GASTRIC SLEEVE SURGERY

​​SADI-S (single anastomosis duodenal-ileal bypass with sleeve gastrectomy) surgery combines a sleeve gastrectomy with duodeno-ileal bypass, a variation on the duodenal switch. This combo restricts how much you can eat, as well as how many calories (and nutrients)  “This technique is gaining traction and offers promising outcomes, especially for patients who are revising a previous sleeve gastrectomy,” according to board-certified bariatric surgeon Dr. Reza Keshavarzi in Miami, FL. He’s especially excited about a “newer magnet-assisted version” of the procedure, “a promising option due to its lower complication profile compared to traditional techniques.”

At their respective practices in Tijuana, Mexico, bariatric surgeons Dr. Jorge Maytorena and Dr. Gabriela Rodriguez Ruiz both offer ​​SADI-S. They both say the procedure is still relatively uncommon, but its popularity is growing as more practices offer it and patient awareness grows. 

Dr. Maytorena considers SADI-S “superior [to sleeve gastrectomy] in terms of weight loss, as long as the patient does not have acid reflux. In that case, the best option would be a Roux-en-Y gastric bypass.” Dr. Ruiz also points out that “SADI-S is better at long term remission of diabetes” than duodenal switch.

The first step in preparing for the procedure is often a GLP-1 like semaglutide, says Dr. Ruiz. “I usually recommend GLP-1 to prep patients for surgery as an aid to help them start their preparation and losing weight.”

As more patients realize the limitations of GLP-1s, both in terms of how much weight loss can be achieved and the longevity of results, they’re turning to weight loss surgeries like this one to lose up to 80% of  excess weight—and sometimes more. 

“In my practice, our patients often lose close to 100 percent of their excess weight,” says Keshavarzi. Beyond the surgery itself, “I personally guide each patient through a long-term protocol focused on maintaining or increasing lean muscle mass and optimizing fat loss,” he explains.

All of the surgeons we spoke to agree that there’s no one right solution for every patient. “For someone with metabolic disease or a history of significant weight regain after a sleeve, SADI-S may be appropriate. But for many others, starting with a sleeve gastrectomy and a solid support plan is the right path,” says Dr. Keshavarzi. “It’s also important to see a doctor that is able to do all the procedures and not just one because they will think their one procedure is the best fit. Go to someone who can give you an unbiased evaluation.”

Dr. Maytorena also stresses the importance of consulting with an expert to determine which procedure will be the healthiest choice for you, with the fewest side effects. “A thorough evaluation is necessary before bariatric surgery, as each patient has different needs that must be considered.”

Most people lose 60-70% of their excess body weight within one year of gastric sleeve surgery, according to UCLA Health.

In the first two weeks, most people lose about one pound a day. Within a month, that tends to slow to about 8 to 10 pounds of weight loss each month.

Patients who follow their provider’s recommendations for ramping up exercise, especially weight training, can lose more inches than those who don’t make lifestyle changes.

Pros

• Creating a smaller stomach through sleeve gastrectomy can help people lose a significant amount of weight, even when other weight-loss options have failed. 
• After a sleeve gastrectomy, most people feel much less hungry.  
• Losing excess weight can help resolve a host of obesity-related health conditions, including type 2 diabetes, high blood pressure, hypertention, heart disease, high cholesterol, joint pain, fatty liver disease, oseteoarthritis, and sleep apnea.
• It’s a less involved surgery with a quicker recovery than gastric bypass surgery. 
• You may experience relief from conditions like diabetes, sleep apnea, and joint pain, and improvements in heart health with reductions in risk of heart attacks and stroke over time. The risk of some cancers is also reduced.  
• Improved fertility is another benefit. 
• Many RealSelf reviewers who’ve had a sleeve gastrectomy report increased quality of life and well-being, both physical and mental. In fact, it has one of the highest Worth It Ratings of any procedure on RealSelf.

Cons

• Gastric sleeve surgery is major procedure, with some significant risks and potential complications. (Read on for more on safety considerations.) 
• The surgery is irreversible, and your weight-loss results aren’t necessarily permanent if you don’t make healthy lifestyle changes. A 2015 study published in the journal JAMA Surgery found that after five years, 38% of patients had not lost or kept off even half their excess weight. 
• Major weight loss can leave excess skin. While many people choose not to do anything about it, if it bothers you, you’d need body lift surgery to remove it.  
• A gastric sleeve procedure can worsen acid reflux and heartburn, so gastric bypass is the preferred option for patients with severe Gastroesophageal Reflux Disease (GERD). 
• The surgery is performed under general anesthesia, which carries certain risks, and generally requires an overnight hospital stay. 
• To keep the weight off, VSG patients have to commit to lifelong changes in lifestyle and diet.
• All types of weight loss surgery are more expensive than new weight loss medications like Wegovy, Ozempic, or other forms of semaglutide.

Related: I’ve Been Taking Ozempic for Weight Loss for 3 Months—Here’s What It’s Really Like

• Average Cost:
• $7,407

• Range:
• $200 - $20,000

The cost of gastric sleeve surgery will depend on the experience level of your surgeon, their practice location, and the number of days you need to stay in the hospital.

Your health insurance plan may cover a portion of the cost of your surgery, if you have documented health issues related to being overweight that make it medically necessary. 

However, some health plans exclude coverage for bariatric surgery, and others require several months of weight management visits before you qualify, so check with your insurance provider.

In some cases, insurance will also cover the surgical removal of excess skin after major weight loss, if it’s causing medical problems.

See our complete guide to sleeve gastrectomy costs

The gastric sleeve surgery photos in our gallery have been shared by the surgeon who performed the procedure, with the patient's consent.

Good candidates for this procedure have a body mass index (BMI) of at least 30 and coexisting (aka comorbid) medical conditions like diabetes, high blood pressure, or sleep apnea.

In most cases, insurance will only approve coverage for patients with a BMI of at least 35 and comorbid conditions, though members of the American Society for Metabolic and Bariatric Surgery (ASMBS) are advocating for improved patient access to care.

“The textbook answer is that you’d qualify with a BMI of 35 to 39 and comorbidity or a BMI of 40 and above with no comorbidity,” says Dr. Mark Pleatman, a recently retired bariatric surgeon in Bloomfield Hills, Michigan. “But recently, researchers have begun saying that for patients with a BMI between 30 and 35 who have a comorbidity, it’s not a bad idea.”

During a pre-op appointment, your doctor will ask for a complete list of all the prescription medications, over-the-counter supplements and drugs, minerals, vitamins, and herbs you take. They will let you know which products might interfere with or be a contraindication to your upcoming surgery. 

Arrange for a ride home and help for the first few days post-op. Reach out to a support system of friends and family members who can motivate and cheer you on. 

To reduce the risk of complications from surgery, you’ll be expected to stop smoking at least 4–8 weeks before surgery. This includes using nicotine patches, vaping, and gum. Your blood may be tested for any traces of nicotine, so commit to quitting. 

If you’re on medication for any form of diabetes, loop in your primary care physician or endocrinologist, to adjust your insulin or pill dosages. 

Before you undergo surgery, you’ll consult with a dietitian and may be encouraged to start an exercise program.

Consider getting support from a therapist for any emotional eating issues too.

Finally, try to arrange to take plenty of time off work, to fully heal. Some people need only a couple weeks, whereas others really do need a full month.

This minimally invasive weight loss surgery is performed in a hospital or surgical center under general anesthesia (meaning you’ll be asleep). It usually takes an hour. 

• Once the anesthesia takes effect, your surgeon will start by making four or five small incisions in your upper abdomen.
• Then they’ll insert a small camera called a laparoscope to survey the abdomen, using the other incisions to insert small surgical instruments.
• They will also insert a long flexible tube (a “bougie,” in medical speak) as a sizer, to ensure that an appropriate amount of stomach is left in place. 
• Your surgeon will then remove a large part of the stomach, leaving a banana-shaped pouch. “If you find a hiatal hernia, you fix it during the surgery,” Dr. Pleatman says. “That adds about 20 minutes to the procedure.”
• Once your incisions are closed, you’ll be taken to a recovery room. You’ll probably need to stay at the hospital or surgery center overnight, to be monitored for any complications. 

RealSelf Tip: Discuss the sleeve size with your surgeon in advance. A large sleeve could compromise your long-term results and your sleeve will stretch over time, but it’s also important not to over-stress your sleeve over time with food.

Expect to miss two to four weeks of work and avoid strenuous activities for the first month post-surgery.

“There’s some pain the day of surgery, but by the following day, most people are up and around,” Dr. Pleatman says. “They feel sore, as though they’ve done a bunch of sit-ups, but they don’t have a whole lot of pain. They’re able to drink liquids and walk around, and they generally go home.” 

Your doctor will give you detailed instructions for recovery, including lifestyle and dietary changes. These are some common recommendations.

• Start with a two-week liquid diet. If you vomit, wait four hours, and then try drinking one ounce of a non-sugary liquid. If you don’t throw up again, you can continue with liquids, including pureed food. If you keep vomiting, call your doctor. (See more below on which foods to avoid.) 
• On day three, you can remove any bandages over your incisions, unless your doctor advises you otherwise. Most people can remove them easily in the shower.  
• You can shower as soon as you want to, but don’t take baths, soak in a hot tub, or go swimming for one month. Pat your incisions dry; don’t rub them.  
• If you don’t have a bowel movement within five days of surgery, you’ll need to take a laxative recommended by your surgeon.  
• About a week after surgery, start to build stamina by walking a little longer every day, so long as it's comfortable for you. “I allow my patients to return to normal activities, including light exercise, as early as 10 days after surgery,” says Dr. Daniel Rosen, a bariatric surgeon in New York City. “The most important thing is to listen to your body. If something causes you pain, don't push through and potentially risk aggravating or damaging something. If your body seems to say that a specific movement is OK, then there’s your green light and you can push ahead.” 
• Avoid aspirin or aspirin-containing products for one week after surgery; these can lead to more bleeding.  
• Don’t take nonsteroidal anti-inflammatories (NSAIDs), such as ibuprofen and naproxen, for one month after surgery. They can irritate the stomach and possibly cause ulcers. 
• Avoid lifting heavy weights until your surgeon thinks you’re ready. 
• It’s safest to wait to get pregnant until at least one year after your surgery. Otherwise, you’ll risk birth defects from vitamin deficiencies or possible twisting or pressure on your intestines. Keep in mind that the birth control pill might not be as effective during that first year, so you may want to consider other options. 

You’ll have a series of follow-up appointments with your surgeon, nurse, and dietitian, to make sure you’re healthy and healing well. These may include:

• An initial follow-up, two to three weeks after the surgery 
• Another, at five or six weeks 
• Additional check-ins at three months, six months, and 12 months, and then yearly for several years. 

You’ll resume seeing your primary care doctor and other specialists early in your recovery, to assess your change in health and medication needs, as well as to keep up with nutritional care and long-term follow-up.

For the first one to two weeks after your procedure, your diet will be limited to sugar-free, noncarbonated liquids.

Then you’ll move on to pureed food for two to three weeks. 

A month after surgery, you can return to solid foods in small portions. You may need to take a daily multivitamin and calcium supplement as well. Dr. Rosen recommends vitamins B12 and D. 

Avoid alcohol for the first full year after your surgery, and plan to continue without it. Its caloric content is high, and it can be absorbed too quickly and be very potent while you’re going through weight loss, which makes it easier to develop a dependency. 

While a sleeve gastrectomy reduces the amount of food you can eat, the kind of food you put in your mouth is up to you.

Your doctor will probably tell you to eliminate foods that are high in sugar and fat or highly processed foods and to incorporate more protein, fruit, and vegetables into your diet.

If you choose not to make this shift or stick with it, it’s likely you’ll gain back the weight you initially lost.

“Many of my patients find they don't crave the same foods they once did,” explains Dr. Rosen. “That said, you can eat the same foods, just in smaller portions.”

RealSelf Tip: One of the major changes after any bariatric surgery is that you can no longer eat and drink at the same time. You need to be able to get enough nutrition from your well-chosen small meals without filling your stomach with liquid.

Modern-day bariatric surgery is exceptionally safe and compares favorably to other general surgical procedures, says Dr. Rosen. “While it's scary to think about what could go wrong, the health benefits will far outweigh the risks—and that's why we recommend these procedures in the first place,” he explains. 

Surgeons at UCLA’s Center for Obesity and Metabolic Health say the procedure has gotten safer over time, but that there still are risks and side effects to consider.

The most serious issues usually occur in the first week after the procedure. Your surgeon will ask you to be alert to any symptoms of complications, including the following.

• Fever or rapid heart rate, which could be a sign of leakage from the staple line. Leakage happens when there is a hole or gap along the staple line in your stomach, allowing contents to seep into the abdominal cavity. This can lead to severe infection or sepsis, which can be life-threatening. UCLA reports a 0.7–3% occurrence of this complication.  
• Stricture or stenosis, a narrowing of the tube that complicates digestion, can happen anywhere along the length of the stapled stomach. This reportedly happens in 1–3% of patients, but many reputable bariatric surgeons say they haven’t had stricture complications within the past five years.  
• Vomiting, which can occur with stricturing.  
• Leg pain, swelling or discoloration in a leg, or difficulty breathing, which could be related to a blood clot that can form in the legs. There’s about a 1% chance of that occurring, depending on the individual’s risk factors, and your surgeon will prescribe a blood thinner, before and after surgery, to prevent it. During recovery, walking and wearing compression socks or stockings can improve circulation. If a blood clot develops and travels to the heart or lungs (called a pulmonary embolism), it can be fatal. The risk is very low; of those who have a blood clot, less than 1% might suffer from an embolism. 

If you have any swelling, heat, or pain at your incision, drainage from the incision, a fever, or shortness of breath, call your surgeon right away.

There are also less serious side effects.

• Acid reflux (including chronic gastroesophageal reflux, or GERD) may develop or worsen after your procedure.  
• Nutrient or vitamin deficiencies (malnutrition) can be mitigated by taking a multivitamin.  
• Nausea, vomiting, or diarrhea might occur in the first few weeks after surgery. Dr. H. Joseph Naim, a bariatric surgeon in Los Angeles, says that this happens because of the increased pressure on your smaller, sleeve-shaped stomach. “Your symptoms usually improve over time and should be managed with nausea medication, attention to small meals, and eating slowly.” 

Other long-term complications can range from gastrointestinal obstruction, caused by strictures and hernias, to very low blood sugar (hypoglycemia), which may need immediate medical attention.

Dumping syndrome, when food gets "dumped" directly from your stomach pouch into your small intestine without being digested, occurs in only a minority (5–7%) of sleeve gastrectomy patients, according to Dr. Guillermo Alvarez, a bariatric surgeon in Piedras Negras, Mexico. 

The syndrome, which is triggered by eating foods that are high in fat, carbohydrates, and sugars, is more likely to occur with a gastric bypass than other types of bariatric surgery procedures. It leads to drastic feelings of discomfort, including nausea, stomach cramps, and diarrhea.

You may also suffer from symptoms of low blood sugar, including feeling faint and sweaty, due to your body's attempts to compensate.

Dietary changes often help reduce the severity of symptoms or prevent them from occurring.

You should lose most of your excess weight within the first six to nine months. Heavier patients, men, and young people lose the most weight in the first few weeks.

Once the extra fat is gone, you could be left with a significant amount of loose skin, which may need to be surgically removed.

Doctors suggest waiting 18 months after gastric sleeve surgery, to fully heal and have your weight settle, before having a body lift.

Your sleeve gastrectomy results will be permanent—if you stick with a healthy diet and exercise regularly. If not, you can expect to regain some (if not all) of the weight you lost.

According to surgeons at UCLA Health, a small amount of weight regain is common among all bariatric procedures after a few years, but up to 20% of patients regain a significant amount of weight after gastric sleeve surgery.

Sleeve gastrectomy is often compared to gastric bypass, another surgical weight-loss procedure.

“Gastric bypass is very effective and provides a little more weight loss than sleeve gastrectomy, but it has its downsides,” Dr. Pleatman says. “For one thing, the complications for gastric bypass are more numerous than that of the sleeve.”

A surgeon performs a gastric bypass by disconnecting a pouch from the stomach and duodenum and then attaching it to the jejunum.

The technique, called a Roux-en-Y gastric bypass, results in food from the stomach being rerouted to the lower part of the small intestine. You absorb fewer calories and nutrients, so it's called a “malabsorptive method” by nutritionists and doctors. 

Many doctors on RealSelf prefer sleeve gastrectomy to gastric bypass because it’s less invasive and comes with less downtime. It also has a lower average cost, according to RealSelf members.

Another advantage of sleeve gastrectomy: it doesn’t make food bypass the intestines, so there’s no reduction in your body’s ability to absorb nutrients. This means there’s less need to take supplements.

With gastric bypass, “you’re at risk for bowel obstruction, vitamin deficiency, osteoporosis, and anemia,” says Dr. Pleatman.

Plus, Roux-en-Y surgery means you can never take a (noncoated) nonsteroidal anti-inflammatory drug (NSAID), like aspirin, naproxen, or ibuprofen, for the rest of your life—or risk getting an ulcer. With sleeve surgery, you need to abstain from NSAIDs for just one month.

In terms of weight-loss results, they have essentially identical outcomes: a study detailing clinical trials from 2018 discovered that there was no significant difference in BMI or weight five years after each surgery.

A new bariatric procedure, called endoscopic sleeve gastrectomy (or gastroplasty), also known as ESG or the accordion procedure, is gaining in popularity. Johns Hopkins Medicine says it “uses an endoscopic suturing device to reduce the size of your stomach. The procedure re-creates what would occur at a surgical sleeve gastrectomy, without the need for surgery.” 

While ESG is an outpatient procedure, it still uses general anesthesia. Your surgeon inserts an endoscope down your throat and into the stomach. The endoscope has a tiny camera and a suturing mechanism that allows your surgeon to suture your stomach into a tube.

Because the surgery itself is limited to the inside of the stomach by going in through the mouth, the risks (beyond those from general anesthesia) are decreased, and you can typically go home the same day. It can also be less expensive than sleeve surgery, and recovery is quicker, but the amount of weight loss you can expect and durability of your results are not the same. 

RealSelf Tip: In a study published in 2020, researchers found that ESG can help people who’ve regained weight after a sleeve gastrectomy. In fact, 100% of participants reported optimal results.

There are a few other weight-loss treatment options worth considering, with the input of an experienced doctor.

• Prescription semaglutide medications have quickly become one of the treatment options of choice for many patients looking for significant weight loss, without the cost and risks of surgery. Wegovy is FDA approved to treat obesity, while Ozempic is FDA approved for the treatment of type 2 diabetes but commonly used “off-label” for weight loss.
• Adjustable gastric band surgery, often referred to as lap band or band surgery, is another option. An adjustable silicone band is placed around the top portion of your stomach, creating a small stomach pouch. Lap band surgery is a reversible procedure that’s considered to be the least invasive weight-loss surgery. However, it has a lower success rate than either gastric bypass or sleeve gastrectomy. Patients also have a high rate of “reoperation,” to remove or replace the lap band device. Lap band is most effective for people who need to lose 40–70 lbs. In general, those with a BMI over 40 would be better served by a more invasive procedure. However, if you want to avoid stapling, a band is the best available option. 
• Duodenal switch surgery, which is typically reserved for people with high BMI, combines a sleeve with an intestinal bypass. It’s done in one or two stages, explains Dr. Moustarah, an expert in duodenal switch surgery. If it’s deemed unsafe to do in one step, the sleeve is performed first; then, 9 to 12 months later, the intestinal bypass is performed. It’s considered a more complex procedure, with a higher risk of complications, so it requires closer follow-up throughout your lifetime. According to Dr. Moustarah, “this operation has the best record of weight loss, durability, and improvements in comorbidities like diabetes, cardiovascular disease, cholesterol, sleep apnea, etc., but it can have serious side effects if patients aren’t actively participating in lifelong follow-up and adhering to proper dietary and medical counseling.” He adds that “the duodenal switch may have a role for some patients whose weight loss response to a gastric sleeve is less than optimal.”

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ASMBS press release, New Study Raises Caution Over Same-Day Gastric Sleeve Surgery (2017)

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Columbia Surgery; Risks and Rewards of Obesity Surgery (2019)

de Moura DTH, et. al,, Endoscopic sleeve gastroplasty in the management of weight regain after sleeve gastrectomy (2020)

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Golomb I, David M.B., Glass A., et. al., Long-term Metabolic Effects of Laparoscopic Sleeve Gastrectomy (2015)Marvin R., Post-Op Laparoscopic Sleeve Gastrectomy Concerns (2017)

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University of California Los Angeles (UCLA) Bariatric Surgery, Gastric Sleeve Surgery: All the things you need to know (2017)