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Gastric Sleeve

  • Sleeve Gastrectomy (Gastric Sleeve) is the most commonly performed bariatric surgery.

  • Sleeve Gastrectomy leads to Weight Loss through a decreased appetite and reduction of stomach size.

  • Surgery is performed with keyhole techniques (laparoscopic) under a general anaesthetic.

  • Hospital stay is usually two nights.

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Sleeve Gastrectomy. 

The Stomach is divided with staplers, creating a narrow tube.  The larger part of the stomach is removed.

Dr Crawford explains weight loss surgery and demonstrates a Gastric Sleeve operation

AM I A CANDIDATE FOR WEIGHT LOSS SURGERY?

Body Mass Index (BMI) is a method for measuring obesity and relates to a person's height and weight. A BMI score is derived by dividing a person's weight (in kilograms) by their height (in meters) squared. BMI=wt/(ht x ht).   A BMI of >35 is an indication that you might benefit from surgery. You can check your BMI here >

Associated health risks

There are a number of medical conditions that have a direct association with obesity. These include type 2 diabetes, hypertension, fatty liver disease, respiratory problems, female infertility, and psychological problems such as depression. Patients who are obese are more likely to suffer from coronary heart disease and stroke. There is clear evidence that obesity is associated with reduced life expectancy. Those who are morbidly, or super obese face a risk of dying that is twice that of others of the same age.

Dieting

Randomised controlled trials have shown that surgery results in greater weight loss than diets. This weight loss is maintained over a longer period when compared with even the best of diets.

Importantly, studies have shown that mortality (risk of dying) is significantly reduced in patients who undergo surgery for weight loss when compared with those who don’t.

WHY SURGERY?

Weight loss surgery should be considered if you:

  • Are unable to achieve a healthy body weight for a sustained period of time, even through medically supervised dieting and exercise.

  • Have a Body Mass Index (BMI) of over 40.

  • Have a BMI of over 35 and are experiencing negative health effects

  • Weigh more than 45 kg above your ideal body weight.

  • Are highly motivated and committed to long term lifestyle changes

WHERE TO BEGIN?

Choosing Surgery

If your goals are to live better, healthier and longer, you may want to choose weight loss surgery such as a Sleeve Gastrectomy

 

Discuss your reasons for having surgery with someone you trust; you will be counting on them to help you during and after weight loss surgery.

WEIGHT LOSS SURGERY

Surgery for obesity has been carried out for decades and numerous advances have been made during this time. In the past, surgery for weight loss was associated with high risks of side effects and complications. Advanced laparoscopic (keyhole) techniques have allowed this to become a safe and reliable means of achieving and maintaining weight loss.

Surgical treatment of obesity is a major undertaking. It means undergoing major surgery and requires a lifelong commitment to compliance with post- operative medical care. It is not a cosmetic procedure for those who are just unhappy with their body image, but rather a medically proven treatment for an established health problem.  Patients should have seriously attempted to achieve and maintain weight loss before considering surgery.

Types of surgical procedures

1.     Restrictive procedures that decrease food intake. This includes SLEEVE GASTRECTOMY (also known as Gastric Sleeve and Vertical Sleeve Gastrectomy) and gastric banding.

 

2.     Malabsorptive procedures alter digestion by diverting food away from the early intestine.  This results in production of powerful hormones that suppress appetite and correct insulin resistance (treating type 2 Diabetes). They can also incorporate an element of restriction. GASTRIC BYPASSES are examples of this type of procedure.

 

Sleeve Gastrectomy: Not only limits how much can be eaten at one time, but also decreases hunger and appetite by pressure in the upper stomach and removal of the part of the stomach responsible for the ‘appetite hormone’ (Ghrelin).

WHAT IS SLEEVE GASTRECTOMY?

Sleeve Gastrectomy is performed using laparoscopic (keyhole) techniques to resect and remove a large segment of the stomach (up to 80% of the total volume), whilst maintaining the normal passage of food anatomically. The remaining stomach looks very similar to a normal stomach, only much narrower. The capacity of the stomach is reduced from about 1.5 litres of food and liquid to approximately 300mls, and this provides the brain feedback via stretch receptors that signal that feeling of fullness and satiety.  Severe hunger is reduced.  Despite being smaller, the remaining stomach will still function normally.

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The surgery involves 4 to 5 small incisions in the abdomen, and dissection and stapling off of the excess stomach (which is removed from the body), using special stapling devices. Care is taken with the stapler to minimize the risk of leakage.

PRIOR TO SURGERY.

You will need to be on an ‘Ultra-low Calorie Diet’ before surgery.  Optifast is taken for 2 weeks to replace ALL meals.  Your nutritionist will advise you on appropriate very low calorie substitutes to give you a break from the optifast.  (Salad or steamed vegetables without dressings or oil for a ‘treat’). 

The usual stay in hospital is 2 post-operative nights.

 

Following Surgery

Day 2-7: Fluids that could be sucked through a thin straw.

Day 7 to week 3-4:  Pureed food.

Week 4+:  Slow introduction of some more solid foodstuffs thereafter, as guided by the team.

 

  • Progress from thin to thick only after the thinner fluids are easily tolerated 

 

Reflux/heartburn is occasionally experienced early after sleeve gastrectomy, you will therefore have an anti-acid tablet for 30 days.  Sometimes it persists long-term and an anti-acid treatment might be required.

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Step 1.  The omentum is separated from the greater curve of the stomach.
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Step 2. The sizing tube is passed through the mouth and the stomach is divided with 5-6 fires of the stapler.
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Step 3. The staple line is stitched, with support of the fatty omentum.
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POTENTIAL COMPLICATIONS OF SLEEVE GASTRECTOMY

Thankfully serious/major complications are rare, but nonetheless they could occur. 

Leak

This is the complication that worries bariatric surgeons the most with respect to this procedure.  The leak is caused by a combination of the intentionally high pressure remnant stomach and either a failure of staples or a failure of healing.  Most leaks occur in the upper part of the staple line where the healing can be most compromised.Leaks could occur: 

  • early (within days of surgery) while you are still in hospital, with peritonitis.  You would need another keyhole surgery to washout and drain the infected fluids, and other procedures such as stents until it healed. This is rare, particularly if you haven't had stomach surgery before.

  • later (within weeks of surgery) when you are home recovering.  The symptoms are sometimes subtle but include new vomit, cough, fever or sweats.  These leaks would usually cause an abscess (localized collection of pus) around the upper stomach.  These are usually managed with small plastic tubes (stents) placed by an endoscope.

There are some patient and surgical factors that influence the likelihood of a leak:

  • Previous surgery (particularly gastric band) due to the scar tissue build up and the possibility of folded over stomach in the staple line.  This is thought to be particularly when the removal of band is performed at the same time as the sleeve operation.

  • Smoking impedes healing and there is some evidence that it might affect leak rates, so smokers should cease prior to surgery if possible.

  • Too tight sleeve.  We know that as we tighten the remaining stomach by using smaller sizing tubes, we run into more problems from leak because of pressure.

  • Other technical aspects, such as type and size of staples, the use of buttressing, the presence of a sliding Hiatus Hernia, where the upper staple-line could be ‘sucked’ up into the negative pressure of the chest influence leak rates. 

Preventing a leak:  There is no absolute way to prevent a leak in Gastric Sleeve.  Early leaks due to technical failure are very rare.  Most leaks occur because of a healing problem and show up at around 2-6 weeks after surgery.

 

         The risk of a leak:  The overall risk of a leak is between 1-2%.  Dr Crawford will explain if he thinks your risk is higher than this.

Reflux (Heartburn)

Many people have reflux before surgery from being overweight.  Some have a Hiatus Hernia which is a weakness in the diaphragm, just above the stomach which is checked for and if necessary corrected during surgery. After surgery, around 30% will suffer some degree of reflux that might mean taking anti-acid tablets long term.  For severe reflux a conversion to a bypass operation might be necessary (about 1/50 patients).

 

         OTHER POTENTIAL COMPLICATIONS

These include but are not limited to the following which are similar for almost any abdominal surgery.

  • Wound infection

  • Bleeding/Clots

  • Pneumonia

  • Heart trouble

  • Hernia

  • Bowel obstruction

General Advice and Possible Minor Side-effects after Surgery

VOMITING

Patients may vomit or feel pain after food intake. This can be can be caused by swallowing too quickly, trapping air, or un-chewed chunks of food getting stuck.  By eating slowly and calmly, you will learn to listen to the signals from your stomach. Notify Dr Crawford if new or persisting vomiting develops after you are home.

VITAMINS

During the phase of rapid weight reduction, vitamin supplements are advisable. A chew-able or liquid vitamin mixture containing multivitamins, in particular the vitamin B complex, is recommended following surgery. Your nutritionist will give you advice around vitamins.

 

PREGNANCY

The period between surgery and weight stabilisation is considered to be a period of starvation. It is not advisable to become pregnant during starvation, despite the fact that the foetus has priority over the mother with regard to nourishment. Should you nevertheless get pregnant, it is advisable to let Dr Crawford and your nutritionist know. You should wait until your weight has stabilised before planning pregnancy. Around 9 to 12 months.

 

MEDICATION

Tablets can be broken down into small pieces or crushed before they are taken. It is common that medication for conditions such as hypertension, diabetes or asthma may need to be altered (reduced) after this operation. Patients should consult their doctor about this.

 

APPOINTMENTS

After surgery, you will see your dietician about a week or two later, you will see Dr Crawford at 4-5 weeks and then as often as required (usually once or twice over the next few moths), before settling in to an annual review. 

PHYSICAL ACTIVITY

It will be important to alter not only your eating habits, but also your level of physical activity. You should to start exercising slowly after surgery. As weight loss is achieved, physical activities will gradually become easier.

LONG TERM FOLLOW-UP AND LIFESTYLE

In order to get the best results from your surgery, it is important that you are committed to long term changes. Regular consultations may be necessary to review your progress, monitor your weight and health, advise you on diet and exercise and look for any long term problems.

Your commitment to dietary and lifestyle changes is essential to ensure the success of your surgery. In the long term you should eat small healthy meals and drink only liquids containing little or no calories such as water, tea, coffee and drinks.

Regular exercise should be a part of your weight loss program and you should aim to exercise for at least 20 to 30 minutes every day.

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