Gastric sleeve surgery, or vertical sleeve gastrectomy, is a bariatric procedure designed to help individuals struggling with obesity achieve significant weight loss. This surgery involves reducing the size of the stomach, thereby restricting food intake and promoting a feeling of fullness with smaller portions. A crucial element in performing this surgery effectively is the use of a bougie.
What is a Bougie?
A bougie is a soft, plastic tube-like medical device. It is measured in French units (F), where 1 French equals 1/3 of a millimeter. During a gastric sleeve procedure, the bougie is inserted endoscopically through the patient’s mouth and down the esophagus. It serves as a guide for the surgeon to determine the size and shape of the new, smaller stomach. Specifically, the surgeon uses the bougie to guide the cutter/stapler, which removes a significant portion (approximately 80%) of the stomach. The bougie ensures that the remaining stomach is of the appropriate size and shape to facilitate weight loss without causing complications. Removing the fundus part of the stomach is crucial, as it is the stretchy part of the stomach and it carries the most ghrelin hormones.
How Bougie Size is Measured
Bougies are measured in French units (Fr), with the conversion being 1F = 0.333 mm. Common bougie sizes used in bariatric surgery range from 27F to 60F. Many expert weight loss surgeons prefer using bougie sizes between 32F and 36F for optimal safety and effectiveness.
Here's a bougie size chart for reference:
- 32Fr = 0.40 inches
- 34Fr = 0.425 inches
- 36Fr = 0.45 inches
- 38Fr = 0.476 inches
- 40Fr = 0.5 inches
- 46Fr = 0.576 inches
- 60Fr = 0.75 inches
The bougie measurement, along with the surgeon’s precision, determines the maximum tolerated stomach volume, also known as “gastric volume."
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Why is the Bougie Used?
The bougie serves two primary purposes:
- Measurement and Guidance: It helps the surgeon measure how much of the stomach will remain untouched during the sleeve gastrectomy and guides where the staples should be placed. This ensures the safe and efficient removal of excess stomach tissue.
- Outcome Definition: It aids in defining the end result of the surgery for the patient, particularly concerning the amount of excess weight loss.
The closer the stapler is to the bougie, the tighter the resulting stomach sleeve will be. However, it is crucial for the surgeon to possess sufficient experience to prevent the pouch from becoming too tight, which could lead to obstructions.
Does Bougie Size Matter?
The size of the bougie significantly influences the outcome of gastric sleeve surgery. A smaller bougie results in a smaller stomach capacity, which typically leads to greater weight loss. Conversely, a larger bougie leaves a larger remaining stomach, potentially allowing for greater food absorption.
For example, a study in Chile demonstrated that patients calibrated with a 34Fr bougie experienced 20% more excess weight loss within a year compared to those calibrated with a 60Fr bougie.
Choosing the Right Bougie Size
The ideal bougie size varies from person to person. Surgeons consider factors such as the patient’s Body Mass Index (BMI), existing stomach size, age, and overall medical condition when selecting the appropriate bougie size.
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It's important to note that the surgeon's skill and experience play a critical role in ensuring the precision and safety of the procedure. Using a smaller bougie can increase the risk of complications if the surgeon is not experienced, potentially leading to nausea and other issues.
For instance, one study revealed that patients undergoing surgery with a 32Fr bougie had twice the rate of emergency room visits compared to those with a 36Fr bougie. The 32Fr group also tended to have longer hospital stays.
Additionally, the bougie helps minimize scarring and prevents twisting of the sleeve tissue, which can cause obstructive symptoms like nausea and vomiting. If the bougie is too small and the surgeon's incision is inaccurate, it can result in sleeve stenosis, a tapered narrowing of the stomach that can impede digestion.
Benefits of Gastric Sleeve Surgery
Gastric sleeve surgery may be a viable option for individuals who have not achieved successful weight loss through diet and exercise, particularly if they suffer from conditions like type 2 diabetes or sleep apnea. The surgery reduces stomach volume, limiting food intake and decreasing hunger by removing the majority of ghrelin-producing hormones.
Compared to other bariatric surgeries like gastric bypass, adjustable gastric band, or duodenal switch, gastric sleeve surgery is considered one of the best options for those seeking a minimally invasive procedure with relatively quick results. Patients can typically expect to lose 65% to 70% of their excess weight within a year.
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Weight Regain After Gastric Bypass
Roux-en-Y gastric bypass (RYGB) is a common and effective surgical procedure for patients with morbid obesity. However, weight regain (WR) can occur, diminishing the surgery's effectiveness and potentially requiring further interventions.
Factors Contributing to Weight Regain
Several factors can contribute to WR after RYGB, including:
- Lifestyle: Poor dietary habits and insufficient physical activity.
- Mental Health: Unrecognized or untreated eating and psychiatric disorders.
- Hormonal/Metabolic Imbalance: Changes in gut hormone secretion and reactive hypoglycemia.
- Surgical Issues: Pouch dilatation, increased stoma size, and gastro-gastric fistula.
Managing Weight Regain
Treatment options for WR after RYGB include:
- Lifestyle Interventions: Diet counseling, increased physical activity, and addressing eating disorders.
- Endoscopic Procedures: Techniques to reduce the size of the gastric pouch and stoma.
- Surgical Revision: Procedures to refashion the gastric pouch or revise the bypass.
The Role of Gut Hormones and Reactive Hypoglycemia
RYGB surgery leads to alterations in gut hormones, such as glucagon-like peptide 1 (GLP-1) and ghrelin, which contribute to weight loss. However, hormonal changes may not be the same in all patients, potentially contributing to WR. Reactive hypoglycemia, characterized by hypersecretion of insulin and low blood glucose levels, can also stimulate appetite and lead to WR.
Surgical Factors in Weight Regain
Surgical factors, such as pouch dilatation and increased stoma size, can contribute to WR after RYGB. Gastro-gastric fistula, a communication between the pouch and remnant stomach, can also reduce the restrictive and malabsorptive effects of the surgery.
Endoscopic and Surgical Interventions for Weight Regain
Endoscopic procedures, such as sclerotherapy and transoral outlet reduction (TORe), can be used to reduce the size of the gastroenterostomy. Surgical refashioning of the gastric pouch, including longitudinal gastric pouch resection and resection of the pouch with a new gastroenteroanastomosis, may also be considered.