – the stomach is smaller so you can't eat as much so you get full quicker so you don’t eat as much. One of the other leading ideas is that there's a hormone that's created in the portion of the stomach that we have removed that's all ghrelin and its considered the ‘big mac attack' hormone. It's the hormone that drives your hunger so you don't think about food as often between meals, and when you do eat, you can't eat as much so you're physically stopped from eating because of a small stomach. There are also some other suggestions with other hormones, GLP-1 and things like that, but it's a little bit more technical, but the first two items that I've mentioned are the most commonly believed reasons for the weight loss after a sleeve gastrectomy.
Bill: We want the big mac attack hormone out.
Dr. Yurcisin: That's exactly right. It helps to slow the hunger drive if you will.
Bill: As I'm thinking about this, the gastric sleeve is less invasive than the gastric bypass, so basically this just involves making a smaller stomach, is that correct?
Dr. Yurcisin: Correct. I’d be very careful about saying it’s less invasive than one of the other operations. You still undergo a general anesthesia, there's still laparoscopic incisions that are made in the abdomen, it’s still usually an admission to a hospital, so less invasive is pretty much a misnomer. They're all pretty minimally invasive, but you are right. We only operate on the stomach when we do a sleeve, whereas when we do a gastric bypass or a duodenal switch, which is another operation, we will operate on both the stomach and the intestines during that operation.
Bill: Let's go a little farther on that. What are the advantages and disadvantages of the sleeve?
Dr. Yurcisin: The advantages are, as you mentioned, it's perceived as being a bit simpler and basically you only operate on the stomach as the target organ versus the stomach and the intestines. There's a little bit less chance of having vitamin and mineral deficiencies afterward as you may have a risk with the gastric bypass or the duodenal switch. You don't have an increased risk of ulceration, which is something that's true of the gastric bypass. You do not have as much of a risk of having things called dumping syndrome where you may feel miserable if you eat carbohydrates after a gastric bypass or sometimes after a duodenal switch, so that's not as prevalent after a gastric sleeve as well as we don't get something called internal herniation, which is a problem that can happen after a gastric bypass. We ovate a lot of those issues that can come up after some of the other bariatric surgeries. As far as drawbacks, one of the biggest potential side effects or complications or morbidities of a sleeve would be heartburn or GERD. Sometimes people who don't have it can get it because of the sleeve, or if you have it, it could be made worse. Another potential drawback or something that may be viewed as a drawback by some people is it's a truly permanent operation. I can't give you back that portion of the stomach that I've removed. It's not like we keep it in a cryochamber somewhere to have it saved for you at a later date, so it is a truly permanent operation. We can't give that part of the stomach back.
Bill: Who's a good candidate for the gastric sleeve?
Dr. Yurcisin: Most patients that would qualify for bariatrics would be a candidate to at least consider a sleeve and it can vary from person to person based on the amount of comorbidities they have. Comorbidities are medical problems that are due to the fact that you're overweight. Some of the main ones would be things like diabetes, high blood pressure, high cholesterol, sleep apnea – the list goes on. The more medical problems you have, the more weight you have to lose. In other words, the heavier you are, the more likely the more aggressive operation like a gastric bypass or the duodenal switch may be better suited for you. That doesn't mean that a gastric sleeve would fail you or fail a person that’s considering those things. It just may not be a member of the armamentarium to try to approach the managing of that person’s obesity as well as their comorbidities. If we put these operations on a scale, the sleeve would be at the lower end of the scale, the bypass somewhere in the middle and the duodenal switch at the top as far as how much weight we can lose and how many medical problems we can get rid of. Usually, one of the tipping point arguments for me is if a patient has diabetes, it starts to push me towards thinking maybe we should be a little more aggressive and consider a bypass or duodenal switch. The sleeve is very good at getting rid of diabetes. It’s just not as good as the others.
Bill: That is great information. You sit down with each of your patients and you go through ‘here's what we can do, here's options, etc.,’ and it’s their choice, but come together on what is right for that patient.
Dr. Yurcisin: I like to look at each patient as Cinderella and I've got a glass slipper in my bag here and I want to try to find the one that fits that person right. One of the most common questions that we get directed towards us is what's the best surgery or which one works the best. It really depends on the individual and the medical problems and the weight that they're trying to get rid of and there are other things that we got to take into account. Sometimes there are patients who want to eventually have a transplant and want to be able to get on the transplant list. Sometimes that changes the operations that we may or may not do for that patient. Sometimes they've had previous surgeries or medical problems that will stop us from being able to do one of the operations or the other. It really depends on the individual to try to determine which is the best operation for them and which is the glass slipper we should put on their foot rather than just saying everybody should get a sleeve or a bypass or a duodenal switch.
Bill: Let's say someone has decided on the gastric sleeve. Can you talk to us about what someone should expect during surgery and recovery?
Dr. Yurcisin: During surgery, they should expect to be asleep and not be aware of anything. The operation usually takes about an hour and it’s usually about one night overnight in the hospital. Usually, when they wake up, they're a bit nauseous and a bit sore that usually gets under control within the first 24-48 hours. They usually go home the next day, probably back to work or back to regular activity within two weeks or so, and then the biggest part is relearning their new stomach. It probably takes a month to a month and a half to really get back to eating in a normal fashion or what they would consider to be a normal fashion. You start with clear liquids in the beginning and you slowly transition to pureed foods and protein shakes and transition to soft things. The last thing we would introduce to the person’s diet if we introduce them at all would be things like pasta, bread, rice, red meat, uncooked or raw vegetables. All those things can be more difficult after the sleeve because the sleeve has physically narrowed the stomach, made it smaller and so processing those items can sometimes be a little bit more difficult in the beginning.
Bill: Recovery long-term. What can someone expect and what about follow up care from Garden State Bariatrics?
Dr. Yurcisin: As far as recovery, usually about a month and a half to three months, somewhere in that ballpark, you're feeling pretty normal and starting to recalibrate your eating habits, your life and you're pretty recovered from the standpoint of the surgery. As far as follow up is concerned, we see the patients for the rest of their lives, but in the beginning, it's more often they come to the office over the course of the first year and they start to come a little less often in the second year, and after that, we see them yearly to make sure we're following the vitamin and mineral levels, making sure there are no new issues that crop up along the way. We're a buddy for life if you will. We got to keep track of our patients, and if a patient of ours moves away or they want to move to Paris, France or wherever, we can find them a bariatric surgeon wherever they're going to help them be managed where they end up.
Bill: That’s great follow up; that care after the surgery is really important. Generally, what kind of results can someone expect with the gastric sleeve?
Dr. Yurcisin: Generally, we can lose about 65% to 70% of the weight that we are overweight, what we call excess body weight. If you take your actual body weight and you subtract from your ideal weight, you'll get your excess body weight. Of that number, you can expect to lose about 65% to 70% of that weight in about two years. Most of that weight, however, comes off in the front end of that weight loss curve and that happens usually within the first six to nine months. You may lose as much as 60% of what you're going to lose in the early time and then it starts to taper, but it continues over the course of the next year. It really matters on how you changed your habits and if you’ve listened to people along the way about what you're supposed to do, following the diet regimen, following the exercise regimen, because that’s at the other end where people could potentially see weight recidivism or weight regain if they're not truly changing their habits. Surgery is merely a tool. The hard part is changing habits that you got you to whatever position you are now over the course of your lifetime and that’s really the most difficult thing a human can do, trying to change an ingrained habit. What we're doing is giving you a tool to make it easier to change that habit and make it easier to be successful when you change that habit so you're not suffering all these setbacks along the way where you're in the gym every day this week, lost two pounds and didn't really see a lot and got frustrated so you regressed for whatever reason. We see more robust results when we apply ourselves, even in a minimal fashion, we apply ourselves maximally and we see a very nice return on our investment. It's really a matter of changing those habits over that time in order to be successful long-term.
Bill: Lifestyle changes afterward really are the key. As you said, the surgery can only do so much. It's really important, those lifestyle changes. Always great to talk to you. Thank you so much for your time. For more information on the gastric sleeve, please visit gsbwc.com. That's gsbwc.com. This is Winning Through Losing, a Weight Loss Surgery podcast with Garden State Bariatrics. I'm Bill Klaproth. Thanks for listening.
ill Klaproth: What is the gastric sleeve and is it right for you? We’re going to find out as we chat with Dr. Basil Yurcisin. He is a bariatric and general surgeon and a partner at Garden State Bariatrics and Wellness Center.
Let's jump right into this. What is the gastric sleeve? Can you explain that to us?
Dr. Basil Yurcisin: Essentially, we take a stomach and we take a portion of the stomach away surgically and we leave you with a sleeve of stomach left over. A normal human stomach is approximately 32 ounces and we take that stomach down to about a 10-ounce stomach that's the shape of a sleeve and that's what it is. We take a portion of the stomach away and we leave a sleeve-shaped stomach remaining.
Bill: What you do then is you take a portion of the stomach away. Do you take that out?
Dr. Yurcisin: It’s surgically removed. We do the operations traditionally laparoscopically, which means with small or keyhole type incisions, and we are able to remove the portion of the stomach that we've taken off the stomach out of the abdomen through one of the larger of those incisions.
Bill: That’s amazing. How does that work with a smaller stomach? The person feels full faster so they don’t eat as much?
Dr. Yurcisin: That’s definitely one of the mechanisms by which we believe the sleeve works. There's still some research being done in this field, but a couple of the most excepted mechanisms are what you just outlined – the stomach is smaller so you can't eat as much so you get full quicker so you don’t eat as much. One of the other leading ideas is that there's a hormone that's created in the portion of the stomach that we have removed that's all ghrelin and its considered the ‘big mac attack' hormone. It's the hormone that drives your hunger so you don't think about food as often between meals, and when you do eat, you can't eat as much so you're physically stopped from eating because of a small stomach. There are also some other suggestions with other hormones, GLP-1 and things like that, but it's a little bit more technical, but the first two items that I've mentioned are the most commonly believed reasons for the weight loss after a sleeve gastrectomy.
Bill: We want the big mac attack hormone out.
Dr. Yurcisin: That's exactly right. It helps to slow the hunger drive if you will.
Bill: As I'm thinking about this, the gastric sleeve is less invasive than the gastric bypass, so basically this just involves making a smaller stomach, is that correct?
Dr. Yurcisin: Correct. I’d be very careful about saying it’s less invasive than one of the other operations. You still undergo a general anesthesia, there's still laparoscopic incisions that are made in the abdomen, it’s still usually an admission to a hospital, so less invasive is pretty much a misnomer. They're all pretty minimally invasive, but you are right. We only operate on the stomach when we do a sleeve, whereas when we do a gastric bypass or a duodenal switch, which is another operation, we will operate on both the stomach and the intestines during that operation.
Bill: Let's go a little farther on that. What are the advantages and disadvantages of the sleeve?
Dr. Yurcisin: The advantages are, as you mentioned, it's perceived as being a bit simpler and basically you only operate on the stomach as the target organ versus the stomach and the intestines. There's a little bit less chance of having vitamin and mineral deficiencies afterward as you may have a risk with the gastric bypass or the duodenal switch. You don't have an increased risk of ulceration, which is something that's true of the gastric bypass. You do not have as much of a risk of having things called dumping syndrome where you may feel miserable if you eat carbohydrates after a gastric bypass or sometimes after a duodenal switch, so that's not as prevalent after a gastric sleeve as well as we don't get something called internal herniation, which is a problem that can happen after a gastric bypass. We ovate a lot of those issues that can come up after some of the other bariatric surgeries. As far as drawbacks, one of the biggest potential side effects or complications or morbidities of a sleeve would be heartburn or GERD. Sometimes people who don't have it can get it because of the sleeve, or if you have it, it could be made worse. Another potential drawback or something that may be viewed as a drawback by some people is it's a truly permanent operation. I can't give you back that portion of the stomach that I've removed. It's not like we keep it in a cryochamber somewhere to have it saved for you at a later date, so it is a truly permanent operation. We can't give that part of the stomach back.
Bill: Who's a good candidate for the gastric sleeve?
Dr. Yurcisin: Most patients that would qualify for bariatrics would be a candidate to at least consider a sleeve and it can vary from person to person based on the amount of comorbidities they have. Comorbidities are medical problems that are due to the fact that you're overweight. Some of the main ones would be things like diabetes, high blood pressure, high cholesterol, sleep apnea – the list goes on. The more medical problems you have, the more weight you have to lose. In other words, the heavier you are, the more likely the more aggressive operation like a gastric bypass or the duodenal switch may be better suited for you. That doesn't mean that a gastric sleeve would fail you or fail a person that’s considering those things. It just may not be a member of the armamentarium to try to approach the managing of that person’s obesity as well as their comorbidities. If we put these operations on a scale, the sleeve would be at the lower end of the scale, the bypass somewhere in the middle and the duodenal switch at the top as far as how much weight we can lose and how many medical problems we can get rid of. Usually, one of the tipping point arguments for me is if a patient has diabetes, it starts to push me towards thinking maybe we should be a little more aggressive and consider a bypass or duodenal switch. The sleeve is very good at getting rid of diabetes. It’s just not as good as the others.
Bill: That is great information. You sit down with each of your patients and you go through ‘here's what we can do, here's options, etc.,’ and it’s their choice, but come together on what is right for that patient.
Dr. Yurcisin: I like to look at each patient as Cinderella and I've got a glass slipper in my bag here and I want to try to find the one that fits that person right. One of the most common questions that we get directed towards us is what's the best surgery or which one works the best. It really depends on the individual and the medical problems and the weight that they're trying to get rid of and there are other things that we got to take into account. Sometimes there are patients who want to eventually have a transplant and want to be able to get on the transplant list. Sometimes that changes the operations that we may or may not do for that patient. Sometimes they've had previous surgeries or medical problems that will stop us from being able to do one of the operations or the other. It really depends on the individual to try to determine which is the best operation for them and which is the glass slipper we should put on their foot rather than just saying everybody should get a sleeve or a bypass or a duodenal switch.
Bill: Let's say someone has decided on the gastric sleeve. Can you talk to us about what someone should expect during surgery and recovery?
Dr. Yurcisin: During surgery, they should expect to be asleep and not be aware of anything. The operation usually takes about an hour and it’s usually about one night overnight in the hospital. Usually, when they wake up, they're a bit nauseous and a bit sore that usually gets under control within the first 24-48 hours. They usually go home the next day, probably back to work or back to regular activity within two weeks or so, and then the biggest part is relearning their new stomach. It probably takes a month to a month and a half to really get back to eating in a normal fashion or what they would consider to be a normal fashion. You start with clear liquids in the beginning and you slowly transition to pureed foods and protein shakes and transition to soft things. The last thing we would introduce to the person’s diet if we introduce them at all would be things like pasta, bread, rice, red meat, uncooked or raw vegetables. All those things can be more difficult after the sleeve because the sleeve has physically narrowed the stomach, made it smaller and so processing those items can sometimes be a little bit more difficult in the beginning.
Bill: Recovery long-term. What can someone expect and what about follow up care from Garden State Bariatrics?
Dr. Yurcisin: As far as recovery, usually about a month and a half to three months, somewhere in that ballpark, you're feeling pretty normal and starting to recalibrate your eating habits, your life and you're pretty recovered from the standpoint of the surgery. As far as follow up is concerned, we see the patients for the rest of their lives, but in the beginning, it's more often they come to the office over the course of the first year and they start to come a little less often in the second year, and after that, we see them yearly to make sure we're following the vitamin and mineral levels, making sure there are no new issues that crop up along the way. We're a buddy for life if you will. We got to keep track of our patients, and if a patient of ours moves away or they want to move to Paris, France or wherever, we can find them a bariatric surgeon wherever they're going to help them be managed where they end up.
Bill: That’s great follow up; that care after the surgery is really important. Generally, what kind of results can someone expect with the gastric sleeve?
Dr. Yurcisin: Generally, we can lose about 65% to 70% of the weight that we are overweight, what we call excess body weight. If you take your actual body weight and you subtract from your ideal weight, you'll get your excess body weight. Of that number, you can expect to lose about 65% to 70% of that weight in about two years. Most of that weight, however, comes off in the front end of that weight loss curve and that happens usually within the first six to nine months. You may lose as much as 60% of what you're going to lose in the early time and then it starts to taper, but it continues over the course of the next year. It really matters on how you changed your habits and if you’ve listened to people along the way about what you're supposed to do, following the diet regimen, following the exercise regimen, because that’s at the other end where people could potentially see weight recidivism or weight regain if they're not truly changing their habits. Surgery is merely a tool. The hard part is changing habits that you got you to whatever position you are now over the course of your lifetime and that’s really the most difficult thing a human can do, trying to change an ingrained habit. What we're doing is giving you a tool to make it easier to change that habit and make it easier to be successful when you change that habit so you're not suffering all these setbacks along the way where you're in the gym every day this week, lost two pounds and didn't really see a lot and got frustrated so you regressed for whatever reason. We see more robust results when we apply ourselves, even in a minimal fashion, we apply ourselves maximally and we see a very nice return on our investment. It's really a matter of changing those habits over that time in order to be successful long-term.
Bill: Lifestyle changes afterward really are the key. As you said, the surgery can only do so much. It's really important, those lifestyle changes. Always great to talk to you. Thank you so much for your time. For more information on the gastric sleeve, please visit gsbwc.com. That's gsbwc.com. This is Winning Through Losing, a Weight Loss Surgery podcast with Garden State Bariatrics. I'm Bill Klaproth. Thanks for listening.