I have frequently been asking what staples are used in sleeve gastrectomy. A stapling device is used with sleeve gastrectomy. This device comes in different shapes and sizes for different bowel thicknesses and applications. However, they all function the same way. The staple cartridges (the part of the stapler that is replaced after each use with a new one) are selected based on the thickness of the segment of the bowel that needs to be stapled and divided.

The stapling and dividing take place simultaneously. The sampler deploys six rows of staples and cuts between them, leaving three rows on one side and three on the opposite side. With the sleeve gastrectomy, this means that the sleeve stomach that is left has three rows of staples, and the segment of the stomach that is removed also has three rows of staples.

Questions that are frequently asked:

1-Can I have a CT or an MRI done? Yes, The titanium staples are safe for both CT and MRI.

2-What are they made from? The staples are made of titanium and alloys, which are non-reactive and safe.

3-How big are the staples? Different staples are of different sizes, mainly in the mm range; see the tip of the pencil in the image for the relative size.

Video of stapler demonstation here

There are no known contraindications from a weight-loss surgical perspective to prevent a post-surgical patient from getting the COVID vaccines.

A patient who has had a Duodenal Switch, Lap Sleeve Gastrectomy, RNY Gastric Bypass, or revisions to Weight Loss Surgery should have the COVID vaccine. The vaccination should be avoided for a few weeks after surgery. For other possible contraindications, please consult your PCP.

Here is a summary of the vaccines and the details of each one approved as of the publication date.

Protein intake requirements change over time following weight loss surgery. This is based on the requirements imposed on our body by a number of variables. These include, activity level, muscle mass, over all health condition to name a few.

A very young muscular athletic male with a BMI or 30 will require much higher protein intake (and absorption) that an inactive older Female with the same BMI. The same young athletic male will require much higher protein intake is he is recovering from a surgery than his baseline.

As we have stated in the past, the protein intake, should be adequate and not excessive. High level of protein intake that are not accounted  for based on muscle mass and activity level, will eventually result in weight gain. The best measure of protein intake in a stable weight patient over 3-4 years post op  is their albumin and protein level. Following your yearly laboratory values at a minimum is an important part of weight loss surgery follow up care.

You also need to adjust protein intake when necessary. Protein needs increase depending on physical needs, infection, healing, pregnancy, surgery, age, injury, etc. Plastic surgery requires higher protein needs for appropriate healing.

Information on protein sources and quality here.

The basic formula for protein intake is 1gm/kg of ideal body weight. The calculator below will provide a guide for the protein into based on your stable weight in lbs.

Recently there has been some research and concern regarding sunscreen and the chemicals within them. This has led to findings that can be concerning but that need further research.

Post weight loss surgical patients, and in general patients who suffer with obesity, before or after weight loss surgery, have low vitamin D level. This may be caused by a number of factors. One such factor may be the reluctance to get skin exposed to sunlight in order for the bodies natural Vitamin D pathways functioning.

The recommendations are for daily exposure to sun. This not only is critical to the vitamin D metabolic pathways, but also help with bone health, immune function, mood, counteracting depression.

In a recently published online article, concerns were raised that some of the ingredients of some of few sunscreens are absorbed in the blood stream. This is a small study, and as the results indicates, it is not recommending to stop using the sun screens. Be aware of your sun exposure, timing exposure, and the ingredients in your sunscreen.

You can find past blog posts on Vitamin D, Bone health, etc here

Question : “Do I have to take higher dose of thyroid medication after the duodenal switch? ”

Answer : “Maybe”

With all weight loss surgical procedures, there may be changes to absorption of medications. It is easily understood why duodenal switch may results in decreased absorption of fat-soluble medication. What is not as clear is the reduction in absorption of other medication with procedures that do not explicitly change the absorption at the level of the small bowel directly.

The research data is all over on this topic. There is published literature that shows improvement in the thyroid function after gastric bypass and the sleeve gastrectomy.  However, the exact mechanism is not completely understood.

There is research that reports “…decreased postoperative levothyroxine requirements.” Other have shows no correlation between the length of the bowel distal to duodenum to absorption of thyroid medication.

With all this confusing data, the best course would be to always “treat the patient and not the lab results.”

If a patients who has been on medications with stable number and symptoms,  suddenly presents with complaints of hypothyroidism after weight loss surgery, it’s possible the medications should be up adjusted even if the thyroid lab values may not be as defining.

Sleeve gastrectomy (SG) is the most commons performed weight loss surgery in the US. There is a subset of patients for which Sleeve Gastrectomy will be inefficient/ineffective. Sleeve Gastrectomy failure may be defined as inadequate weight loss or weight regain. However, in some cases this may also include non resolution of some of the co-morbidities of obesity, and/or recurrence of others. 

Biertho, et. al, (Surgery for Obesity and Related Diseases 14 (2018) 1570–1580) Published a study titled “Second-stage duodenal switch for sleeve gastrectomy failure: A matched controlled trial” where 118 patients were decided in two groups. One group had the duodenal switch as a singe procedure, and the second group had the sleeve gastrectomy followup by the second stage duodenal switch. They concluded that “Second-stage DS is an effective option for the management of suboptimal outcomes of SG, with an additional 41% excess weight loss and 35% remission rate for type 2 diabetes. At 3 years, the global outcomes of staged approach did not significantly differ from single-stage BPD-DS; however, longer-term outcomes are still needed.”

They showed that the remission rate of the obesity-related co-morbidities was improved.

The weight loss rate that had stopped, or in some cases where weight gain had been noted, were both reversed where by at at average of 24 months after addition of the DS to the SG patients would experience additional 39% Mean excess weight loss.  

With regards to alternative approaches they indicate “ Other forms of revisions have been described, (i.e., adjustable or nonadjustable gastric band, plication, endoscopic balloon), with limited scientific evidence on their efficacy or safety. These procedures are mostly considered investigational and should be performed under Ethical Review Board approved protocols.”

In summary, patients may be offered a number of alternative if they are experiencing weight regain, inadequate weight loss, or return of co-morbidities after sleeve gastrectomy failure. We have seen a variety of them in our office. Patients who have had band placed on the sleeve, or are scheduled to have gastric balloons placed. As I have always said, buyers beware and know your outcomes and resolution of co-morbities.

Duodenal switch operation, (not the single anastomosis look alike) results in sustained weight loss and resolution of the co-morbidities. A second stage Duodenal Switch can mean adding the intestinal procedure to an existing Sleeve Gastrectomy.  Some patients have required an adjustment to their Sleeve Gastrectomy in addition to adding the Duodenal Switch intestinal portion.  Finding the right balance for each patient is a crucial part of our practice.

The American Society for Metabolic and Bariatric Surgery (ASMBS) and MBSAQUIP-A on March of 2019, published and updated list of “Endorsed Procedures and Devices”

Endorsed Procedures and Devices | American Society for Metabolic and Bariatric Surgery

Note that any surgical procedures that does not employ two anastomosis, are not endorsed and are only recommended to be performed with an IRB (Institutional Review Board) or an IRB exemption. Duodenal Switch, Sleeve Gastrectomy, Roux en Y Gastric Bypass, Gastric Balloon, Adjustable Gastric Banding, and Nerve Blocking which are endorsed procedures.

SIPS, SADI-S, SIPS, Loop DS are all in the category of the “Non-Endorsed Procedures and Devices”. To see an anatomical comparison of these procedures to the Duodenal Switch procedure.

Patients should request that their consent be clearly defined and should explicitly outline the procedure that is being proposed to them. This is to avoid a patient having a procedure that they assumed, or are led to believe to be a Duodenal Switch operation with two anastomosis. Do your due diligence and know the procedure you want. Investigate if the surgeon you are working with performs the procedure you are interested in. Have them draw a picture of the procedure or give you a diagram of the procedure.