Sleeve gastrectomy in detail

What is sleeve gastrectomy surgery?

A sleeve gastrectomy involves reducing the stomach size by about 75%.  It is divided vertically from the top to the bottom, leaving a banana shaped stomach, like a tube or sleeve. The sleeve gastrectomy is usually performed laparoscopically (by keyhole surgery) and takes around 1 hour to perform. This typically involves making five small cuts on your tummy, to enable the camera and instruments necessary to perform the operation to be inserted. One of the cuts does need to be enlarged at the end of the operation to remove the part of the stomach that has been cut away. Post-operative stay is usually 1-2 days.

Figure 1 - Part of the stomach that is removed in a sleeve gastrectomy

How does the sleeve gastrectomy work?

The sleeve gastrectomy works in a number of ways:

  • The size of the residual stomach restricts the amount of food you can eat at one sitting, helping you stick to a diet. There is no escaping from this. You need to stay on a healthy, restricted diet to lose weight

  • The part of the stomach that is removed produces hormones that makes you feel hungry. One of these hormones is called ghrelin. If you don't have this hormone, you feel less hungry

  • The rate of emptying from the stomach increases slightly and this also affects hormones produced in the small bowel that in turn influence the brain's control of eating

The gastric sleeve is a relatively new operation.  However, the evidence suggests that it has a similar weight loss profile to gastric bypass surgery.  The average weight loss is 60% of excess body weight at five years.  Much of this weight will be lost in the first two years.

Alternatives to sleeve gastrectomy

It would be best to avoid surgery altogether. Making major lifestyle changes to include dieting, healthy food choices and regular movement and exercise will be required after surgery anyway, and many people find that these things alone help them to lose weight without the need to undergo an operation. Others find that the addition of prescribed weight loss drugs such as Orlistat provides all the help they need to get their weight down.

If these things don't help, or the effects don't last, it is reasonable to consider weight loss surgery at which point the major consideration becomes which operation is best for you. Apart from a sleeve gastrectomy, current surgical options include the gastric bypass, gastric band, duodenal switch and the gastric balloon.

Benefits of sleeve gastrectomy

Sleeve gastrectomy surgery is a relatively safe operation, and appears to have fewer risks and complications than gastric bypass surgery. On the other hand, when compared to the gastric band , the sleeve gastrectomy is a more invasive and riskier procedure but produces better weight loss results in most people.

For most patients who have sleeve gastrectomy surgery, the benefits in terms of losing weight are much greater than the risks. In particular, most patients with recently diagnosed diabetes mellitus (less than 5 years) can be cured of their diabetes with a sleeve gastrectomy. This may all happen within a few weeks of surgery, well before any significant weight loss has occurred.

Risks of sleeve gastrectomy

Performing a sleeve gastrectomy involves an operation. There are thus the risks of the general anaesthetic, and there are the risks of the operation itself.

Modern anaesthetics are very safe, but being overweight does add a slight risk when having a general anaesthetic, and if for example you have other illnesses such as diabetes or heart disease then the anaesthetic risk is a little higher. At Weight Loss Surgery Scotland you will undergo a careful preoperative assessment where any potential risk factors are identified. Other specialists can be called in for opinions if required, and the consultant anaesthetists will meet you to discuss your anaesthetic beforehand. The hospital operating and anaesthetic facilities are state-of-the-art and all precautions are taken to reduce the risks.

A sleeve gastrectomy does involve removing part of your stomach so there will be a staple line where the stomach is cut. This staple line can leak. This is a serious complication and can require urgent, further surgery to correct. Damage to your stomach, intestines or liver is possible during the operation and bleeding or perforation of the stomach or bowels may be the result. Bleeding is not usually too much of a problem as long as it is recognised and fixed promptly. The need for a blood transfusion as a result of a gastric bypass is highly unlikely. Similarly, perforation of the stomach or bowels is not usually of major concern if the perforation is recognised and fixed.

The other main risk of surgery is blood clots. This can happen to anyone having any operation, not just a weight loss surgery operation. Every attempt is made by the Weight Loss Surgery Scotland team to minimise this risk around the time of your operation. We do this by using injections to thin the blood, as well as special stockings and calf pumps during the procedure. Getting you up out of bed and moving as quickly as possible after the operation is also important to keep the blood circulating in your legs.

Long term complications of the sleeve gastrectomy operation

Stomach dilation
If you regularly overeat into the small stomach remnant, it will stretch up and get bigger. This will mean you can eat bigger meals and thus lose less weight, or indeed put weight on. Sometimes, if picked up early, more careful eating behaviour can reverse this

Vitamin and other nutrient deficiencies
These are unusual as your intestines are still normal.  However, as you will be generally eating less, we recommend that you take a multivitamin supplement (including iron and calcium) every day anyway, to prevent any future problems

Is my sleeve gastrectomy for life?

You should consider the sleeve gastrectomy as an operation for life.  Occasionally, your weight loss may not be sufficient by a sleeve gastrectomy alone, and further surgery, to incorporate a gastric bypass or duodenal switch may be necessary.

Will you keep me under review?

Yes, we will follow you closely over the post-operative period but once you have recovered from your surgery, an annual check up is often all that is necessary. This would include doing some blood tests to look for early signs of nutrient deficiencies. You will be able to eat most foods with time. Some foods will pass through the bowel very quickly, and trial and error will help you avoid these. However, we recommend that you do take multivitamin tablets (which often contain other important things like iron and calcium) to minimise the risk of deficiencies. Such follow up can often be arranged with your GP and does not require you to return to see your hospital specialist.

Gallstones are common in the UK. Patients who lose weight are more likely to develop gallstones. You may require an operation to remove your gallbladder along with the stones at some point after your sleeve gastrectomy if they cause symptoms.