Gastric Sleeve (Sleeve Gastrectomy)

Gastric Sleeve (Sleeve Gastrectomy)

 

What is a sleeve gastrectomy?
Sleeve gastrectomy, also known as the gastric sleeve, is a medical procedure used to treat obesity. It has been shown to be a safe and clinically effective weight-loss surgery. Sleeve gastrectomy reduces the risks of potentially life-threatening obesity-related conditions (e.g., diabetes, high blood pressure, sleep apnoea and high cholesterol) with a 75% chance that these conditions will either improve or resolve following sleeve gastrectomy. This leads to significant improvements in your health in the long term.

How does sleeve gastrectomy work?
Sleeve gastrectomy works by reducing the size of your stomach. Naturally, the smaller the stomach you will have after the operation will decrease the portion size you can eat, as you’ll feel full very quickly and continue to feel full for several hours. 

Besides helping you eat less due to the reduced stomach size, sleeve gastrectomy works by reducing your appetite. The removed part of your stomach produces a hormone called ‘ghrelin’. This hormone stimulates your appetite and makes you feel hungry. Taking out this part of your stomach will reduce your ghrelin hormone level and hence will reduce your hunger feeling. This added benefit will help you in losing weight after this procedure. 

In the first 18 months following surgery, you can expect to lose an average of 66% of the extra weight you are carrying over and above a normal body weight (excess body weight).

What happens during surgery?

Sleeve gastrectomy is carried out laparoscopically (keyhole surgery) under general anaesthesia. Your surgeon will make about five small incisions in your belly. Through one of the incisions, he/she will insert a thin telescope connected to a tiny high-definition video camera. The camera will be connected to a TV screen in theatre which your surgeon will be looking at during the surgery. Through the other cuts, long thin instruments are introduced which your surgeon will use to perform the operation.

During this stomach-reduction surgery, your surgeon will divide and seal any blood vessels supplying the part of the stomach that will be removed.

He/she will then use a special surgical stapling device to surgically staple and seal your stomach using a calibration guide tube to measure the size of the stomach tube left behind. The surgeon then removes the bulk of your stomach (about 70%) permanently, leaving behind a thin banana-shaped stomach tube or ‘sleeve’, hence the name sleeve gastrectomy. No intestines are removed or bypassed during this procedure. The operation takes usually about one hour. 

Aftercare and recovery
When you wake up after the operation, you will be in the recovery area of the operating department. The recovery team will ensure you are not in pain and that you are safely woken from the anaesthetic. Then you will be transferred to either the ward or the High Dependency Unit based on a pre-operative assessment of your medical problems. 

On your first night following surgery, the nursing staff will monitor you carefully, checking your blood pressure and other vital measurements regularly throughout the night. You will be allowed to drink fluids straight away and will also have additional fluids via a drip. Pain killers and anti-sickness medications will be given to you as needed.

In the morning following the operation, you will have breakfast (liquidised diet) and will usually see the physiotherapist who will help you with breathing exercises and mobilisation. It is important to start moving and walking as soon as possible after the operation. During your hospital stay and for three weeks afterwards, you will be given a small injection under your skin to thin your blood slightly to reduce the risk of you forming clots in your legs (deep vein thrombosis).

On the second day following the operation, the dietician will review you on the ward and provide further advice about your diet. It is expected usually that you will have a liquid-only diet for about 2-3 weeks, followed by soft, ‘mashed-up’ food for another 2-3 weeks. Afterwards this, you can progress to normal solid food, just in much smaller quantities now

Your surgeon will review you on a daily basis during your hospital stay. Most patients stay in the hospital for two nights and go home on their second day after surgery. 

On your day of discharge, the hospital will supply you with the medications you need following surgery which will include:

  1. Anti-acid medication – taken for three months after surgery
  2. Vitamins – to be continued indefinitely
  3. Pain killers
  4. Blood-thinning injections (daily for three weeks following surgery)

Exercise post-op
You will be encouraged to mobilise and walk straight after surgery. Gentle exercises like walking, housework and swimming could be started shortly after surgery. However, heavy lifting and strenuous gym work should be avoided for the first 6 weeks following surgery.

Gastric sleeve wound care
Your surgeon will either use dissolvable stitches, surgical glue or clips to close the skin at the end of your operation. All of these techniques produce similar results in terms of the final appearance of your scars.  If clips are used, you will usually have them taken out 10 days after the surgery at your local GP practice. The nursing staff will check your wound healing during your hospital stay and give you instructions on wound care before your discharge.

Is a sleeve gastrectomy right for me?
If you have tried to lose weight by eating healthier and exercising but these measures were not effective, then you might qualify to have a bariatric procedure to help you with your weight loss. In general, weight loss surgery could be an option for you if: 

  • Your body mass index (BMI) is 40 or higher or if your BMI is above 35 and you also suffer from obesity-related medical conditions which may improve with the surgery (e.g., diabetes, high blood pressure or sleep apnoea).
  • Your BMI is greater than 30 (greater than BMI 27.5 if you are of Asian origin) and you have type 2 diabetes.
  • You are committed to a healthy life after surgery by maintaining lifestyle and diet changes in the long term. 

Sleeve gastrectomy is an effective weight-loss surgery which reduces your weight and improves/resolves many of the obesity-related medical conditions you might have. It will also improve your ability to perform routine daily activities and can help improve your quality of life. 

You surgeon might recommend sleeve gastrectomy to you if: 

  1. Your BMI is less than 65 and you have a diet that doesn’t contain a large number of sugary foods. Gastric sleeve in this situation could be done as primary surgery. 
  2. Your BMI is > 65. Gastric sleeve could, in this case, could be used as a first surgery to help you lose enough weight so you can then safely have a more extensive type of weight-loss surgery later on (usually about 12 months after the gastric sleeve operation).
  3. You are older or have other risk factors for surgery like heart, lung or liver problems. Sleeve gastrectomy may be in this situation a safer choice for you than other longer and more complicated weight-loss surgeries.

Rarely, the decision to perform sleeve gastrectomy (instead of gastric bypass) is made during the operation. Reasons for making this decision include an excessively large liver or extensive scar tissue and bowel adhesions that would make the gastric bypass procedure too long or unsafe.  If we think it’s likely that this might be necessary for you, we will explain this plan to you beforehand and ensure that you are happy to proceed on that basis.

What are the side effects and risks of a sleeve gastrectomy?
There are several potential complications of sleeve gastrectomy operation. Your surgeon will explain these risks to you in detail during your consultation with him/her before the operation. 

The following are serious or frequently occurring risks.  Fortunately, most of them are uncommon, particularly in the hands of an experienced bariatric team like Phoenix Health:

Short-term risks:

  • Bleeding (blood transfusion may be required)
  • Infection and wound pain 
  • Organ, bowel or vascular damage including the risk of splenectomy (removal of the spleen).
  • Conversion from laparoscopic (keyhole) to open surgery
  • Staple line leak (2%) which may require further surgery and a prolonged hospital stay on the ward and/or intensive care
  • Anaesthetic complications (heart attack, chest infection, sickness and vomiting).
  • DVT and pulmonary embolism (blood clots in the legs and lungs)
  • Portal Vein Thrombosis – an extremely rare but serious complication

Long-term risks:

  • Stomach ulcer, fistula and/or stricture (narrowing) or twist requiring post-operative dilatation (stretch) or re-operation.
  • Acid reflux – this is probably the most common side effect after sleeve gastrectomy and might require you to take antacid drugs long-term (or at higher doses).  Rarely, the reflux is sufficiently severe to merit conversion of the sleeve gastrectomy to a Roux-en-Y gastric bypass.
  • Nutritional deficiencies (vitamins, minerals, protein)
  • Alopecia (hair loss)
  • Gallstone formation (10% risk of future cholecystectomy)
  • Excessive weight loss and/or loose skin on stomach, thigh, arms and breasts
  • Poor weight loss
  • Weight regain and stretching of the gastric sleeve with time
  • Psychological difficulties adapting to weight loss and its consequences. 

Your surgeon will also discuss with you your estimated mortality risk from this surgery. This varies greatly between patients as everyone has different risks based on their weight and other illnesses. The average risk to life after sleeve gastrectomy is around 1 in 500.  To put this into perspective, the average risk of death after a hip replacement is about 1 in 250.

Is the sleeve gastrectomy reversible?
Sleeve gastrectomy is not reversible because the removed part of the stomach will be taken out of your body. Therefore, it is considered a permanent operation.

If you commit to the aftercare process, it will have a very good long-term impact not only on your weight but also on many weight-related medical problems you might have such as diabetes, high blood pressure, sleep apnoea, depression and infertility. 

If you fail to reach the expected weight loss after surgery, your surgeon might discuss with you alternative or additional medical and/or surgical interventions (revisional surgery or ‘re-do’ surgery) which could be offered at the time to help you achieve your target.

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