Laparoscopic Sleeve Gastrectomy

Laparoscopic Sleeve Gastrectomy

Also known as Sleeve Gastroplasty, Tube Gastroplasty, Tube Gastrectomy.

In summary

You want to eat less, and the stomach holds less food and therefore eat less.

The Sleeve Gastrectomy leaves you with a smaller stomach and simply cannot hold anywhere near as much food initially. The volume of food you can eat does increase with time, but does not return to the previous volume.

Most of the stomach is removed leaving a narrow tube

The stomach is usually a bit like a typical balloon, in that it is round and the more you fill it the bigger it gets, but deflates again when it is emptied. As the stomach fills with food you start to fill full because the stretch of the stomach stimulates a message to be sent to the brain which we call “I am getting full”. But the stomach does not need to be completely full to get this message. And the way it gets this message is a combination of nerves and hormones being activated. The Sleeve Gastrectomy leaves you with a stomach only one quarter to a third of the original size. And it is in the shape of a tube, or looks a bit like a sleeve of a long sleeved top. This new shape means that it no longer works like a round balloon but like a long narrow balloon. If you try to inflate a long skinny balloon you will have trouble getting it to expand, unless you use a pump. This is because it is very hard to inflate cylindrical shaped things. With this in mind, imagine how much food you would need to eat to get the Sleeve to stretch! It is basically impossible to do this with food, and so the stomach remains small, and does not enlarge like it does after some other operations, such as the older versions of stomach stapling. So ths stomach is small and does not enlarge from eating. But there is more to this operation than that…read on…

Improved version of “Stapling”

The Sleeve Gastrectomy appears on the surface to be the same as “stomach stapling”. Technically it is stomach stapling, but is a major improvement. The refinements have overcome the problems seen in stomach stapling in the past.

There were a large number of stomach stapling operations in the past. Generally speaking, they involved making the stomach smaller by stapling off a small section of stomach, and leaving the rest of the stomach to just sit there, on the other side of the staple line, out of the way. A band was placed at the bottom of the newly sectioned off stomach (stomach pouch) to slow down eating and to keep the patients full for longer with a smaller meal.

But the bands were not adjustable. Generally the tightness of the bands was just right, but sometimes too loose and the weight loss poor and sometimes too tight and blockages occurred. And because an operation was required to modify this, patients with these problems became dissatisfied. (Hence the popularity in some ways of the adjustable Gastric Bands we use today). The bands used in stomach stapling resulted in blockages of food when people ate too fast, or didn’t chew well etc. The Sleeve overcomes this problem by not having a gastric band, but instead uses the normal, end of the stomach (the pylorus). The pylorus is a valve-like muscle that slows down emptying of the stomach. And so the Sleeve fills and empties like a normal stomach and feels quite normal to eat with compared to the older versions of stomach stapling and the adjustable gastric bands.

The stomach in stomach stapling held less food because of the way it was partitioned. But the staples sometimes gave way and the stomach resumed the previous size and weight regain occurred. This does not happen with Sleeve Gastrectomy because the un-required part of the stomach has been removed. (This may sound an odd explanation. It comes down to the fact that if you partition off a part of the body surgically or otherwise, the body will usually only enable a passage to reform between the 2 partitions if the tissues on both sides of the partition are the same…confused? In other words, the staple line cannot biologically give way in the Sleeve because there is nothing on the other side of the staple line for the stomach to give way in to.) So, the staples in the Sleeve do not give way and therefore the Sleeve does not result in weight regain like seen with stomach stapling.

The stomach pouch in stomach stapling sometimes stretched, resulting in weight regain. This is because there was a band at the bottom of the pouch, which created high pressures inside the stomach pouch when patients ate and this caused the pouch to stretch. After a bit of stretching the pouch got larger and larger because it was a round shaped pouch. The Sleeve does not have a band, and is a cylinder and so does not stretch.

So, in summary, stomach stapling had the problems of blockages due to a non-adjustable band, staple line blow out and stomach re-enlargement, and was not adjustable. The Sleeve is not adjustable, but the other problems have been overcome.

 

Decreased stomach capacity and decreased Ghrelin

The Sleeve Gastrectomy has a feature that no other weight loss operation has which appears to be very important. The Sleeve decreases the body’s Grehlin hormone. The stomach secretes a hormone called Ghrelin, which is an important part of weight control. Grhelin stimulates the brain to want to eat, and sets up various mechanisms to enable fat growth. Grhelin levels in the body are increased by eating, among other things. If you eat very rarely, or have been fasting for some reason, it is helpful for the body to have a way of making sure you are hungry when you do finally eat again. And also it is handy that you are able to store or hold on to whatever nutrients you eat. But in obesity this hormone is central to the reaon you can’t lose weight with dieting. The moment you eat something when you have been on a diet, you are well and truly hungry and put weight back on with ease. This is an important hormone, and is really quite clever at preventing weight loss.

The Sleeve decreases Grhelin, and is the only weight loss operation to do so. This is thought to partly explain the high weight loss seen in this operation. The Sleeve Gastrectomy is the only operation to do this because it is the only operation that removes part of the stomach, all the others leave the stomach in place, and just partition it off on some way, leaving it to continue to make Grhelin and prevent weight loss.

Less drive to eat and can only eat small meals

If we add this all up the Sleeve decreases the capacity to eat, the drive to eat and these effects are sustained for years after the surgery and are unlikely to wear off. The only challenge remaining to achieve good weight loss with a Sleeve Gastrectomy is to avoid eating high calorie liquids, because this will decrease the effectiveness of the surgery and therefore result in less weight loss.

Many patients with the Sleeve who have had a gastric band report that the volume of food you can eat with a Sleeve does increase after a few months to years. Usually this increase is small, and such that you can still only eat a very small meal, such as an entre sized meal. The Sleeve therefore prevents big eating sessions, no matter what food is eaten essentially.

 

Compared with Gastric Bands

Minimal follow up

On average we need to see patients who have had the Sleeve Gastrectomy only twice in the first year and then annually after that. Compare this with Gastric Bands where the average number of consultations with the surgeon is 8 for the first year and then 1 or 2 per year, and Bypass 4 in the first year then annually. The reason we don’t need to see patients who have had a Sleeve Gastrectomy very often is there is very little that needs to be done. It is really quite easy to live with a Sleeve and there are no issues of malabsorption or excessive weight loss, and of course there are no adjustments required. People find the weight loss is initially almost automatic in most cases. Some people experience eating squeezing for the first few months, which is difficulty eating most foods, but this settles by itself with time.

Minimal lifestyle changes

Because the eating style of Sleeve is so much like “normal eating”, you don’t have to change much to get it to work. Obviously the more effort you put in to losing weight and the better your diet is the more weight you will lose. But unlike the gastric Band where you need to follow a long list of simple eating rules the Sleeve is more straightforward. The eating rules with a band are easy for some people to follw and difficult for others. How much of your lifestyle are you willing and able to change to lose weight? What do you know from your previous attempts at weigh loss? F you can make big lifestyle changes and maintain them, then the band is a reasonable choice. But if, realistically, you will not change how and when you eat to make the band or Bypass work, then you should consider the Sleeve. This is because with a Sleeve Gastrectomy there are less rules to follow to avoid problems such as blockages and sabotage.

More weight loss

The Sleeve Gastrectomy will on average result in more weight loss than a Gastric Band. The difference between the 2 operations when it comes to weight loss is small, at 70% for the Sleeve, and 50 to 60% for the Band. But this difference is just statistics. The real difference we see clinically is that sweet eaters, high calorie soft food eaters, and many other eating styles do better with a Sleeve because the volume of food is non-negotiable, whereas for a Gastric Band, if you eat a certain way you can eat more (see above).

More natural and durable

When you eat something with the Sleeve Gastrectomy, food enters the stomach as normal (unlike the band where it is slowed up by the band) and leaves the stomach through the normal, natural passageway (the pylorus). So food travels normally through the part of the body the gives you fullness. So fullness feels normal, and eating feels normal. This is not the case for the band or the bypass. So how does that help? No matter what you are feeling like, no matter how distracted you are, no matter how hungry, food goes down normally and makes you feel full quickly. So imagine you are inclined to eat really large meals when you are very hungry, especially after a stressful day at work, and you quite like a bit of drive through convenient, fast food. (Nothing wrong with that in general, by the way, but perhaps you tend to do it too often.) With a Gastric Band you are likely to get a blockage and find it difficult to eat and eventually stop eating the take away and be less inclined to get it next time you feel like this. The Sleeve Gastrectomy will let you eat the take away normally, but only a much smaller amount, the meal ending when there is simply no room left in your stomach to eat anything more. So both the band and the Sleeve help with impulsively high calorie eating, but for the person with the Sleeve the feeling is more natural.

And if there is a moment or a period in your life when you are determined to eat your take away, and you have a Gastric Band, you might find some way to get the food down so you can keep on eating, because at that time you want to eat more, even though it will mess up your weight loss. With the Sleeve Gastrectomy, no matter how hard you try, you will still only eat a small meal. This durability gives people with a Sleeve the comfort that the weight control is going to persist, no matter how they are feeling, and is less subject to sabotage. Neither operations are effective at weight control unless you have a calorie controlled diet.

Not adjustable or reversible

Once the Sleeve Gastrectomy operation is finished, if there is any adjustment required, you would have to have a further operation. Fortunately this is only rarely required, in less than 2%. And there is no way of returning the stomach to its original size and shape. So the operation is not reversible or adjustable, but it can be modified if required. The modifications that can be achieved are, however, quite limited, and seldom needed. This being the case, many patients are very pleased this is the case. Their weight problem was not temporary and was not reversible, so why should the solution be reversible? This can be comforting to some and concerning to others. You need o choose the operation that suits you best.

 

Compared with Gastric Bypass

No malabsorption

The Sleeve Gastrectomy does not result in any malabsorption of any nutrients of clinical significance. Nonetheless, as this is an operation that results in weight loss, and less eating, nutritional monitoring is still performed. The Gastric Bypass is associated with a number of potential nutritional problems, most of which are easily managed. Malabsorption does not occur with the Sleeve Gastrectomy, and therefore the problems of flatulence, belching, diarrhoea, abdominal distension and malodour that can occur with malabsorption are not a concern.

Minimal follow up

There really isn’t much to be achieved by frequent follow up after a Sleeve Gastrectomy. So we need to see you initially after the surgery to do the post surgical visit, and then just every few months or so for the first year or until the weight loss levels off, and then just annually to ensure you are continuing to achieve your goals. You need to see the dietitian a handful of times in the first few months around the time of the surgery, and then there is no need for dietetic follow up. The nutritional monitoring is done by either your GP or surgeon. There is no real chance of excessive weight loss, no troubleshooting tips required, and no dietary modification along the way to prevent the various problems seen with malabsorption. The Sleeve,compared to the Gastric Bypass, is quite straightforward to monitor.

Minimal lifestyle changes

The Sleeve Gastrectomy allows a full range of food to be eaten mostly as you please: as long as you have a calorie controlled diet, you will lose weight. A bypass does not let you eat certain meals, such as meals which are too high in sugar or fats, (eg lollies or fatty chips) because very fatty foods and very sugary foods make you feel unwell with a bypass. This does not occur with the Sleeve.

Safer

The Sleeve Gastrectomy has a major complication rate of 2% compared with Bypass of 5%. The major complications of the 2 operations are similar in type, but more frequent with the bypass.

Less weight loss

The weight loss expected on average with a Sleeve Gastrectomy is around 70% compared with 75 to 80%. Some studies show the weight loss for Sleeves and Bypass as similar, but this is not yet clear.

Sleeve: 2 night stay in hospital, Epworth Eastern

The Sleeve Gastrectomy is performed at Peninsula Private Hospital (Frankston), Epworth Richmond and Epworth Eastern (Box Hill). The usual stay in hospital is 2 nights, but 3 nights is not uncommon.

2 weeks off work

The time you will need off work for a Sleeve Gastrectomy is usually 2 weeks, but this varies depending on how physical your job is etc.

Weight loss takes 6 to 24 months

Most people who have a Sleeve Gastrectomy achieve most of their weight loss in the first 6 months, and then the weight loss slows down and flattens and eventually stops. There are no cases of excessive weight loss.
Some people say that their weight loss with a Sleeve Gastrectomy is so easy at first, and the lifestyle and eating changes so minor that there is a risk of failing to really change the way they eat, and therefore run the risk of not losing as much weight as they thought they would. So we recommend that people having a Sleeve Gastrectomy should still put in every ounce of effort they can manage to assist their weight loss, to be active in trying to lose even more weight, so they won’t be disappointed with their final weight.

 

Sleeve Eating Rules

Chew well and Take your time Eating

The Sleeve Gastrectomy requires you to eat slowly and chew thoroughly to prevent food getting blocked. Food is just as likely to get blocked with a Sleeve as without it, as the size of the Sleeve is wider than you oesophagus, and so anything that gets down the oesophagus is not like to get blocked. But blockages can and do occur in the Sleeve. If blockages occur they can last longer than if they occurred in the oesophagus, they can be more unpleasant and more difficult to resolve. So best avoided by eating more slowly. Also, you need to eat more slowly because your point of fullness comes on quite abruptly for some people. One minute happily eating away, nice and slowly, next mouthful is suddenly one too many. Better to not have had 2 mouthfuls too many and get a painful blockage. Eat slowly and it will be easier to predict when to stop eating.

Avoid eating and drinking together

The volume of the stomach after a Sleeve Gastrectomy is fixed. If you want to eat or drink something, you will manage only around 250ml (a cup) and you will be unable to eat or drink anything further. We can easily drink a cup of liquids faster than we can eat a cup of food. So if you are eating and drinking at the same time, and you take a big gulp of your drink, you might not have left enough room for that yummy curry you just spent hour making or spent big bucks paying for. So separate liquid and solid meals to avoid disappointment and frustration.

Avoid Liquid Calories

Liquid calories like soft drinks and wine and chocolate (Chocolate is liquid by the time it is inside you and warmed up by your body) will go through your Sleeve faster than solids. With time the Sleeve Gastrectomy gets faster at dealing with liquids and empties quicker and you can therefore get more drinks in. This effect is not as dramatic as for the Gastric Band but is worth keeping in mind.

How is the Sleeve done?

The operation

The Sleeve Gastrectomy is a laparoscopic (key hole) operation requiring 5 small incisions in the upper abdomen. Each incision is 5 to 15mm. Instruments are inserted through these incisions and the liver is lifted out of the way to reveal the stomach. The stomach is then separated from the surrounding structures on the left side, leaving the right side of the stomach in place. A bougie (38F sizing tube) is inserted into the stomach (from the mouth) and then a device that is part stapler and part cutter is placed on the stomach, gently pushing up against the bougie so that a standardised sized stomach is made. This will hold 150ml at the end of the operation. With the muscles of the stomach relaxing and over time the stomach will hold around 250ml. The first time the stapler/cutter device is used it is right at the end of the stomach, which is so called an Extended Sleeve. (A standard Sleeve or a Vertical Sleeve leaves a pouch at the lower stomach. An extended Sleeve is the operation used in our clinic.) So with successive staplings and cuts of the stomach it is trimmed off and sealed at the same time until two-thirds has been removed. The upper 2cm or so of the stomach staple line is then sutured to reinforce the staples here to prevent leakage. The fat in the abdomen is then sutured to the staple line to prevent bleeding, and to stop kinking of the stomach. A drain tube is not required. The stomach is then removed via the 15mm incision in the right upper abdomen. Please watch this operation by clicking on the media button above.

 

 

 

 

 

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Royal Australasian College of SurgeonsAMA - Australian Medical AssociationFRACS - Fellow of the Royal Australasian College of Surgeonsmattu - Minimal Access Therapy Training Unit GuildfordIFSO - International Federation for the Surgery of Obesity and Metabolic DisordersMonash University
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