Laparoscopy Sleeve Gastrectomy, also known as vertical or tube gastrectomy is the most commonly performed weight loss operation in Australia.
This operation involves minimally invasive or key hole (laparoscopic) access to remove a large portion of the stomach roughly amounting to 70%, reducing its capacity from about 1500ml to 200 – 250 ml. This is a permanent and irreversible effect.
In this operation stomach looses more distensible outer portion while retaining the control of both inlet and outlet valves. Remaining stomach also has smaller volume of all the cell types represented in the large stomach. (acid, enzyme and hormone secreting) and has its nerve supply undisturbed.
Quick Info
With a small volume stomach you come to the point of satiety with a much smaller volume of food.
Most patients feel much less hunger after sleeve surgery due to the reduced level of the hormone Ghrelin, commonly known as the hunger hormone.
Reliable short term weight loss usually around 75-80% of excess weight loss at the end of 12 months.
No implanted device or need for adjustment like in the Gastric Band.
Learn more about Sleeve Gastrectomy
Dr Senerath Werapitiya takes you through the weight-loss procedure
Sleeve Gastrectomy
Explainer video taking you through the steps of the procedure.
Effects of Sleeve Gastrectomy
Stomach is a capacious and distensible muscular sac that receives the ingested meal. Stomach has an exit valve (pylorus) that controls the emptying. It is usual for the stomach to keep the meal for up to 2 hours while slowly emptying into the intestine. When the stomach is full to a capacity you come to the point of satiety when you feel full with no hunger. After the sleeve gastrectomy with a small volume stomach you come to the point of satiety with a much smaller volume of food.
It’s not the size of the stomach that causes weight loss after a specific type of bariatric surgery, but rather a change in the gut metabolism, say researchers. There is an increasing body of evidence now showing that effects of bariatric surgery is beyond smaller meals and caloric restriction. Changes in the gut hormone response to a meal, bile acid and gut bacterial changes after surgery are all thought to have a wider effect on body metabolism that may have a stronger effect on weight loss and weight maintenance.
- Reliable short term weight loss usually around 75-80% of excess weight loss at the end of 12 months.
- Preserved quality of eating enabling you to eat most if not all what you could eat before surgery, in much smaller portions with fullness and satisfaction of a large meal.
- No implanted device or need for adjustment like in the Lapband. Metal staples used to seal the cut edge of the stomach don’t dissolve and leads to no issues.
- Technically easy to perform compared to a gastric bypass operation and has a good chance of being able to complete laparoscopically in challenging patients. ( previous major abdominal surgery or very high body weight)
- Less chance of long term nutritional deficiency, no increased risk of ulcerations or dumping syndrome compared to gastric bypass.
- Long term data beyond 10 years is lacking for sleeve gastrectomy.
- High chance of long term Gastro oesophageal Reflux disease (GORD). Patients predominantly with heart burn may need to take strong acid suppression medication to counter GORD. Patients with fluid reflux with possible aspiration symptoms may also need further surgical treatment for symptom control. Although not proven sleeve gastrectomy also may increase the risk of Barrett’s oesophagus due to chronic reflux. Barrett’s oesophagus is a pre-cancerous condition.
- Sleeve gastrectomy is not reversible. However to address the post-operative issues option of revisional surgery is available. Although definite data is lacking many believe up to 30% of sleeve patients may require a second operation in the long term either due to weight regain or reflux etc. Commonest revisional option is to convert the sleeve to a gastric bypass procedure.
Obesity has been shown to increase the risk of death from a variety of medical illnesses.
Obesity places individuals at an increased risk of diabetes, high blood pressure, respiratory disease, heart disease, high cholesterol, stroke, arthritis, clotting problems and cancer, all of which can increase the risk of disability and may even cause premature death.
I have not been able to maintain a healthy weight following diet and exercise with my own best efforts. This is the reason why you should consider surgery as a weight loss option, fully understanding the quite drastic nature of this option.
The surgeon, with the help of the dietitian and other support staff, will give you a detailed explanation of the sleeve gastrectomy procedure as well as other surgical options including the gastric band procedure, and gastric bypass procedures. You will be provided with drawings, as well as written and verbal information regarding this procedure. You will be strongly encouraged to make every reasonable effort to investigate and understand the details of the operation.
The sleeve gastrectomy operation is primarily restrictive with some hormonally driven metabolic benefits. This operation involves reducing the stomach capacity from its normal size of 1500ml down to a cup size (250ml). This is achieved by removal of close to 70% of the stomach with a keyhole (laparoscopic) operation. This operation is not reversible.
Just as there may be expected benefits from the sleeve gastrectomy procedure in my case, I understand that all surgical procedures including the proposed sleeve gastrectomy procedure involve risks. I understand that the list of complications includes the following but may not be limited to this.
Bleeding: Surgery involves incisions and cutting that can result in bleeding, from minor to massive bleeding, which may even lead to death in extremely rare circumstances. Management of bleeding after surgery may require blood transfusion and emergency surgery. Bleeding is most serious when it is within the abdominal cavity with the potential risk of delayed recovery and chance of infection in the short term.
For patients on blood thinners and/or blood pressure medication – Blood thinners can lead to a higher chance of bleeding after surgery and hence the need for me to stop such medication under medical supervision prior to surgery. Uncontrolled high blood pressure is another factor that may increase the risk of bleeding and I know the importance of taking my blood pressure medication as usual.
Leak: (staple line failure / the most feared complication) – With a sleeve gastrectomy, stapling is involved in creating the stomach tube. The staple line is meant to be watertight without any leakage of stomach content to the abdominal cavity. I understand that there is a rare risk of leaking (1 – 2%), particularly in the first three weeks after the surgery when tissue healing is incomplete. Leaking from the staple line is a serious problem. The leak may allow stomach acid, bile, bacteria, and digestive enzymes to escape into the abdominal cavity causing severe tissue damage and infection (peritonitis) that may even be potentially lethal. Common symptoms of a leak are abdominal pain, nausea, fever, increased heart rate, increased respiration and feeling sick.
If a leak is suspected, you may have to undergo further tests including x-rays and possibly emergency surgery. I am aware that the emergency surgery usually involves placement of multiple drains and a nasal feeding tube. I am also aware that resolution of a leak can take a long period of time, usually requiring me to have in hospital care for a long period of time, sometimes weeks or even months. In the process, I may also require intensive care treatment or transfer to a different hospital for optimal care. I understand the risk of leak is higher if sleeve gastrectomy is done as a revision surgery following failure of a previous gastric band.
Complications can very rarely be lethal.
Infection: The most serious infection is peritonitis associated with a leak, which is fortunately extremely rare. There is also a chance of other minor infections like wound infection, bladder infection etc.
Blood Clot: Also called deep vein thrombosis (DVT) and pulmonary embolus. This is a very rare complication, but if it occurs, can lead to death. Blood thinning medications will be administered while I am in hospital to minimise the risk of blood clotting and calf compression stockings will be used. It is important that you get out of bed as early as possible and move my feet and legs to try and help prevent blood clots. I also understand the importance of preventing dehydration and keeping up with my fluids.
Nausea, Vomiting and Headache: It is common to feel some nausea and headache following surgery. There may also be vomiting. This is partly as a result of the fasting period prior to the surgery leading to some degree of dehydration, the effects of anaesthesia and pain relief medication that I am going to be receiving, as well as the effects of the surgery itself. The powerful pain medication that I am going to be on will increase the chance of nausea and I understand the importance of seeking help with anti-nausea medication early to minimise the chance of vomiting.
Laparoscopic entry associated risks: Laparoscopic surgery uses punctures to enter the abdominal cavity which can lead to abdominal organ injury, (bowel, spleen, liver etc.) or lead to a puncture of a vessel that can lead to bleeding and even death in rare circumstances. I understand that this risk is higher after previous open abdominal surgery due to possible intra-abdominal adhesions (scar tissues).
Anaesthetic complication: General anaesthesia these days is very safe, however, it is not without possible complications. I understand I will have a full description of the anaesthetic associated complications from my anaesthetist.
Indigestion, Acid/Bile reflux: I am aware that there is a high chance of long-term Gastro Oesophageal Reflux disease (GORD) after sleeve gastrectomy. Patients predominantly with heart burn may need to take strong acid suppression medication to treat GORD. I am aware that in the long term about 30% of post sleeve gastrectomy patients are on daily anti-reflux tablets. Patients with fluid reflux and possible aspiration symptoms may also need further surgical treatment for symptom control. The typical anti-reflux operation (fundoplication) is not possible with the available small stomach. Although not proven there is concern that sleeve gastrectomy also may increase the risk of Barrett’s oesophagus due to chronic reflux. Barrett’s oesophagus is a pre-cancerous condition that may require regular endoscopies for monitoring and/or other forms of treatment.
Vitamin and mineral deficiencies: Like any bariatric operation, after sleeve gastrectomy there is high chance of vitamin and mineral deficiencies. I understand that I need to take vitamin and mineral supplements for life to protect myself from these problems. I also know that I need to have at least yearly blood tests to measure the blood levels of these vitamins and minerals. I have been given detailed written information regarding the nutritional supplements by my bariatric dietitian. Common deficiencies that can occur after a sleeve gastrectomy include iron, vitamin D, calcium, B12, thiamine and folate deficiencies. I know that in some cases the deficiencies can be so severe that they can lead to brain or nerve damage and the operation may have to be reversed as a result.
Hair loss: Many patients develop hair loss for a period after the operation. When this occurs it usually starts about 3 – 4 months after surgery and resolves about 7 – 9 months after the operation. This usually responds to the increased oral intake of protein and vitamins, but it may only recover partially.
Inadequate weight loss / weight regain: I recognize that the sleeve gastrectomy surgery is no means a perfect treatment and that one of the risks that I face is a real possibility of inadequate weight loss following this surgery. I also recognize that I may lose enough weight in the short term but may regain weight at a later stage (30% chance). I understand that I need to follow the dietitian’s instructions and continue my follow up commitments with the dietitian and the surgeon to minimize the chance of this happening.
Extensive weight loss: I clearly understand that I might suffer malnutrition and lose too much weight. I am well aware that some patients sustain excessive weight loss after weight loss operations. I understand that excessive weight loss may require intense medical management including in hospital care and intravenous or tube feeding to prevent malnutrition, vitamin and mineral deficiencies or even death. I am aware that up to 1% of people may lose an excessive amount of weight. As a part of this agreement, I promise and agree to monitor my weight and health carefully, and if excessive weight loss occurs, I will submit to early and appropriate treatment.
Mechanical Issues: Mechanical issues associated with the stomach tube can develop in the form of some narrowing or segmental dilatation leading to a pouch. This may require further surgery to manage. Most patients take a few weeks to get used to the restriction offered by the new anatomy of sleeve gastrectomy. Rarely, there can be significant delay in being able to progress through the stages of post-surgery diet. In rare situations endoscopic balloon dilatation of the stomach tube may become necessary. Rarely, there may be narrowing in the region of the mid part of the stomach where it turns, known as angularis. This can lead to obstructive symptoms and food intolerance. This may require corrective surgery, albeit uncommonly.
After sleeve gastrectomy the stomach is supposed to be a narrow tube of uniform width which is constructed with the help of a calibration tube during surgery. Over the next few years, the high pressure within the stomach tube can lead to distension, which commonly happens at the thin walled top part of the stomach tube forming a pouch. Attachments of the stomach to the diaphragm are weakened during sleeve gastrectomy causing a risk of the top part of the stomach tube migrating into the chest cavity (hiatus hernia). These factors can lead to problems of meal comfort and fluid reflux and regurgitation. Corrective surgery may become necessary when symptoms are troublesome.
Complications of Pregnancy: I understand that obese pregnant women are at higher risk for an adverse peri-natal outcome. I am also aware that there are well known risks to the patient and the baby after weight loss surgery for morbid obesity. Vitamin and mineral deficiencies can put new born babies of post sleeve gastrectomy mothers at risk.
NO PREGNANCY SHOULD OCCUR FOR THE FIRST 12 MONTHS AFTER THE OPERATION.
Sleeve gastrectomy has been shown to cause multiple types of vitamin and mineral deficiencies including iron, B12, folate, thiamine, vitamin D, calcium, and many others. Many of these deficiencies have been shown to cause birth defects or are suspected that they could cause birth defects. We also know that many patients who lose weight, feel that they are well after surgery and forget to take their vitamins. I understand and take full responsibility to be certain not to miss any of my vitamins and obtain a specialist obstetric consultation if I decide to go ahead with pregnancy following surgery.
Unplanned Pregnancy: Warning to women using oral contraceptive pills: Typical failure rates among pill users can be as high as 5.5 % according to some surveys. Other factors that have been shown to increase the risk of pill failure are smoking, diarrhoea, vomiting, drug interaction, systemic illness, psychological stress, and menstrual disturbances. It is important to recognize that birth control pills may not be an effective method of birth control after sleeve gastrectomy. Couples need to plan another form of non-oral birth control starting from a few months before and for the first 6 – 12 months after surgery.
Dumping Syndrome: I understand that dumping syndrome is primarily a problem after gastric bypass surgery but very rarely can occur even after sleeve gastrectomy in some patients. Symptoms of dumping syndrome include weakness, sweating, nausea, diarrhoea, palpitation, and dizziness soon after a meal. I also understand that consuming a heavy load of refined sugars/refined carbohydrates, rapid eating, and drinking while eating are all factors that may increase the risk of dumping.
Bowel Obstruction: Any abdominal operation can lead to post-operative scarring which may lead to bowel obstruction.
Port site hernia (Incisional hernia): Extremely rarely, contents within the abdominal cavity can protrude through the muscle slits at the sites of access ports known as a port site incisional hernia. This can be easily corrected with surgery.
Depression: Depression and anxiety are common medical illnesses and have been found to be particularly common after weight loss operations. It is important that you have the full support of your family. I understand the need to seek help early from my GP or notify my surgeon in the event of unusual mood changes.
Osteoporosis: There is a growing appreciation that weight loss procedures may be associated with the development of osteoporosis and bone disease. Gastric surgery and weight loss in morbidly obese individuals can cause increased bone resorption and increased bone loss. Treatment and prevention include Calcium and Vitamin D supplementation and increased weight bearing activity.
Need for further surgery in the future: Weight loss surgery comes with no assurance to be able to achieve or maintain a a certain body weight target. In fact some long term weight regain is almost universal and outright failure with regaining all or even more than what you lost may happen in the long term. Up to 30% of post sleeve gastrectomy patients may end up with significant weight regain and may be in need of further measures for weight control including revisional surgery. In another 5%, long term post sleeve gastrectomy complications like intractable reflux / regurgitation, mechanical issues leading to blockages ect may require further corrective surgery when other measures fail to resolve the issue.
The practice of medicine and surgery is not an exact science and there is no guarantee about the results that may be obtained from this procedure.
In the practice of medicine, other unexpected problems, risks or complications not discussed may occur. During the course of the proposed procedure, unforeseen conditions may be revealed requiring the performance of additional procedures (eg. Repair of a hiatus hernia, release of bowel adhesions). There are no guarantee or promises made concerning the results of any procedure or treatment.
The proposed sleeve gastrectomy is a serious undertaking with known long-term risks. To minimise this risk and to enable them to be detected at an earlier stage and enable prompt treatment, I understand the importance of regular and life-long follow up.
I promise that I will make every effort to follow Dr. Werapitiya’s directions to protect myself from these problems that may be associated with the sleeve gastrectomy procedure. I also promise to return to my surgeon’s clinic at 1, 3, 6 and 12 months following surgery and every year thereafter for evaluation and further education.
