Should I Choose the Vertical Sleeve (VSG) or Gastric Bypass (RNY)?September 29, 2017
If you are considering bariatric surgery, at some point you will ask yourself which of the surgeries you should choose. Although there are a lot of different options, for most patients this choice most often boils down to either the Vertical Sleeve (VSG) or Gastric Bypass (RNY).
The Lap-Band and the Duodenal Switch (DS) are good operations for the very carefully selected patient, but together they comprise less than 5% of the bariatric surgeries performed in the US. With that in mind, I will focus on the Vertical Sleeve Gastrectomy (VSG) and the Roux-en-Y Gastric Bypass (RNY), in the following discussion.
One other caveat before I get started: the choice between Sleeve and Gastric Bypass often is not a black and white decision. In many times, it comes down to a gut feeling (pun intended!) about which surgery you feel more comfortable with.
I can sometimes offer some insight on why one surgery may be better than another for a particular patient, but many times you could make an outstanding argument for EITHER surgery--both have lots of benefits and some drawbacks.
The surgeon you choose may have strong opinions about one surgery or the other, which may contradict my own opinions that are stated in this article, and if you feel comfortable with the surgeon that you’ve chosen, you should give some serious weight to their recommendations.
Why Patients Choose Vertical Sleeve Gastrectomy (VSG)
The Sleeve Is “Less Invasive”
Maybe, maybe not! Patients often choose the Sleeve Gastrectomy because they perceive that it is a “less invasive” surgery than Gastric Bypass. While it’s true that the Sleeve Gastrectomy is a simpler surgery to perform and thus may have a slightly lower 30-day complication rate, it must be kept in mind that in performing the Sleeve Gastrectomy, you are permanently removing a portion of the stomach. In other words, the Sleeve is an irreversible surgery.
Now, it would be rare to actually need that removed portion of the stomach for anything. However, I don’t know if it should really be considered “less invasive” to permanently remove a large portion of the stomach versus leaving the stomach in and bypassing it. Contrary to what you may read on the Internet, the Gastric Bypass CAN be reversed by a skilled surgeon--although the chances of ever needing it reversed are very, very slim indeed.
Patients Recover More Quickly After Sleeve Gastrectomy
Not true. I use the same five small incisions to perform either surgery. Although the Gastric Bypass takes longer to perform (I personally average around 30 minutes to perform a Sleeve and 60 minutes for Gastric Bypass), it doesn’t appear to significantly increase the amount of pain in my experience.
Generally, with either surgery, my patients are up walking within a few hours after either surgery and the vast majority leave the hospital the morning after surgery. Many of them use no pain medications after five days and a significant number of them return to work a week after surgery, no matter which surgery was performed. Of course, there are outliers, but generally, recovery is pretty quick with either surgery.
Do Patients Lose Weight Slower And Have Less Loose Skin?
Probably not. It’s true that OVERALL weight loss isn’t quite as high with the Sleeve (an “average” patient generally loses 10-20 pounds more with Gastric Bypass), but the RATE of weight loss appears to be about the same.
The general pattern is that most patients lose about ⅔ of the weight they’re going to lose in the first six months after the surgery, and the other ⅓ in the second six months.
There also doesn’t appear to be a significant difference in the amount of loose skin between one surgery or the other, it’s mostly dependent on the total amount of weight you lose, your age, the elasticity of your skin, if you’ve smoked in the past, etc. If you lose more than 100 pounds, it is very likely that you will have some loose skin to deal with, no matter which surgery you choose.
Better Absorption of Vitamins With The Sleeve
This is probably true. All bariatric surgeries require daily lifelong supplementation with vitamins. However, the Sleeve does appear to have better absorption of medications and vitamins compared to Gastric Bypass, hence lower rates of vitamin deficiencies. This is probably related to the higher amount of acid present in the Sleeved stomach that aids in the breakdown of hard minerals (calcium and iron), and the lack of bypassed bowel in the Sleeve.
If you are someone who has a heck of a time remembering to take medications regularly, you would put yourself at a lower risk of vitamin deficiency if you choose the Sleeve Gastrectomy instead of the Gastric Bypass. That being said, I don’t think any surgeon would operate on a patient if they knew the patient wasn’t ever going to take any vitamins.
Also, if you are a younger, healthier patient who doesn’t need the strongest surgery ever invented, you may lean towards a Sleeve Gastrectomy, because if you’re going to live with a surgery for the next 60 years and go through periods in life where you aren’t as consistent at taking your vitamins, it may be better to go with the surgery (Sleeve) that has a better absorption of calcium and better chance of avoiding hip fractures, etc, when you’re 70 years old. The same can be said for iron levels and anemia, etc.
These deficiencies, of course, can generally be avoided with very careful supplementation in a Gastric Bypass, but I know that in “real life” many patients don’t take vitamins as recommended and can put themselves at risk for osteoporosis (low calcium), anemia (low iron levels), or all of the difficulties that come along with low vitamin B levels.
Better Absorption of Medications With The Sleeve
This is probably true as well. Some patients may choose a Sleeve because they have particular medications that they REALLY need to absorb well. A good example of this would be a patient who has received a kidney transplant. With the better absorption of medications after the Sleeve, it may be easier for their doctors to manage these medications after Sleeve versus having the decreased absorption after Bypass.
Other patients may have found just the right balance of antidepressant medications and are worried about altering the absorption too much. Of course, this must be weighed against the increased remission rates of medical problems such as diabetes, high blood pressure, high cholesterol, etc, with Gastric Bypass.
The Sleeve Is More Tolerant of Over-The-Counter Pain Medications (NSAIDS)
True. Yet another group of patients who choose a Sleeve over a Bypass are those who are dependent on a class of medications called NSAIDs (ibuprofen, naproxen, aspirin--generally, most of the over-the-counter pain medications EXCEPT acetaminophen) for the relief of joint pain or other medical issues.
Those medications can cause irritation and ulceration in ANY stomach pre- or post-surgery, but the Gastric Bypass pouch is especially sensitive to those medications. One of the more common causes of stomach ulcers in a Gastric Bypass patient is the regular use of NSAID medications. If you can’t imagine a life without the regular use of NSAIDs, a Sleeve is probably a better choice than a Bypass for you. A Sleeve isn’t a guarantee against ulcers, but they appear to be much less common than those found in Gastric Bypass.
The Sleeve Allows Patients To Use Nicotine
Um, no! HOWEVER, if someone told me that I MUST perform bariatric surgery on a patient who would eventually continue smoking, a Sleeve Gastrectomy would most likely be a much safer surgery for someone who resumes using nicotine.
In saying this, I’m in no way condoning nicotine use after bariatric surgery, just saying that if I had the choice, I’d much prefer Sleeve to Bypass in someone who was smoking/vaping, etc.
I may be criticized for even bringing this up in this way, but my main desire is to help patients have a healthy and fulfilling life as possible, and no matter how hard some patients try to stop smoking, it may be a life-long battle for them.
If a patient has quit smoking 10 times before in their life and always eventually comes back to it, first I would recommend getting medical help and support to quit the nicotine habit, but secondly, a Gastric Bypass would make me uneasy due to the risk of life-threatening ulcers if the patient were to resume smoking later on down the road. In fact, I’ve only reversed a Gastric Bypass a couple of times, and both of them were for patients who couldn’t quit smoking and as a consequence had recurrent life-threatening stomach ulcers.
The Sleeve Is The Easiest WLS To Convert to A Strong Surgery For A "Second Chance"
True! In my opinion, this may be one of the most important decision-points in deciding between the different surgeries. If you’ve made it this far into the article, please don’t stop reading now!
Obesity is a chronic disease. We can’t cure it with an operation or any other intervention. Some patients, even when following the “rules” will regain weight. We don’t know the exact number, but I believe there’s evidence that that 1 out of 3 patients gains a significant portion of the “lost” weight back some years after surgery.
In my opinion, after you have had bariatric surgery and get down to a healthier weight, you should NOT consider yourself as “ex-obese”. Instead, you should consider yourself as someone who HAS obesity, and that obesity is now “well controlled”. I know that maybe a depressing thought, but hopefully understanding the disease is also empowering and that knowledge can help us prevent some weight regain.
As a surgeon who regularly performs revisional surgery, the message that many patients seemed to get 10-20 years ago was that their bariatric surgery “cured” obesity, and they often weren’t offered much along the lines of postoperative follow-up. Sure, maybe a follow-up phone call here or there, but it didn’t seem that anyone back then was treating patients as if they had a chronic condition that needs lifelong support.
So what do we do with patients who have regained weight after bariatric surgery? I could go into the 20 different procedures that have been attempted to make a Gastric Bypass a stronger metabolic surgery, but instead, let me tell you that very simply there is no easy AND powerful long-term solution to the problem of weight regain after Gastric Bypass.
Gastric Bypass can be altered to make it somewhat more powerful, but the risk is much higher than the original surgery, and the benefits are essentially unknown and often somewhat disappointing.
On the other hand, if a patient has had a Sleeve Gastrectomy in the past and has regained weight, it is a fairly simple minimally-invasive surgery to convert the Sleeve Gastrectomy to a Duodenal Switch, which then becomes a stronger surgery than Bypass or Sleeve alone. Newer ways of performing the Duodenal Switch are becoming more accepted which only requires one new connection. The caveat here is that these patients have to be carefully selected because the stronger you make the surgery, the higher risk there is of nutritional deficiencies.
The Sleeve Isn't The Best Option For Heavier Patients With More Severe Obesity
Yes and no. For my heavier patients (perhaps BMI over 55), I often recommend that they consider Sleeve Gastrectomy as a possible staged procedure. In this case, we perform the Sleeve and after a few years to see where the weight loss took them, if the patient needs further weight loss or resolution of medical problems, we then converting the Sleeve to a Duodenal Switch.
It is unusual to see patients lose more than 200 pounds after either Gastric Bypass OR Sleeve Gastrectomy, so if someone has more than 200(ish) pounds or so to lose, a better option than Gastric Bypass may be starting off with a Sleeve and then converting to Duodenal Switch down the line. In this situation, you may be able to avoid getting “stuck” at a particular weight with Gastric Bypass without a lot of options to make it a stronger surgery.
In summary, a Sleeve by itself probably won’t cause as much overall weight loss as Gastric Bypass. It may also be supposed that long-term weight regain may occur in more Sleeve patients than Gastric Bypass patients.
However, a Gastric Bypass patient who regains weight is one of the most difficult surgical problems to deal with. On the other hand, the Sleeve can be converted to a Duodenal Switch fairly easily, which then becomes the most powerful of the modern bariatric surgeries.
Why Patients Choose Roux-en-Y Gastric Bypass (RNY)
The Gastric Bypass Is Much Better For Treating Heartburn/Acid Reflux
True. One of the main drawbacks of the Sleeve is that it can cause either brand new heartburn or worsen pre-existing heartburn in patients. While the occasional gastric bypass patient does still experience heartburn/GERD/reflux, it is an excellent surgery for heartburn with very high remission rates.
We don’t have exact numbers yet, but it appears that 10-20% of patients with sleeve gastrectomy will either get new reflux, or pre-existing reflux will continue or worsen. Some small portion of these will return in the future to be revised to gastric bypass for heartburn/reflux problems. It should be noted that the LINX (registered trademark, Torax medical) procedure is an intriguing new option to treat reflux in these patients as well.
The Gastric Bypass Has A More Powerful Dumping Syndrome
Mostly true. The preferred eating style may cause patients to choose one surgery over another. Patients who are “volume-eaters” and don’t snack much probably do well with either surgery. However, some patients who really crave sweets may choose gastric bypass for the benefit/negative reinforcement of the “dumping” symptoms (sweating, palpitations, abdominal discomfort, fatigue) that are generally stronger after gastric bypass than the sleeve.
However, some patients who really crave sweets may choose Gastric Bypass for the benefit/negative reinforcement of the “dumping” symptoms (sweating, palpitations, abdominal discomfort, fatigue) that are generally stronger after Gastric Bypass than the Sleeve.
In other words, if a Gastric Bypass patient eats simple carbs or foods that are too rich, they generally will feel worse than a Sleeve patient, and some patients really want that negative feedback and choose the Bypass for that reason.
HOWEVER, this dumping may be a two-edged sword, as some patients discover that they can treat the low-blood sugar/dumping that occurs with yet another dose of carbohydrates (followed by another ‘crash’ soon after) and get into the “grazing” pattern of spiking and crashing all day long which can cause weight regain. These patients legitimately feel excessive hunger, but don’t realize that it’s actually the types of food they are eating (processed carbohydrates) that are the root cause of the hunger pangs.
The Gastric Bypass Is A Pretty Good Choice For "Middle Of The Road" Patients
In my opinion, true.
For our lighter patients who don’t have many health problems, a Sleeve is also an excellent option because they may not need the extra weight-loss strength a Bypass may give them. For our heavier and sicker patients, the Sleeve is a good first step to get them healthy enough to perform a Duodenal Switch.
The Gastric Bypass is an excellent, one-step, stand-alone bariatric surgery for the patient who is sort of “middle of the road” as far as excess weight and medical problems are concerned. Compared to a Sleeve alone without Switch, Gastric Bypass has significantly higher remission rates of diabetes, cholesterol, and most other weight-related health problems.
Of course, with either surgery, the chance of remission is related to the severity of the disease (for example, with diabetes, how many medications are required to keep the disease controlled and how many years the patient has had the problem). But generally speaking, for the patient who is at relatively high risk for heart attack or stroke in the next 10 years, Gastric Bypass does a better job than a Sleeve of lowering health risk as a stand-alone procedure.
Also, some of our heavier patients choose Bypass because they don’t like the stepwise approach (Sleeve to Duodenal Switch) to surgical weight loss and are okay accepting whatever weight loss the Bypass gives them, knowing that they will usually lose more weight overall than if they were to have Sleeve Gastrectomy alone.
How To Decide Between Vertical Sleeve (VSG) or Gastric Bypass (RNY)
Again, for many patients, a solid argument could be made to perform EITHER surgery. Unless you have a compelling reason to choose one over the other (ie severe GERD, diabetes, etc), you might have to have a crystal ball to figure out which surgery is the absolute best for YOU. I often tell patients that if they like the idea of going with a “gentler” surgery (Sleeve) and are okay with a somewhat higher chance that they would want it converted another surgery down the line, then the Sleeve is an excellent option.
I approach the Sleeve as a staged operation. I tell my patients that being extremely conservative, you could estimate that 50% of Sleeve patients at some point in the future will consider conversion to either Gastric Bypass or Duodenal Switch due to poor initial weight loss, weight regain, non-remission of medical problems, or bothersome GERD.
As a surgeon, I’m okay with that. I think it’s a great way to get the right strength of surgery for the right patient...assuming the patient has that plan in mind as well. It does bother me a bit sometimes to hear the Sleeve spoken about as the best thing since sliced bread as a stand-alone procedure. I believe that we will see that many Sleeve patients at some point down the line that would benefit from conversion to a stronger procedure. In my mind, this is not a condemnation of the Sleeve procedure, it’s more of a recognition that obesity/metabolic disease is a chronic illness that isn’t ever completely cured.
On the other hand, if a patient wants one of the best one-step operations for the remission of their medical problems, and swear on their grandmother’s grave that they will take care of it by taking their vitamins three times a day and avoiding simple carbohydrates like the plague, then the Gastric Bypass is a great choice.
If you’re still reading, I congratulate you on your persistence and bring up the last point that may be of some comfort: bariatric surgery has generally become very safe if you compare the small risk of surgery to the lasting health benefits. Whether you choose a Sleeve Gastrectomy or a Gastric Bypass, in the end, either choice will likely be a great investment in your future health, so for many patients, your decision isn’t between “good” or “bad”, it’s between “good” and “better”. Good luck!
ABOUT THE AUTHORDr. Benjamin Shadle is the Medical Director for Bariatric Surgery at Sutter Roseville Medical Center and continues his dream of helping his patients achieve healthier and happier lives through bariatric surgery and impacting the health of families for the better. He understands that obesity, diabetes, hypertension and other related diseases can have a tremendous negative impact on a patient's health and quality of life as well as family members.
Read more articles by Dr. Shadle!