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Gastric sleeve surgery (sleeve gastrectomy), also known as tube gastrectomy, involves permanently removing the lateral two-thirds of the stomach, leaving patients with a crescent shaped sleeve that joins the oesophagus and the small intestines.
Laparoscopic ("keyhole") surgery is used to remove the stomach leaving patients with a narrow tube with a capacity of 100 ml (half a cup). This increasingly popular procedure has been performed in Australia since the mid 2000s, and is conducted under general anaesthetic.
The size of the remnant stomach is gauged by a tube (measuring approximately 12.5 mm in diameter) which is passed through the stomach during the surgery. The cut edge of the stomach is then carefully sealed with a stapling device. Some surgeons place a stitch along the staple line or may reinforce it with buttressing material and synthetic glue.
The weight loss occurs in approximately 12 months. Initially the surgery is very restrictive, but over the next 12 months as the new stomach recovers patients move towards the ability to eat 3 small meals. Post operatively patients are on a puréed diet for 2 weeks and then progress to a soft diet.
Sleeve gastrectomy does not require the same intensity of follow up as the gastric band and by 6 months most patients can eat approximately 25% of their previous meals and are able to include all food groups. At Adelaide Bariatric Centre we see our patients 2 to 4 weeks after discharge, then every 3 months for the first year following surgery. After this, patients are reviewed 6 monthly.
Because the stomach is now much smaller, the patient feels full after a much smaller meal, but can usually eat a wide range of foods. It does not feel like you are on a diet. Some studies suggest that because the outer curve of the stomach is removed a hormone called ghrelin is produced in much smaller amounts and this may also assist in appetite reduction. However, this will not reduce the desire to eat when it is driven by emotions such as boredom, loneliness or social expectations.
As the stomach is mainly a storage facility and most of the nutrients are absorbed in the small intestine, nutrition should not generally be affected by a sleeve gastrectomy. So, because all the food that is eaten is absorbed normally, it is still important to choose healthy foods and avoid calorie dense foods.
Occasionally you may feel light headed. This is due to the fact that you are not drinking as much liquid as you were able to before surgery, therefore the volume in your body is reduced. When this occurs, do not panic. If you can find a comfortable place to sit or lie down, do so. Your body will adjust and the blood will be redistributed adequately after a short interval. However, if this is occurring too frequently, (more than three times a day) please call us. Aim to drink 1.5 litres of fluid per day and monitor your intake. Remember to sip on fluids in between meals and do not worry if you are not drinking a lot of water because juice, milk, soup etc. are all okay.
ALTERED BOWEL HABITS
Bowel habits may be altered after the surgery. In the beginning, you may have watery bowel movements. Do not expect your bowel movements to be regular until you start eating solid food. For most, bowel habits should become regular and you should have one bowel movement every day and usually less in quantity than you are used to. Laxatives can be used such as lactulose and benefibre if required.
During the first two months after surgery, you will probably experience a few episodes of vomiting. It is important to remember your new stomach is approximately 100 mL (just under half a cup) and can be easily overwhelmed. You must eat slowly and stop when you feel full. Meals will take up to 45 minutes. Vomiting can occur due to too fast eating, poor chewing and inappropriate food. Please make sure you follow the dietary advice carefully.
Too much vomiting or retching will cause secondary swelling and possible obstruction of the passageway. If you vomit more than three times a day, take advantage of our 24 hour emergency service and call us. If you cannot keep anything down for more than eight hours you also need to call the office.
Nausea is a side effect of many gastric operations. This problem may start early after the operation or a couple of weeks after discharge from the hospital. This is the side effect of the operation that is responsible for some of the massive rapid weight loss. Even though you may experience severe nausea you should make an effort to eat at least three or four small meals a day and drink at least three to four cups of water a day. Place one litre of water in the fridge in the morning so you know how much you have drunk during the day. The feeling of nausea may be severe but it is rarely associated with vomiting but if vomiting does occur what comes up is not what was eaten but rather white saliva. The clinic can provide medications to reduce nausea, however if it is severe or you are vomiting food, this may need further investigation by X-ray or endoscopic exam.
Anorexia, complete lack of appetite, forgetting to eat, is a problem some patients experience. Make an effort to eat at least three to four meals a day.
Further surgery may be necessary after the sleeve gastrectomy. The revisional surgery which is offered at the Adelaide Bariatric Centre would either be repeat sleeve gastrectomy or conversion to a Roux-en-Y gastric bypass. Revision surgery is of higher risk than the initial procedure and whilst generally able to be performed laparoscopically, the risk of need to complete the surgery as an open procedure should be taken into account.
The initial weight loss after a sleeve gastrectomy is very impressive and it is quite common for patients to lose up to 70% of their excess weight in the first 2 years. But the remnant stomach does stretch and patients find that after a time they are able to eat more. This does tend to result in some weight re-gain. We find that the majority of our patients are able to maintain 60 to 65% of excess weight loss.
Any operation to help with weight loss is only as effective as the lifestyle changes that go with it. Good food choices as well as regular exercise are still necessary.
Remember that success with weight control is characterised by 3 small meals per day of lean source protein, low starch carbohydrate, adequate fruits and vegetables and aiming for keeping caloric intake below 1500 calories per day.
The sleeve gastrectomy with reduced hunger and early satiety gives people a powerful tool to help with long term weight loss. It is unlike being on a diet.
Gastric sleeve patients are required to follow a 2 to 4 week very low calorie diet (VLCD) before undergoing surgery.
This diet is recommended for pre-operative patients due to the need to shrink the patients’ liver. Sticking to your prescribed VLCD is important, as a critical part of your operation will be done in an area of your upper abdomen covered by the left side of your liver.
By following this preoperative diet you will help make life easier for your surgeon and your operation shorter and safer for you.
Weight-related co-morbidities such as diabetes, obstructive sleep apnoea and hypertension resolve along with successful weight loss.
Laparoscopic surgery is generally safe especially when compared with open surgery, but there are potential hazards. The procedure requires a general anaesthetic. Patients are usually in hospital for two to three days.