Gastric Sleeve With a BMI of 50 or More

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Gastric Sleeve With a BMI of 50 or More

A sleeve gastrectomy can be done at a body mass index (BMI) of 50 or more; nearly one in four U.S. bariatric surgery patients in one registry analysis was in this range. In a large U.S. study, sleeve patients starting at 50 or above lost about 30% of their body weight in a year. Surgical risk is higher, and some people later need a second procedure.

How common this is, and what the guidelines say

You are not an unusual case. In an analysis of data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), the U.S. quality registry, 173,110 of 751,952 bariatric surgery patients (23.0%) had a BMI of 50 or more (Verhoeff and colleagues, Obesity Surgery, 2022).

The 2022 guidelines from the American Society for Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) address this group directly. They state that surgery "should be considered as a preferred method to achieve clinically significant weight loss in patients with extreme BMI." They also state that there is no consensus on which procedure to prefer for people with an especially high BMI.

Expected weight loss with a sleeve at this BMI

The 2019 clinical practice guideline from ASMBS and four other societies (Mechanick and colleagues) lists a target of 25% to 30% of total body weight for a sleeve, 30% to 35% for a gastric bypass and 35% to 45% for a duodenal switch.

A large U.S. comparison looked only at people with a BMI of 50 or more. Using the Bariatric Outcomes Longitudinal Database for 2007 to 2012, Celio and colleagues (Surgical Endoscopy, 2017) compared 8,868 sleeve patients with 42,119 bypass patients. At 12 months, average total weight loss was 29.7% after a sleeve and 34.5% after a bypass.

Losing 30% of body weight takes a BMI of 55 down to about 38.5. That is simple arithmetic and not a prediction for any one person, but it shows why a sleeve alone may leave someone who starts above 50 with a BMI still over 35. In the same study, diabetes had resolved at 12 months in 50.8% of sleeve patients who had it and 61.6% of bypass patients.

Surgical risk at a higher BMI

The 2022 ASMBS/IFSO guidelines summarise the evidence in both directions. Older studies linked a BMI over 50 to higher surgical risk, and people with a BMI over 60 are "considered to be at especially high risk," with longer operating times and more complications around the time of surgery in some reports. Other studies found no significant difference in complications, hospital stay or 30-day mortality compared with a BMI under 60.

The registry figures give a sense of scale:

In the MBSAQIP analysis, a BMI of 50 or more was independently associated with serious complications (odds ratio 1.08) and with death within 30 days (odds ratio 2.49). An odds ratio above 1 means the event was more likely than in patients with a lower BMI. The authors call this BMI range the greatest independent risk factor for death within 30 days.
In the Celio study, the adjusted 30-day complication rate was 11.1% after a sleeve and 11.5% after a bypass, which was not a significant difference. Sleeve patients had lower adjusted rates of reoperation (2.4% against 4.0%), readmission (5.5% against 6.9%) and 30-day mortality (0.2% against 0.3%).

Those results come from registries covering many hospitals; they are not this practice's figures. Complications themselves are described on our gastric sleeve risks page.

Where the operation is done matters at very high BMI. The 2019 guideline states that men with a BMI over 55 and women with a BMI over 60 should be referred to an accredited comprehensive center. Surgery with Dr. Davtyan is done at a hospital where he has surgical privileges. Ask the office which hospital would be used, what its accreditation level is, and whether it is suited to your BMI.

Staged approaches

A staged plan means doing a sleeve first and, if needed, a second operation after weight has come down. The reasoning is that the sleeve involves no intestinal connection, and that a later procedure can be done at a lower weight.

The 2019 guideline's procedure table reflects this. It describes the sleeve as "versatile for challenging patient populations," and it notes that both the gastric bypass and the duodenal switch "can be used as second stage after SG" (sleeve gastrectomy). A second stage is not automatic, and not everyone needs one. Our pages on sleeve to bypass conversion and gastric sleeve revision options have background. Ask whether Dr. Davtyan would plan in stages for you and which second procedures are available.

Alternatives to weigh

Gastric bypass as the first operation. The Celio study found more weight loss and more resolution of diabetes, high blood pressure and reflux at one year after bypass than after a sleeve in people with a BMI of 50 or more, along with more reoperations and readmissions. Its authors concluded that the results favour bypass in patients of appropriate risk. See gastric bypass versus gastric sleeve.
Weight loss before surgery. Some surgeons ask for it to shrink the liver and make the operation easier; see the pre-surgery liver diet. Practices differ, so ask whether it would be requested in your case and by what method. The 2022 guidelines add that there are no data to support weight loss required by an insurer as a condition of approval.
Medication. Ask the office whether medical weight loss with GLP-1 medications is available. Whether medication is used alone, before surgery or after it is an individual decision.

A sleeve cannot be reversed, so it is worth settling these questions before you choose.

Frequently asked questions

Is there an upper BMI or weight limit for a gastric sleeve?

The 2022 ASMBS/IFSO guidelines do not set one, and they cite reports of surgery in patients with a BMI over 70. Limits can still exist in practice. A hospital's equipment and accreditation level may matter, and the 2019 guideline's referral advice applies at very high BMI. Ask the office about any limit at the hospital where your surgery would be done.

Will a sleeve be enough to get me under a BMI of 35?

It depends on where you start. The 2019 guideline lists a target of 25% to 30% of total body weight for a sleeve. From a BMI of 50, a 30% loss gives about 35; from 60, about 42. Some people lose more and some less. Your surgeon can go through the numbers for your height and weight.

Do I need extra tests before surgery because my BMI is over 50?

Possibly. The MBSAQIP analysis found that patients with a BMI of 50 or more had more endocrine, lung and vascular conditions and poorer functional capacity before surgery than other patients. Our page on tests before gastric sleeve surgery lists what the 2019 guideline includes. Ask which of these Dr. Davtyan would need in your case.

If I start with a sleeve, how long before a second stage is considered?

The guidelines cited here do not set a fixed interval. The question usually comes up once weight loss after the sleeve has levelled off and your follow-up visits show where you have settled. The decision is based on your weight, your health conditions, reflux symptoms and what you want, and it is one to make with your surgeon.

Talk with Dr. Davtyan in Rancho Cucamonga

Dr. David G. Davtyan, MD, FACS, FICS, FASMBS, is a bariatric surgeon with Davtyan Medical Weight Loss & Wellness at 8330 Red Oak Street, Suite 201, Rancho Cucamonga, CA 91730. Call 909-355-2525 or toll free 877-9-BE-SLIM (877-923-7546), or use our contact page. The first consultation is complimentary, and Hablamos Español. More topics are in our Rancho Cucamonga gastric sleeve guide.

Gastric Sleeve With a BMI of 50 or More

Gastric Sleeve With a BMI of 50 or More

How common this is, and what the guidelines say

Expected weight loss with a sleeve at this BMI

Surgical risk at a higher BMI

Staged approaches

Alternatives to weigh

Frequently asked questions

Is there an upper BMI or weight limit for a gastric sleeve?

Will a sleeve be enough to get me under a BMI of 35?

Do I need extra tests before surgery because my BMI is over 50?

If I start with a sleeve, how long before a second stage is considered?

Talk with Dr. Davtyan in Rancho Cucamonga

Sources

More in the Gastric Sleeve in Rancho Cucamonga guide

Understanding the sleeve

Weighing your options

Getting care in Rancho Cucamonga

Adult BMI Calculator

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Glendale

Rancho Cucamonga

South Coast Lap-Band

Marina Del Rey Hospital

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