Outcome of sleeve gastrectomy as a primary bariatric procedure (Br J Surg 2014; 101: 661–668)

For almost six decades now, surgeons have been trying to fool Mother Nature by changing the gastrointestinal anatomy either to decrease absorption or to increase 'satiety'.This paper addresses an impressively large series of the newest primary bariatric procedure: the vertical sleeve gastrectomy (VSG).Attention should be paid to this study, because it serves as an example of how one should evaluate prospectively a new procedure (VSG is a new primary bariatric procedure).Other than the incredibly well marketed, but questionably effective or durable, laparoscopic adjustable gastric band, VSG probably affects normal physiology less than any other currently accepted standard bariatric procedures such as Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion-duodenal switch (BPD-DS), as it involves no anastomosis, no anatomical bypass and no malabsorption.Indeed, VSG preserves the gastroduodenal flow of ingested nutrients, which should allow for normal iron and calcium absorption as well as maintenance of the enteroinsular axis.In addition, VSG may offer the advantage of removing the source of the proappetite (or orexigenic) hormone ghrelin, combined with a type of 'restriction' not present after total gastrectomy (the still innervated, remnant gastric sleeve -is there a satiety signal from the small gastric remnant?).These putative aspects of VSG appear to be major advantages of VSG, but, as history has taught us, strategically 'designed' bariatric operations -jejunoileal bypass, stapling (banded) gastroplasties and, most recently, gastric bandings -often have unanticipated consequences secondary to lack of insight into mechanisms of appetite, satiety and absorptive physiology.So, what is the exact status of VSG?It is still unclear how this bariatric operation works: orexigenic hormonal disruption, neurally mediated restrictive physiological effects on appetite or satiety, or some other mechanism?Does the sleeve dilate and thereby 'dilute' the desired 'restrictive pathophysiology'?Does weight regain occur, as after RYGB?What about the development of gastro-oesophageal reflux?Is ghrelin secretion restored over time as the stomach adapts?Will VSG replace RYGB and BPD-DS as the first-line bariatric operation because of its lesser morbidity?Only time will tell and, therefore, long-term studies are needed.With a 4-year follow-up of 62 patients and 5-year follow-up of only 19 patients, the Eindhoven group is not quite there yet, but this group can do it.They should be encouraged -and they should be congratulated on their approach and diligence.