Gastric Sleeve for Weight Loss

A study published in the New England Journal of Medicine compared the standard treatment of medication, diet and exercise to weight-loss surgery for the treatment of type 2 diabetes.

“This study shows in addition to gastric bypass, sleeve gastrectomy improves or resolves type 2 diabetes following surgery, and is more effective than medical management alone,” says Noel Williams, MD, director of the Penn Metabolic and Bariatric Surgery Program.

During a sleeve gastrectomy, or gastric sleeve, a sleeve-shaped tube is created from a small portion of the stomach, and most of the stomach is removed. Food passes through this tube directly into the intestines. Nutrients and calories are absorbed from food normally, but patients feel full sooner and stay full longer.

Sleeve gastrectomy is typically considered for patients with a body mass index (BMI) of 50 or higher. The surgery is performed laparoscopically and can be a permanent surgical solution to manage weight. A second operation may be required, however, if significant weight loss is required to improve the patient's health.

Let Penn Help You Lose Weight

Learn if weight-loss surgery is right for you and attend a free information session about the Penn Metabolic and Bariatric Surgery Program.

At this free session, you will learn more about weight-loss surgery at Penn, and meet physicians and team members from the Penn Metabolic and Bariatric Surgery Program

Register for this free event here.

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Gastric Sleeve or Gastric Bypass: What’s the Difference?

Two commonly preformed weight-loss surgery procedures are the Roux-en-Y gastric bypass and the sleeve gastrectomy. Gary Korus, MD, FACS, bariatric surgeon at Penn Medicine, discusses the differences between these procedures.

Roux-en – Y Gastric Bypass

This laparoscopic procedure restricts food intake and shortens the digestive track by creating a small gastric pouch from the upper portion of the stomach. The intestine is surgically connected to this pouch, creating a small opening for food to pass through. The remaining larger portion of the stomach and part of the intestines are bypassed. The Roux-en-Y gastric bypass procedure limits the amount of food consumed and reduces the calories and nutrients absorbed from food.“The gastric bypass had been around for more than 25 years. Most people keep most of their weight off long-term,” says Dr. Korus. “It is also the only procedure that gives you feedback if you eat things you shouldn’t such as concentrated sweets.”

Sleeve Gastrectomy

During a sleeve gastrectomy, a sleeve-shaped tube is created from a small portion of the stomach and the majority of the stomach is removed. Food passes through the new stomach tube directly into the intestines. Nutrients and calories are absorbed from food normally, but patients feel full sooner and longer. Sleeve gastrectomy is performed laparoscopically and can be a permanent surgical solution to manage weight. Dr. Korus notes, “The gastric sleeve or sleeve gastrectomy provides an alternative for the patient that restricts what they eat without altering the route the food or beverages takes through the G.I. tract.”

Which Procedure is Better for Me?

How do you know which option is best for you? “The decision about what procedure is best for you can be made with your surgeon,” says Dr Korus. “Factors including your medical condition, medications, previous surgeries and dieting history will play a role in this decision.”

Lose Weight at Penn Medicine

Penn can help you lose weight.

Learn about medical weight loss in Philadelphia, and the Penn Bariatric and Metabolic Surgery Program at a free information session about weight-loss surgery in Philadelphia.

There, you will hear about your weight-loss surgery options, and how Penn can help you lose weight and get healthy for good.

Register for a free information session today.

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Your Daily Dose: Vitamin B12 Supplements after Weight Loss Surgery

Cara Stewart, RD, LDN, member of the Penn Metabolic and Bariatric Surgery team, explains the importance of the vitamin B12 supplements after weight loss surgery.

Vitamin B12 is the most common vitamin deficiency people experience after weight loss surgery. That is why it is important to supplement your diet with vitamin B12, especially after gastric bypass and sleeve gastrectomy.

Vitamin B12 is essential for proper nerve function, metabolism and red blood cell production. Deficiency can lead to B12 deficiency anemia, which causes fatigue, rapid heart rate, easy bruising and bleeding, stomach upset and diarrhea or constipation.

If the deficiency remains unaddressed, it can result in permanent nerve damage, including tingling or numbness in fingers and toes, difficulty walking, mood changes, memory loss and dementia.

Weight loss surgery reduces the acidity in the stomach, which makes absorption of vitamins and nutrients more difficult. That is why vitamin B12 deficiency is particularly common after surgery and supplementation is often required long after recovery.

Proper supplementation involves taking a daily form of vitamin B12 that dissolves under the tongue or getting a monthly injection, which is typically done by your primary care physician. 

To prevent vitamin B12 deficiency, follow the dietary recommendations for supplementation after weight loss surgery and get your blood work checked regularly by a primary care physician or bariatric care team.

If you experience the symptoms associated with B12 deficiency, please check with your health care team.

- Cara Stewart, RD, LDN

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150 Pounds Gone - I Feel Fabulous and Unstoppable!

Jackie Savoy, is a 47-year-old working mom of three. Her weight-loss surgery was performed by David Wernsing, MD, at Penn in February 2011. Here, she talks about how a sleeve gastrectomy procedure helped her lose almost 150 pounds and is helping her cross things off of her “bucket list.”

I chose to have bariatric surgery as a last resort for regaining my life. I’d been overweight ever since I was a child. As a mom and wife, I always put everyone else’s needs before mine. I decided it was time to do something for me and my health so that I could be the joyful, healthy person I wanted to be.

I weighed 328 pounds before I began my weight-loss journey with the Penn Metabolic and Bariatric Surgery Program, and today I credit the program’s team with saving my life.

Happy – On the Outside

Before surgery, I was happy on the outside.

Logistically, I tried to mask the fact my weight affected my lifestyle. I hated airplanes and avoided amusement parks because I was always fearful I wouldn’t fit in a seat or on a ride. I dreaded going to restaurants, because I worried if I had to go to the bathroom, I wouldn’t have enough room to move through the tables. And going to my kids’ schools for “Back to School Night” was a nightmare because I could never fit into the school seats.

I stopped going to my family physician because I was so afraid he would lecture me and tell me to go on a diet. When I finally did go, I learned I had hypertension and needed medication.

Through a sleep study, I also found out I had severe sleep apnea. In fact, while “sleeping” for eight hours, I learned I had only really been sleeping four hours because my breathing had stopped more than 150 times during the night. It’s a miracle I never fell asleep at the wheel of my car.

Finally, as a certified public accountant, I worried my clients wouldn’t trust my knowledge or professionalism. I was fearful everyone was judging me and my professional capabilities based on my weight.

A Team Approach to Weight-loss Surgery

I went to a weight-loss surgery information session at Penn Medicine without telling anyone because I knew this was a decision I needed to make on my own. I was extremely impressed with what I learned at that information session, and made my first appointment with the Penn Metabolic and Bariatric Surgery Program. From that moment, I knew I had a team of compassionate experts on my side to help me reach my goals.

My surgeon, dietitian and support group leader became constant sources of support and encouragement. With their help, I lost 47 pounds before surgery and was ready to begin a new chapter in my life.

Determined to Succeed

Since I joined the Penn Metabolic and Bariatric Surgery Program, I’ve lost almost 150 pounds, and have completely reinvented my life so I can continue to meet my lifestyle goals.

I wake up early to exercise every morning, and challenge myself with different activities. I track everything I eat to make sure I meet my nutritional guidelines. And I am having a ball shopping for my new, size 12 body.

I am also off all my hypertension medications and no longer have sleep apnea. I feel healthy and I have the energy to do the things I once thought I could not.

I’ve begun crossing things off my “bucket list” – things I could have never done before my weight-loss surgery. I took golf lessons, skied, and am training to run my first 5K race.

I feel fabulous and unstoppable!

But, perhaps the biggest difference is that I truly love myself. I put my needs first. I don’t care what other people think about me because I know I am healthy and strong.

I no longer hide in the shadows – I want to be seen and heard!

I never knew how good life could be until the team at the Penn Metabolic and Bariatric Surgery Program helped me start living.

Get more information about weight-loss surgery at Penn

Learn if bariatric surgery is right for you and attend a free information session about the Penn Metabolic and Bariatric Surgery Program.

At this free session, you will learn more about weight-loss surgery at Penn, and meet physicians and team members from the Penn Metabolic & Bariatric Surgery Program.

Register for this free event here.

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What is a Gastric Sleeve?

A recent study published in the New England Journal of Medicine compared the standard treatment of medication, diet and exercise to weight-loss surgery for the treatment of type 2 diabetes.

“This study shows in addition to gastric bypass, sleeve gastrectomy improves or resolves type 2 diabetes following surgery, and is more effective than medical management alone,” says Noel Williams, MD, director of the Penn Metabolic and Bariatric Surgery Program.

During a sleeve gastrectomy, or gastric sleeve, a sleeve-shaped tube is created from a small portion of the stomach, and most of the stomach is removed. Food passes through this tube directly into the intestines. Nutrients and calories are absorbed from food normally, but patients feel full sooner and stay full longer.

Sleeve gastrectomy is typically considered for patients with a body mass index (BMI) of 50 or higher. The surgery is performed laparoscopically and can be a permanent surgical solution to manage weight. A second operation may be required, however, if significant weight loss is required to improve the patient's health.

Get more information about weight-loss surgery at Penn

Learn if bariatric surgery is right for you and attend a free information session about the Penn Metabolic and Bariatric Surgery Program.

At this free session, you will learn more about weight loss surgery at Penn, and meet physicians and team members from the Penn Metabolic & Bariatric Surgery Program

Register for this free event here.

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What is Bariatric Surgery?

Bariatric surgery is a type of weight-loss approach that uses surgical procedures to help patients lose weight, avoid or reverse some diseases such as type 2 diabetes and high blood pressure, and improve overall health.

Because every patient considering bariatric surgery is unique, the Penn Metabolic & Bariatric Surgery Program offers a full range of bariatric surgical options. This ensures that patients receive the bariatric surgery that will provide them with the best possible results.

Here are four types of bariatric surgery at Penn.

Sleeve Gastrectomy

Sleeve gastrectomy is typically considered for patients with a body mass index (BMI) of 50 or higher. During the surgery, a sleeve–shaped tube is created from a small portion of the stomach and the majority of the stomach is removed. The small intestine is not surgically altered. Sleeve gastrectomy may require a second operation like conversion to Roux-en-Y gastric bypass (see below) if even more weight loss is required to improve a patient's health.

Robotic-assisted Bariatric Surgery

All procedures performed by Penn bariatric surgeons are available using a minimally invasive approach called laparoscopic surgery. Laparoscopic surgery offers many benefits for patients including shorter recovery times and less post-operative pain. In addition, Penn performs robotic-assisted bariatric surgery for the adjustable gastric band and sleeve gastrectomy procedures. Penn's bariatric specialists are highly experienced in robotic-assisted surgery and have performed more than 500 robotic LAP-BAND® and sleeve gastrectomy procedures.

Roux-en-Y Gastric Bypass (RGB)

The most common type of bariatric surgery performed in the United States, during the Roux-en-Y procedure a Penn surgeon divides a small gastric pouch from the upper portion of the stomach and attaches it directly to the small intestine, completely bypassing the larger part of the stomach.

Adjustable Gastric Band

The adjustable gastric band does not divide or reattach any part of the gastrointestinal tract. During the procedure, a Penn surgeon places a band around the upper portion of the stomach creating a small pouch with a narrow opening to the lower stomach. The food eaten stays in the small pouch for more time, so the patient feels full longer. The band is adjustable, which means it can be tightened or loosened after surgery as needed.

Get more information about weight-loss surgery at Penn

Learn if bariatric surgery is right for you and attend a free information session about the Penn Metabolic and Bariatric Surgery Program. 


At this free session, you will learn more about weight loss surgery at Penn, and meet physicians and team members from the Penn Metabolic & Bariatric Surgery Program.

Register for this free event here. 

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Does milk give you problems? A guide for choosing milk alternatives

Cara Stewart, RD, LDN, member of the Penn Metabolic and Bariatric Surgery team, provides a list of healthy milk alternatives.  

Milk is not the beverage of choice for everyone. Despite its nutritional benefits and popularity as a complement for everyday foods like coffee and cereal, cow’s milk is actually problematic for many people, especially those suffering from lactose intolerance or milk allergies and those who are vegans.

In fact, some patients become lactose intolerant after gastric bypass or sleeve gastrectomy surgery.

But the good news is that there are more lactose-free milk options available today than ever before. Follow this guide to choose the best milk alternative for you.

Lactose-free Milk - Lactase enzyme is added to regular cow’s milk to break the lactose down into a simpler sugar.

• Protein per cup: 8 grams
• Flavor: Slightly sweeter than regular milk.
• Where to purchase: Grocery store refrigerated section; available in low-fat, conventional and organic varieties; refrigerated cartons.

Goat and Sheep Milks - Milk from other animals contains lactose with a high degree of cross-reactivity, meaning that people with an allergy to cow’s milk have a high chance of reacting to these milk varieties as well.

• Protein per cup: Goat milk - 9 grams; Sheep milk - 14 grams
• Flavor: Sweeter than cow’s milk; grassy undertones.
• Where to purchase: Whole Foods or local farm market; refrigerated cartons.

Soy Milk - Made from cooking and pressing soybeans.

• Protein per cup: 7 grams
• Flavor: Nutty, beany flavor with thick consistency.
• Where to purchase: Grocery store; shelf stable and refrigerated cartons in variety of flavors.

Nut Milk - Made by soaking and grinding nuts into pulp, then straining the creamy liquid. Almond milk is the most readily available, but there are other nut milks including hazelnut and cashew as well.

• Protein per cup: 1 gram
• Flavor: Nutty with thin consistency.
• Where to purchase: Grocery store; shelf stable and refrigerated cartons in a variety of flavors.

Hemp Milk - Made from the seeds of cannabis plants, hemp milk does not contain psychoactive substances. It is a good source of omega-3 and -6 fatty acids.

• Protein per cup: 2 grams
• Flavor: Nutty, earthy flavor with thick texture.
• Where to purchase: Natural foods store, Whole Foods; shelf stable cartons.

Grain Milks - Made from cooked grains such as oats or barley.

• Protein per cup: 4 grams
• Flavor: Mild, grainy and nutty.
• Where to purchase: Whole Foods or natural foods store; shelf stable cartons.

Rice Milk - Made from cooked rice.

• Protein per cup: 1 gram
• Flavor: Sweet with watery consistency.
• Where to purchase: Grocery store; shelf stable cartons.

Coconut Milk - Made from coconut meat and the water inside the coconut.

• Protein per cup: 4 grams
• Flavor: Slight coconut flavor; creamy texture.
• Where to purchase: Grocery store; refrigerated cartons.

- Cara Stewart, RD, LDN

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Having a Baby After Weight Loss Surgery

Cara Stewart, RD, LDN, member of the Penn Metabolic and Bariatric Surgery team, and Monica A. Mainigi, MD, fertility specialist at Penn Fertility Care, provide important information for women trying to become pregnant and maintain a healthy pregnancy after weight loss surgery.

Many women struggle with fertility as a result of their weight. In fact, obesity puts women at greater risk for ovulation dysfunction and menstrual irregularity, both of which can interfere with fertility. In addition, obesity can lead to an increased risk of miscarriage and decreased success with fertility treatments. For overweight women who are having a hard time conceiving, weight loss surgery may be an option to consider.

For women considering pregnancy after they have had bariatric surgery, it is important to keep the following information in mind.


Fertility boost
Obesity can interfere with hormone production, making it more difficult to get pregnant.  Weight loss after bariatric surgery can lead to regular cycles and ovulation, and improved fertility. In fact, a 2005 study published in the Journal of Clinical Endocrinology and Metabolism found that surgical weight loss for women with PCOS often resolved their reproductive and metabolic abnormalities. 

Healthier pregnancy, healthier baby
After weight loss surgery, medical conditions such as high blood pressure and diabetes are significantly improved or resolved leading to a lowered risk of developing serious complications during pregnancy or delivering a baby born with complications.  Many women are still obese after weight loss surgery which places them at a higher risk for gestational diabetes and preeclampsia, but the risk is far less than before surgery.  Pregnant women who have had bariatric surgery should see a high-risk obstetrician to best manage prenatal care.

Give it time
It is important to wait at least 18 months after surgery to start trying to get pregnant. In the period immediately following gastric bypass or sleeve gastrectomy, rapid weight loss causes stress on the body, including diminished nutrition intake, which can cause complications for an expecting mother and growing baby. Effective contraception is absolutely critical for women pursuing weight loss surgery.  For women with an adjustable gastric band, fluid may be removed from the band during pregnancy to accommodate the need to eat more calories.

Keep supplementing
Good nutrition is especially important for women trying to conceive.  After weight loss surgery, patients are at a higher risk for deficiencies of certain nutrients, including vitamin B12, folic acid, calcium, iron, and vitamin D. It essential to continue taking vitamin and mineral supplements as recommended by the bariatric team.

Be ready for weight gain
After having weight loss surgery, it can be difficult to accept that pregnancy is a time when it is normal, healthy and necessary to gain weight.  Healthy weight gain during pregnancy is important to nourish a growing baby, but work with the program dietitians to avoid unhealthy weight gain during pregnancy.

The Penn Metabolic and Bariatric Surgery Program offers lifelong follow-up care and nutritional support for patients who have had weight loss surgery. Women considering pregnancy after weight loss surgery should discuss their plans with the bariatric surgery team.

For more information on fertility services at Penn Medicine, visit the Penn Fertility Care website.

- Cara Stewart, RD, LDN and Monica Mainigi, MD

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Taking Vitamin and Mineral Supplements: Make time even if you feel fine!

Cara Stewart, RD, LDN, member of the Penn Metabolic and Bariatric Surgery team, outlines the important vitamin and mineral supplements to take after weight loss surgery.

After weight loss surgery, you need to commit to taking a regimen of vitamin and mineral supplements for the rest of your life. Eating smaller amounts of food means your body receives fewer nutrients. In addition, after gastric bypass or sleeve gastrectomy surgery, your system does not absorb some vitamins and minerals as well.

This table highlights the functions of several key nutrients and the symptoms of their deficiency. The damage to your body from many of the deficiencies is permanent, so be sure to follow your dietician’s instructions for taking supplements and have your lab values checked routinely with your primary care physician.

NUTRIENT	WHAT IT DOES	DEFICIENCY
Vitamin B1 (thiamine)	Helps all cells of the body produce energy from carbohydrates	Fatigue, weak muscles, nerve damage
Vitamin B12	Works with folate to make red blood cells Vital part of every cell Helps body use fatty acids and some amino acids	Anemia, fatigue Permanent nerve damage including tingling or numbness in hands and feet
Folate (folic acid)	Plays essential role in making new body cells Works with B12 to form hemoglobin in red blood cells Helps reduce risk of neural tube defects (spina bifida) in developing fetus	Anemia caused by malformed blood cells that won’t carry as much oxygen Increased risk of neural tube defects in developing fetus
Vitamin A	Promotes normal vision, helps eyes see normally in the dark Promotes growth and health of all cells Keeps tissues healthy to prevent infection Works as an antioxidant	Night blindness Dry, scaly skin Reproductive problems
Vitamin D	Promotes absorption of calcium and phosphorus Regulates amount of calcium in blood	Osteoporosis (loss of bone mass) Osteomalacia: softening of bones
Calcium (**NOTE: Supplements are still needed even if blood levels are normal)	Helps bones remain strong by slowing rate of bone loss with age Helps muscles contract and heart beat Promotes normal nerve function	Osteoporosis
Iron	Essential part of hemoglobin that carries oxygen in blood Supports healthy immune system	Iron deficiency anemia Fatigue Infections

- Cara Stewart, RD, LDN

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Feeling Tired or Sluggish? The Culprit Could be Iron

Cara Stewart, RD, LDN, member of the Penn Metabolic and Bariatric Surgery team, discusses the impact bariatric surgery has on iron levels and provides tips for iron supplements.

Your body uses iron to produce red blood cells. Insufficient iron in your diet may put you at higher risk for developing iron deficiency or iron deficiency anemia. Iron deficiency is a condition in which the body does not produce enough normal red blood cells for optimal health. Symptoms of iron deficiency include:

• Tiredness
• Shortness of breath
• Decreased physical performance
• Learning problems in children and adults
• Increased risk for infection

People who have had bariatric surgery are more prone to iron deficiency because of their reduced intake of iron-rich foods, such as red meat, seafood, and poultry. In addition, gastric bypass and sleeve gastrectomy patients produce less stomach acid, which can interfere with iron absorption. Maintaining an optimal iron level is particularly challenging for people who have had gastric bypass, as the surgery circumvents the primary site of iron absorption.

While some people with bariatric surgery are still able to obtain adequate iron from food, others rely on iron supplements to maintain a healthy iron level. For those who require iron supplements, the following tips can help maximize iron absorption while minimizing any unpleasant side effects.

• Take 250 mg of vitamin C or consume foods rich in vitamin C when taking an iron supplement. Examples of good sources of vitamin C include:

- Bell Pepper
- Broccoli
- Brussel sprouts
- Citrus fruits
- Cantaloupe
- Cauliflower
- Kale
- Parsley
- Strawberries

• Take iron supplements with food to prevent nausea or abdominal discomfort.

• Prevent constipation by consuming adequate fiber through your diet and supplements, drinking enough fluids and exercising regularly.

• Avoid calcium supplements and dairy when taking an iron supplement or consuming iron-rich food. Calcium can inhibit the absorption of iron. Separate consumption of calcium and iron by at least two hours.

• Avoid tea, cola, coffee, red wine, pomegranates and berries when taking an iron supplement or eating iron-rich food. These foods and beverages contain tannins, which can inhibit iron absorption.

Make sure to check with your healthcare team to determine whether an iron supplement might be helpful for you.

- Cara Stewart, RD, LDN

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