Sleeve Gastrectomy

Background

The sleeve gastrectomy, also known as the gastric sleeve resection, or tube gastrectomy, is an operation where approximately 90% of the stomach is removed to reduce its capacity to around 100 to 200mL.

Normally, the stomach is a pouch which can take a large volume of food and fluid and expand while doing so. This allows us to eat a meal which is much larger than required to maintain a healthy weight. Almost all weight loss procedures attempt to reduce the stomach’s capacity in some way. With a sleeve gastrectomy the large redundant part of the stomach is removed permanently.

Who Qualifies for A Sleeve Gastrectomy?

You may be eligible for a sleeve gastrectomy if you have a body mass index (BMI) that is greater than 40 (or greater than 35 with weight related illnesses) and you have tried all other types of diets without long-term success.

The Surgery

The sleeve gastrectomy procedure is performed with laparoscopic (keyhole) technique under general anaesthesia. Five small incisions (between 5 and 15mm in length) are made for the insertion of keyhole surgery instruments. Using these instruments, the size of the stomach is reduced by stapling along the length (over a sizing device called a bougie) to form a long tube that looks similar to a banana. The majority of the stomach is then removed and discarded.

How does the surgery help you to lose weight?

The sleeve gastrectomy procedure helps you to lose weight in two ways;

  • Reduces the amount of food that can be eaten at one time – The volume of food the pouch can take is greatly reduced which allows you to feel full from a small portion of food.
  • Suppresses appetite the stomach secretes a hormone call ghrelin, which is involved in appetite stimulation. By decreasing the size of the stomach, the amount of ghrelin produced is also decreased therefore suppressing appetite.

It is important to remember that surgery is a TOOL for weight loss. It is vital that eating behaviours are modified to get the best result from the procedure. It is important to eat a variety of healthy foods, to limit your intake of calorie dense foods and liquids and to slow your speed of eating to improve food tolerance. If eating behaviours are not adapted after surgery, weight loss will be limited or weight regain can be possible in the future. More detailed information about correct eating behaviours will be covered during your visit with the dietitian.

Expected weight loss

The sleeve gastrectomy is quite successful in initial weight reduction as well as maintaining the weight loss. Weight loss after a sleeve gastrectomy tends to be faster than the other common operation. Most patients can expect to lose 60 to 70% of their excess body weight over 6 to 12 months.

Advantages of a sleeve gastrectomy

  • Great dietary quality of life. All foods can usually be eaten, but in much smaller quantities.
  • Generally rapid and reliable weight loss.
  • It does not require any on-going adjustments which are required with other procedures, such as the gastric band. However, regular follow up is necessary to ensure weight loss is appropriate and intake is nutritionally adequate.

Disadvantages of a sleeve gastrectomy

Disadvantages of the sleeve gastrectomy are generally related to the magnitude of the surgery:

  • Complications, although rare, are generally more serious than with other weight loss procedure, such as gastric banding. If a leak occurs it can be a problem which can take months to resolve.
  • The sleeve gastrectomy is a relatively new operation. As a result, there is very little long-term data (data which extends to over 10 years) to know what will happen with weight loss. It is likely that the sleeve will dilate with time and weight loss will not be as good after ten years as it was after one to two years. All bariatric surgeries suffer in some way from this problem.

Risks of the Sleeve Gastrectomy

As with any surgical procedure, the sleeve gastrectomy operation has a risk profile which is important to understand before proceeding. The following is a comprehensive list of issues which can occur. This list is extensive and is not intended to worry you, but simply inform you about the range of possible complications, regardless of how rare the issue may be.

Possible Acute Complications

Acute surgical complications can include (but are not limited to):

  • Bleeding – Postoperative bleeding can require blood transfusion and occasionally reoperation. Bleeding can occur in roughly 1 in 200 patients.
  • Leaks at the staple line- This is the most feared complication of sleeve gastrectomy. It occurs in roughly 1 in 100 patients. This can at times require a repeat surgery, occasionally in the first few days after surgery. If these leaks persist they can turn into either communications with the skin or wound (fistula) or persistent infections within the abdominal cavity (abscesses). If this complication occurs the length of stay in hospital can be extended to weeks or potentially months after surgery. This can be a life-threatening problem.
  • Infection – This may require treatment with antibiotics and occasionally reoperation.
  • Wound issues ‚ÄúPeople with a higher BMI are at a higher risk of complications involving wound infections, haematomas (large bruises) and poor wound healing.
  • Other extremely rare issues – As this surgery affects the function of the gut, some patients are unable to tolerate adequate intakes of food which can result in the requirement of long-term nutritional support via intravenous methods, called TPN (total parenteral nutrition).
  • Damage to organs – any keyhole procedure can be complicated by unintentional injury to the organs near the area of operation. This may require a repeat operation to repair of the damaged organs.
  • Blood clots – Deep Venous Thromboses (clots in the veins) and pulmonary embolus (clots in the lungs)
  • Pneumonia/ chest infection

Possible Long Term Complications

  • Any intra-abdominal procedure related to the gastrointestinal tract can be complicated in the long-term by problems associated with adhesions(scar tissue) related to the gut.
  • Any intra-abdominal procedure has a low risk of subsequent herniaformation related to the wound closure
  • Both of these conditions could lead to the necessity for repeat surgery, sometimes even in the emergency setting
  • Increased chance of gastro-oesophageal reflux (heartburn). If reflux occurs post operatively some patients can require acid suppressing medication. This operation is avoided for those people with severe symptoms of reflux prior to surgery.
  • There are occasional issues related to malabsorption of micronutrients these are usually easily managed with supplemental vitamins and minerals. Long-term monitoring of blood tests is required.

Pre-Operative Diet

When you have a date for surgery, you will be advised to have a very low calorie liquid meal replacement diet for 14 days prior to surgery. OptifastTM is the recommended meal replacement and is available from your local Chemist. The diet helps you to lose weight, particularly from the liver, and therefore optimizes the safety of the procedure. Your will receive more detailed information about this when you see you dietitian.

Post Operative Care

The hospital stay after surgery is generally three to five days. After the procedure you will start on clear fluids only (water, black tea, broth, juices). These will need to be sipped slowly in small amounts. An x-ray study is performed after the operation to check the size of the stomach pouch and to exclude a leak from the stapled edge of the stomach. You will then be able to have free fluids for the rest of your hospital stay. During the next 4 to 6 weeks, while your body heals, you will gradually increase the texture and volume of the food you take. Further information, including a dietary guidelines booklet, will be provided at your appointment with the dietitian.

Appointments

Surgeon

The first post-operative clinic visit will be arranged about 1 to 3 weeks after surgery. At this appointment your wounds will be assessed and any other issues will be discussed.

Dietitian

The dietitian will phone you within the first week following surgery to review your intake.

Your first post-operative clinic visit will be at 3 to 6 weeks following surgery and then 3 to 6 monthly for the first two years.

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