Obesity Surgery

, Volume 20, Issue 10, pp 1448–1455 | Cite as

Morbid Obesity and Sleeve Gastrectomy: How Does It Work?

  • Joanna Papailiou
  • Konstantinos Albanopoulos
  • Konstantinos G. Toutouzas
  • Christos Tsigris
  • Nikolaos Nikiteas
  • George Zografos


Laparoscopic sleeve gastrectomy is known to be a safe and effective procedure for treating morbid obesity and is performed with increasing frequency both in Europe and the USA. Despite its broad use, many questions about the remaining gastric tube diameter, its long-term efficacy, its effects on gastric emptying, and the hormones involved still remain to be answered. In order to use such a relatively new surgical procedure wisely, it is essential for every surgeon and physician to understand how sleeve gastrectomy acts in obesity and what its potential benefits on the patients’ metabolism are. This review focuses on the most important pathophysiologic questions referred to sleeve gastrectomy on the literature so far, in an attempt to evaluate the different issues still pending on the subject.


Obesity Bariatric surgery Metabolic surgery Sleeve gastrectomy Ghrelin GLP-1 Gastric emptying 


  1. 1.
    Clinical Issues Committee of the American Society for Metabolic and Bariatric Surgery. Position statement: sleeve gastrectomy as a bariatric procedure. Surg Obes Rel Dis. 2007;3:573–6.CrossRefGoogle Scholar
  2. 2.
    Deitel M, Crosby R, Gagner M. The first international consensus summit for sleeve gastrectomy (SG), New York City, October 25–27, 2007. Obes Surg. 2008;18:487–96.CrossRefPubMedGoogle Scholar
  3. 3.
    Mognol P, Chosidow D, Marmuse J. Laparoscopic sleeve gastrectomy as an initial bariatric operation for high-risk patients: initial results in 10 patients. Obes Surg. 2005;15:1030–3.CrossRefPubMedGoogle Scholar
  4. 4.
    Lee CM, Cirangle PT, Jossart GH. Vertical gastrectomy for morbid obesity in 216 patients: report of two-year results. Surg Endosc. 2007;21:1810–6.CrossRefPubMedGoogle Scholar
  5. 5.
    Himpens J, Dapri G, Cadiere G. A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: results after 1 and 3 years. Obes Surg. 2006;16:1450–6.CrossRefPubMedGoogle Scholar
  6. 6.
    Han MS, Kim WW, Oh JH. Results of laparoscopic sleeve gastrectomy (LSG) at 1 year in morbidly obese Korean patients. Obes Surg. 2005;15:1469–75.CrossRefGoogle Scholar
  7. 7.
    Moy J, Pomp A, Dakin A, et al. Laparoscopic sleeve gastrectomy for morbid obesity. Am J Surg. 2008;196:e56–9.CrossRefPubMedGoogle Scholar
  8. 8.
    Akkary E, Duffy A, Bell R. Deciphering the sleeve: technique, indications, efficacy, and safety of sleeve gastrectomy. Obes Surg. 2008;18:1323–9.CrossRefPubMedGoogle Scholar
  9. 9.
    Frezza E. Laparoscopic vertical sleeve gastrectomy for morbid obesity: the future procedure of choice? Surg Today. 2007;37:275–81.CrossRefPubMedGoogle Scholar
  10. 10.
    Langer F, Bohdjalian A, Felberbauer F, et al. Does gastric dilatation limit the success of sleeve gastrectomy as a sole operation for morbid obesity? Obes Surg. 2006;16:166–71.CrossRefPubMedGoogle Scholar
  11. 11.
    Roa PE, Kaidar-Person O, Pinto D, et al. Laparoscopic sleeve gastrectomy as treatment for morbid obesity: technique and short-term outcomes. Obes Surg. 2006;16:1323–6.CrossRefPubMedGoogle Scholar
  12. 12.
    Milone L, Strong V, Gagner M. Laparoscopic sleeve gastrectomy is superior to endoscopic intragastric balloon as a first stage procedure for super-obese patients (BMI ≥ 50). Obes Surg. 2005;15:612–7.CrossRefPubMedGoogle Scholar
  13. 13.
    Perikh M, Gagner M, Heacock L. Laparoscopic sleeve gastrectomy: does bougie size affect mean %EWL? Short-term outcomes. Surg Obes Rel Dis. 2008;4:528–33.CrossRefGoogle Scholar
  14. 14.
    Jacobs M, Bisland W, Gomez E, et al. Laparoscopic sleeve gastrectomy: a retrospective review of 1- and 2- years results. Surg Endosc. 2010;24:781–85. doi:10.1007/s00464-009-0619-8.CrossRefPubMedGoogle Scholar
  15. 15.
    Frezza EE, Chiriva-Internati M, Wachtel MS. Analysis of the results of sleeve gastrectomy for morbid obesity and the role of ghrelin. Surg Today. 2008;38:481–3.CrossRefPubMedGoogle Scholar
  16. 16.
    Weiner RA, Weiner S, Pomhoff I, et al. Laparoscopic sleeve gastrectomy—influence of sleeve size and resected gastric volume. Obes Surg. 2007;17:1297–305.CrossRefPubMedGoogle Scholar
  17. 17.
    Baltasar A, Serra C, Perez N, et al. Laparoscopic sleeve gastrectomy: a multi-purpose bariatric operation. Obes Surg. 2005;15:1124–8.CrossRefPubMedGoogle Scholar
  18. 18.
    Yehoshua RT, Eidelman LA, Stein M, et al. Laparoscopic sleeve gastrectomy—volume and pressure assessment. Obes Surg. 2008;18:1083–8.CrossRefPubMedGoogle Scholar
  19. 19.
    Schwartz GJ, McHugh PR, Moran TH. Gastric loads and cholecystokinin synergistically stimulate rat gastric vagal afferents. Am J Physiol. 1993;265:R872–6.PubMedGoogle Scholar
  20. 20.
    Piessevaux H, Coulie B, Caenepeel P, et al. Role of impaired gastric accommodation to a meal in functional dyspepsia. Gastroenterology. 1998;115:1346–52.CrossRefPubMedGoogle Scholar
  21. 21.
    Gagner M, Deitel M, Kalberer TL, et al. Symposium review: the second international consensus summit for sleeve gastrectomy, March 19–21, 2009. Surg Obes Rel Dis. 2009;5:476–85.CrossRefGoogle Scholar
  22. 22.
    Gagner M, Rogula T. Laparoscopic reoperative sleeve gastrectomy for poor weight loss after biliopancreatic diversion with duodenal switch. Obes Surg. 2003;13:649–54.CrossRefPubMedGoogle Scholar
  23. 23.
    Keidar A, Appelbaum L, Schweiger C, et al. Dilated upper sleeve can be associated with severe postoperative gastroesophageal dysmotility and reflux. Obes Surg. 2010;20:140–7.CrossRefPubMedGoogle Scholar
  24. 24.
    Dapri G, Cadiere G, Himpens J. Laparoscopic seromyotomy for long stenosis after sleeve gastrectomy with or without duodenal switch. Obes Surg. 2009;19:495–9.CrossRefPubMedGoogle Scholar
  25. 25.
    Baltasar A, Serra C, Pérez N, et al. Re-sleeve gastrectomy. Obes Surg. 2006;16:1535–8.CrossRefPubMedGoogle Scholar
  26. 26.
    Greenstein AJ, Vine AJ, Jacob BP. When sleeve gastrectomy fails: adding a laparoscopic adjustable gastric band to increase restriction. Surg Endosc. 2009;23:884.CrossRefPubMedGoogle Scholar
  27. 27.
    Miguel GP, Azevedo JL, Gicovate Neto C, et al. Glucose homeostasis and weight loss in morbidly obese patients undergoing banded sleeve gastrectomy: a prospective clinical study. Clinics (Sao Paulo). 2009;64:1093–8.Google Scholar
  28. 28.
    le Roux CW, Aylwin SJ, Batterham RL, et al. Gut hormone profiles following bariatric surgery favor an anorectic state, facilitate weight loss, and improve metabolic parameters. Ann Surg. 2006;243:108–14.CrossRefPubMedGoogle Scholar
  29. 29.
    Schwartz MW, Woods SC, Porte D Jr, et al. Central nervous system control of food intake. Nature. 2000;404:661–71.PubMedGoogle Scholar
  30. 30.
    Wren AM, Seal LJ, Cohen MA, et al. Ghrelin enhances appetite and increases food intake in humans. J Clin Endocrinol Metab. 2001;86:5992–5.CrossRefPubMedGoogle Scholar
  31. 31.
    Nagaya N, Kojima M, Uematsu M, et al. Hemodynamic and hormonal effects of human ghrelin in healthy volunteers. Am J Physiol Regul Integr Comp Physiol. 2001;280:R1483–7.PubMedGoogle Scholar
  32. 32.
    Horvath TL, Diano S, Sotonyi P, et al. Ghrelin and the regulation of energy balance: a hypothalamic perspective. Endocrinology. 2001;142:4163–9.CrossRefPubMedGoogle Scholar
  33. 33.
    Hansen TK, Dall R, Hosoda H, et al. Weight loss increases circulating levels of ghrelin in human obesity. Clin Endocrinol (Oxf). 2002;56:203–6.CrossRefGoogle Scholar
  34. 34.
    Tolle V, Kadem M, Bluet-Pajot MT, et al. Balance in ghrelin and leptin plasma levels in anorexia nervosa patients and constitutionally thin women. J Clin Endocrinol Metab. 2003;88:109–16.CrossRefPubMedGoogle Scholar
  35. 35.
    Shimizu Y, Nagaya N, Isobe T, et al. Increased plasma ghrelin level in lung cancer cachexia. Clin Cancer Res. 2003;9:774–8.PubMedGoogle Scholar
  36. 36.
    Date Y, Murakami N, Toshinai K, et al. The role of the gastric afferent vagal nerve in ghrelin-induced feeding and growth hormone secretion in rats. Gastroenterology. 2002;123:1120–8.CrossRefPubMedGoogle Scholar
  37. 37.
    Nakazato M, Murakami N, Date Y, et al. A role for ghrelin in the central regulation of feeding. Nature. 2001;409:194–8.CrossRefPubMedGoogle Scholar
  38. 38.
    Cummings DE, Purnell JQ, Frayo RS, et al. A preprandial rise in plasma ghrelin levels suggests a role in meal initiation in humans. Diabetes. 2001;50:1714–9.CrossRefPubMedGoogle Scholar
  39. 39.
    Tschöp M, Smiley DL, Heiman ML. Ghrelin induces adiposity in rodents. Nature. 2000;407:908–13.CrossRefPubMedGoogle Scholar
  40. 40.
    Asakawa A, Inui A, Kaga T, et al. Ghrelin is an appetite stimulatory signal from stomach with structural resemblance to motilin. Gastroenterology. 2001;120:337–45.CrossRefPubMedGoogle Scholar
  41. 41.
    Masuda Y, Tanaka T, Inomata N, et al. Ghrelin stimulates gastric acid secretion and motility in rats. Biochem Biophys Res Commun. 2000;276:905–8.CrossRefPubMedGoogle Scholar
  42. 42.
    Wren AM, Small CJ, Ward HL, et al. The novel hypothalamic peptide ghrelin stimulates food intake and GH secretion. Endocrinology. 2000;141:4325–8.CrossRefPubMedGoogle Scholar
  43. 43.
    Pardina E, Lopez-Tejero MD, Llamas R, et al. Ghrelin and apolipoprotein AIV levels show opposite trends to leptin levels during weight loss in morbidly obese patients. Obes Surg. 2009;19:1414–23.CrossRefPubMedGoogle Scholar
  44. 44.
    Lin E, Gletsu N, Fugate K, et al. Ghrelin levels in the morbidly obese. Arch Surg. 2004;139:780–4.CrossRefPubMedGoogle Scholar
  45. 45.
    Tschöp M, Viswanath D, Weyer C, et al. Circulating ghrelin levels are decreased in human obesity. Diabetes. 2001;50:707–9.CrossRefPubMedGoogle Scholar
  46. 46.
    Shiiya T, Nakazato M, Mizuta M, et al. Plasma ghrelin levels in lean and obese humans and the effect of glucose on ghrelin secretion. J Clin Endocrinol Metab. 2002;87:240–4.CrossRefPubMedGoogle Scholar
  47. 47.
    van Dielen FM, van't Veer C, Buurman WA, et al. Leptin and soluble leptin receptor levels in obese and weight-losing individuals. J Clin Endocrinol Metab. 2002;87:1708–16.CrossRefPubMedGoogle Scholar
  48. 48.
    Ybarra J, Bobbioni-Harsch E, Chassot G, et al. Persistent correlation of ghrelin plasma levels with body mass index both in stable weight conditions and during gastric-bypass-induced weight loss. Obes Surg. 2009;19:327–31.CrossRefPubMedGoogle Scholar
  49. 49.
    Ariyasu H, Takaya K, Tagami T, et al. Stomach is a major source of circulating ghrelin, and feeding state determines plasma ghrelin-like immunoreactivity levels in humans. J Clin Endocrinol Metab. 2001;86:4753–8.CrossRefPubMedGoogle Scholar
  50. 50.
    Moller N, Nygren J, Hansen TK, et al. Splachnic release of ghrelin in humans. J Clin Endocrinol Metab. 2003;88:850–2.CrossRefPubMedGoogle Scholar
  51. 51.
    Lee HM, Wang G, Englander EW, et al. Ghrelin, a new gastrointestinal endocrine peptide that stimulates insulin secretion: enteric distribution, ontogeny, influence of endocrine, and dietary manipulations. Endocrinology. 2002;143:185–90.CrossRefPubMedGoogle Scholar
  52. 52.
    Cummings DE, Weigle DS, Frayo RS, et al. Plasma ghrelin levels after diet induced weight loss or gastric bypass surgery. N Engl J Med. 2002;346:1623–30.CrossRefPubMedGoogle Scholar
  53. 53.
    Langer F, Reza Hoda M, Bohdjalian A, et al. Sleeve gastrectomy and gastric banding: effects on plasma ghrelin levels. Obes Surg. 2005;15:1024–9.CrossRefPubMedGoogle Scholar
  54. 54.
    Wang Y, Liu J. Plasma ghrelin modulation in gastric band operation and sleeve gastrectomy. Obes Surg. 2009;19:357–62.CrossRefPubMedGoogle Scholar
  55. 55.
    Adami GF, Cordera R, Marinari G, et al. Plasma ghrelin concentration in the short-term following biliopancreatic diversion. Obes Surg. 2003;13:889–92.CrossRefPubMedGoogle Scholar
  56. 56.
    Karamanakos SN, Vagenas K, Kalfarentzos F, et al. Weight loss, appetite suppression, and changes in fasting and postprandial ghrelin and peptide-YY levels after Roux-en-Y gastric bypass and sleeve gastrectomy: a prospective, double blind study. Ann Surg. 2008;247:401–7.CrossRefPubMedGoogle Scholar
  57. 57.
    Hyland NP, Pittman QJ, Sharkey KA. Peptide YY containing enteroendocrine cells and peripheral tissue sensitivity to PYY and PYY(3-36) are maintained in diet-induced and diet-resistant rats. Peptides. 2007;28:1185–90.CrossRefPubMedGoogle Scholar
  58. 58.
    Wapnir RA, Teichberg S. Regulation mechanisms of intestinal secretion: implications in nutrient absorption. J Nutr Biochem. 2002;13:190–9.CrossRefPubMedGoogle Scholar
  59. 59.
    Koda S, Date Y, Murakami N, et al. The role of the vagal nerve in peripheral PYY 3-36-induced feeding reduction in rats. Endocrinology. 2005;146:2369–75.CrossRefPubMedGoogle Scholar
  60. 60.
    Batterham RL, Cohen MA, Ellis SM, et al. Inhibition of food intake in obese subjects by peptide YY(3-36). N Engl J Med. 2003;349:941–8.CrossRefPubMedGoogle Scholar
  61. 61.
    Spiller RC. Effects of serotonin on intestinal secretion and motility. Curr Opin Gastrenterol. 2001;17:99–103.CrossRefGoogle Scholar
  62. 62.
    Boey D, Heilbronn L, Sainsbury A, et al. Low serum PYY is linked to insulin resistance in first-degree relatives of subjects with type 2 diabetes. Neuropeptides. 2006;40:317–24.CrossRefPubMedGoogle Scholar
  63. 63.
    Jackson PJ, Douglas NR, Chai B, et al. Structural and molecular evolutionary analysis of agouti and agouti-related proteins. Chem Biol. 2006;13:1297–305.CrossRefPubMedGoogle Scholar
  64. 64.
    Cone RD. Anatomy and regulation of the central melanocortin system. Nat Neurosci. 2005;8:571–8.CrossRefPubMedGoogle Scholar
  65. 65.
    Banks WA, Kastin AJ, Huang W, et al. Leptin enters the brain by a saturable system independent of insulin. Peptides. 1996;17:305–11.CrossRefPubMedGoogle Scholar
  66. 66.
    Kotidis E, Koliakos G, Baltzopoulos V, et al. Serum ghrelin, leptin and adiponectin levels before and after weight loss: comparison of three methods of treatment—a prospective study. Obes Surg. 2006;16:1425–32.CrossRefPubMedGoogle Scholar
  67. 67.
    Kohno D, Nakata M, Maekawa F, et al. Leptin suppresses ghrelin-induced activation of neuropeptide Y neurons in the arcuate nucleus via phosphatidylinositol 3-kinase- and phosphodiesterase 3-mediated pathway. Endocrinology. 2007;148:2251–63.CrossRefPubMedGoogle Scholar
  68. 68.
    Wickremesekera K, Miller G, Naotunne TD, et al. Loss of insulin resistance after Roux-en-Y gastric bypass surgery: a time course study. Obes Surg. 2005;15:474–81.CrossRefPubMedGoogle Scholar
  69. 69.
    Ballantyne GH, Farkas D, Laker S, et al. Short-term changes in insulin resistance following weight loss surgery for morbid obesity: laparoscopic adjustable gastric banding versus laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2006;16:1189–97.CrossRefPubMedGoogle Scholar
  70. 70.
    Adami GF, Cordera R, Camerini G, et al. Recovery of insulin sensitivity in obese patients at short term after biliopancreatic diversion. J Surg Res. 2003;113:217–21.CrossRefPubMedGoogle Scholar
  71. 71.
    Sarson DL, Scopinaro N, Bloom SR. Gut hormone changes after jejunoileal (JIB) or biliopancreatic (BPB) bypass surgery for morbid obesity. Int J Obes. 1981;5:471–80.PubMedGoogle Scholar
  72. 72.
    Vidal J, Ibarzabal A, Romero F, et al. Type 2 diabetes mellitus and the metabolic syndrome following sleeve gastrectomy in severely obese subjects. Obes Surg. 2008;18:1077–82.CrossRefPubMedGoogle Scholar
  73. 73.
    Silecchia G, Boru C, Pecchia A, et al. Effectiveness of laparoscopic sleeve gastrectomy (first stage of biliopancreatic diversion with duodenal switch) on co-morbidities in super-obese high-risk patients. Obes Surg. 2006;16:1138–44.CrossRefPubMedGoogle Scholar
  74. 74.
    Rizzello M, Abbatini F, Casella G, et al. Early postoperative insulin-resistance changes after sleeve gastrectomy. Obes Surg. 2010;20:50–5.CrossRefPubMedGoogle Scholar
  75. 75.
    Yada T, Dezaki K, Sone H, et al. Ghrelin regulates insulin release and glycemia: physiological role and therapeutic potential. Curr Diabetes Rev. 2008;4:18–23.CrossRefPubMedGoogle Scholar
  76. 76.
    Bergmann JF, Chassany O, Petit A, et al. Correlation between echographic gastric emptying and appetite: influence of psyllium. Gut. 1992;33:1042–3.CrossRefPubMedGoogle Scholar
  77. 77.
    Verdich C, Madsen JL, Toubro S, et al. Effect of obesity and major weight reduction on gastric emptying. Int J Obes. 2000;24:899–905.CrossRefGoogle Scholar
  78. 78.
    Mason EE. Gastric emptying controls type 2 diabetes mellitus. Obes Surg. 2006;17:853–5.CrossRefGoogle Scholar
  79. 79.
    Naslund E, Backman L, Holst H, et al. Importance of small bowel peptides for improved glucose metabolism 20 years after jejunoileal bypass for obesity. Obes Surg. 1998;8:253–60.CrossRefPubMedGoogle Scholar
  80. 80.
    Flatt PR, Green BD. Nutrient regulation of pancreatic β-cell function in diabetes: problems and potentional solutions. Biochem Soc Trans. 2006;34:774–8.CrossRefPubMedGoogle Scholar
  81. 81.
    Flint A, Raben A, Astrup A, et al. Glucagon-like peptide 1 promotes satiety and suppresses energy intake in humans. J Clin Invest. 1998;101:515–20.CrossRefPubMedGoogle Scholar
  82. 82.
    Pereferrer FS, Gonzàlez MH, Rovira AF, et al. Influence of sleeve gastrectomy on several experimental models of obesity: metabolic and hormonal implications. Obes Surg. 2008;18:97–108.CrossRefPubMedGoogle Scholar
  83. 83.
    Melissas J, Koukouraki S, Askoxylakis J, et al. Sleeve gastrectomy: a restrictive procedure? Obes Surg. 2007;17:57–62.CrossRefPubMedGoogle Scholar
  84. 84.
    Bernstine H, Tzioni-Yehoshua R, Groshar D, 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. 2009;19:293–8.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science + Business Media, LLC 2010

Authors and Affiliations

  • Joanna Papailiou
    • 1
  • Konstantinos Albanopoulos
    • 1
  • Konstantinos G. Toutouzas
    • 1
  • Christos Tsigris
    • 2
  • Nikolaos Nikiteas
    • 3
  • George Zografos
    • 1
  1. 1.1st Department of Propaedeutic Surgery, Hippocration HospitalAthens Medical SchoolAthensGreece
  2. 2.1st Department of Surgery, Laikon HospitalAthens Medical SchoolGoudi, AthensGreece
  3. 3.2nd Department of Surgery, Laikon HospitalAthens Medical SchoolGoudi, AthensGreece

Personalised recommendations