This is a relatively new approach. It is the first component of the duodenal switch operation and involves removing the lateral 2/3rds of the stomach with a stapling device. It can be done laparoscopically ( keyhole surgery) but is not reversible. It basically leaves a stomach tube instead of a stomach sack.Sometimes it is offered to patients as part of a two stage Bypass operation particularly if they are super obese ( BMI>55) because it allows good weight loss until the patient gets down to a safe weight and the more radical bypass can then be offered laparoscopically when they are at a safer weight. The residual stomach capacity is about 200mls so a generous entree should be possible.


Issues with Tube gastrectomy
1. Stomach tube may stretch up over time leading to late weight regain. The extent of this is currently unknown
2. The amount of weight reduction is in the region of 40-60% of excess wt lost over the first 1-2 years.
3. There is no malabsorbtion to nutrients
4. If weight is regained the second stage of Duodenal Switch or Gastric Bypass can be added laparoscopically.


DIETARY INSTRUCTIONS
The Gastric Sleeve Resection operation is often the first step towards intestinal bypass for high cardiopulmonary risk patients. Fortunately a majority of patients do benefit from Sleeve Resection alone.


The following 6 rules are very important eating habits:
1. Only eat small quantities: The capacity of the stomach has changed. Also the amount of food intake has to change. Nevertheless it is not always easy to stop eating at the right time. What do we mean, if we say small quantities? For example one slice of bread for breakfast or 2 potatoes and a small piece of fish for lunch.

2. Chew well and swallow food only completely mashed: You need more time for chewing and also not all food is possible to chew well. The list of "unsuitable food" will show you the products which are usually not easy to chew.

3. Never eat and drink at the same time: The reduced capacity of the stomach will no longer permit to take in both: liquid and food at the same time. The usual amount of beverage, 2-3 litre liquid per day, are desirable. It´s better to drink between or before meals.

4. Do not lay down or rest after eating: because in a horizontal position reflux is more likely. The food also remains longer in the prestomach and leads to a very uncomfortable accumulation of mucus.

5. Eat five times a day: This is important, because if you only eat 2-3 times a day, it is not possible to have a great variety of food. Consequently, as you can only eat small amounts, you do not get enough proteins, minerals and vitamins. In addition, when eating 5 times daily, it is less likely that you are overpowered by sudden hunger attacks where you probably forget the new eating habits.

6. Watch for beverages rich in calories: In our experience, many people take in a lot of their calories with soft drinks, hot chocolate and milk shakes. This is also possible after the operation, so consider this before drinking high calorie liquids. The type of liquid should be varied and include tea or coffee, diluted fruit- or vegetable juice, light drink with artificial sugar, low fat variants of butter milk, mineral water without gas.

You must not take aspirin or any other drug such as non-steroid anti-rheumatic drugs, that may irritate your stomach, without gastric protection. Therefore you must inform your doctor of this advice (gastric mucosal prophylactic)

In recent years, better clinical understanding of procedures combining restrictive and malabsorptive approaches has increased the choices of effective weight loss surgery for thousands of patients. By adding malabsorption, food is delayed in mixing with bile and pancreatic juices that aid in the absorption of nutrients. The result is an early sense of fullness, combined with a sense of satisfaction that reduces the desire to eat.

According to the American Society for Bariatric Surgery and the National Institutes of Health, Roux-en-Y gastric bypass is the current gold standard procedure for weight loss surgery. It is one of the most frequently performed weight loss procedures in the United States. In this procedure, stapling creates a small (15 to 20cc) stomach pouch. The remainder of the stomach is not removed, but is completely stapled shut and divided from the stomach pouch. The outlet from this newly formed pouch empties directly into the lower portion of the jejunum, thus bypassing calorie absorption. This is done by dividing the small intestine just beyond the duodenum for the purpose of bringing it up and constructing a connection with the newly formed stomach pouch. The other end is connected into the side of the Roux limb of the intestine creating the "Y" shape that gives the technique its name. The length of either segment of the intestine can be increased to produce lower or higher levels of malabsorption.


Advantages
* The average excess weight loss after the Roux-en-Y procedure is generally higher in a compliant patient than with purely restrictive procedures.
* One year after surgery, weight loss can average 77% of excess body weight.
* Studies show that after 10 to 14 years, 50-60% of excess body weight loss has been maintained by some patients.
* A 2000 study of 500 patients showed that 96% of certain associated health conditions studied (back pain, sleep apnea, high blood pressure, diabetes and depression) were improved or resolved.


Risks
* Because the duodenum is bypassed, poor absorption of iron and calcium can result in the lowering of total body iron and a predisposition to iron deficiency anemia. This is a particular concern for patients who experience chronic blood loss during excessive menstrual flow or bleeding hemorrhoids. Women, already at risk for osteoporosis that can occur after menopause, should be aware of the potential for heightened bone calcium loss.
* Bypassing the duodenum has caused metabolic bone disease in some patients, resulting in bone pain, loss of height, humped back and fractures of the ribs and hip bones. All of the deficiencies mentioned above, however, can be managed through proper diet and vitamin supplements.
* A chronic anemia due to Vitamin B12 deficiency may occur. The problem can usually be managed with Vitamin B12 pills or injections.
* A condition known as "dumping syndrome " can occur as the result of rapid emptying of stomach contents into the small intestine. This is sometimes triggered when too much sugar or large amounts of food are consumed. While generally not considered to be a serious risk to your health, the results can be extremely unpleasant and can include nausea, weakness, sweating, faintness and, on occasion, diarrhea after eating. Some patients are unable to eat any form of sweets after surgery.
* In some cases, the effectiveness of the procedure may be reduced if the stomach pouch is stretched and/or if it is initially left larger than 15-30cc.
* The bypassed portion of the stomach, duodenum and segments of the small intestine cannot be easily visualized using X-ray or endoscopy if problems such as ulcers, bleeding or malignancy should occur.