There exists a small percentage of obesity patients who suffer such extreme overweight (BMI>55) that traditional strategies such as Roux-en-Y Gastric Bypass may be insufficient to bring them to a near normal weight range.  For these patients, desperate for relief from a life of unending pain and suffering, doctors have devised a 2-step strategy to gradually reduce the patient's excess body weight whilst avoiding any organic shock effects which could potentially damage the patient's health.  Most patients at this weight level have built their high BMI over many year, so doctors understand that radical weight loss cannot occur with a short time line.  Rather it must be taken gradually, allowing the patient's body and metabolism to adjust to restricted nutritional intake.  Of particular importance is the necessity to interrupt the hunger-consumption loop that has for so many years driven their weight gain and obesity.

With these considerations in mind, doctors will often recommend for extreme patients, a Gastric Sleeve or VSG (Vertical Sleeve Gastrectomy) as the first step to reduce excess weight before taking the patient through a more complex procedure such as Gastric Bypass or Duodenal Switch.  In VSG surgery nearly 80% of the stomach is removed leaving a small sleeve-shaped upper part to perform normal stomach functions.  This procedure not only physically restricts the amount of food a patient can ingest, it also sharply reduces the body's production of the body's hunger inducing hormone which stimulates overeating.

Individuals with a high Body Mass Index will often suffer a variety of ailments that make them unacceptable candidates for a single weight loss surgery.  For example, extremely high BMI patients usually have chronic medical conditions such as Type II diabetes and hypertension.  Moreover, full anesthesia can pose high risk to such patients who can suffer serious breathing problems during surgery.  Medical staff are particularly aware of this problem and take great care to properly manage airway and pulmonary function during surgery.  Even physical mobility may be severely restricted and many doctors prefer that patients be ambulatory before taking them to a lower weight level.

Safety is indeed the main purpose for treating extreme obesity with a 2-stage approach.  This 2-step strategy has been proven to be relatively safer for high-risk weight loss surgery patients.  This is an important consideration since the possibility of patient mortality, present in any surgical procedure, is amplified with extreme obesity

Use of VSG is a logical choice in these cases because Gastric Sleeve can be quite effective in producing weight reduction results similar to Gastric Bypass.  As a slightly less radical procedure it is often used where other procedures may present risks.  For example, patients taking anti-coagulants are usually referred for Gastric Sleeve.  Patients who do not want to radically change the gastro-intestinal structure of their lower digestive tract often will opt for Gastric Sleeve.  And, female patients contemplating a future pregnancy also will sometimes choose a Gastric Sleeve procedure because it can be less restrictive in nutritional intake, and can be overcome if the patients must take in more food over a short period of time

For patients with extreme overweight at the upper end of the curve, there is hope. Numerous cases have shown that a combined strategy which allows the patient's body to adjust over time to reduced food intake can achieve amazing weight loss results while reducing patient comorbidities and surgical risk.