Gastric Sleeve: Keep It Simple
We greatly believe that keeping things simple is the easiest way for everyone concerned no matter what we do. In this regard, the beauty of the gastric sleeves also known as the sleeve gastrectomy is in its simplicity. Basically, we are removing 70-80% of the stomach in a vertical fashion, leaving behind a banana-like tube which creates a restrictive process in which patients can eat much less than before. Because we are not rerouting the intestines, there is no malabsorption and there are no food restrictions. There is no dumping, no internal hernias, and no marginal ulcers as seen with a gastric bypass. Also, because we are not placing a foreign body, there are no foreign body reactions, nothing to adjust, and no port problems… Therein lies its simplicity.
However, what is not so simple – and we do not yet understand – is that by removing the portion of the stomach called the fundus, we are also eliminating hormones that create hunger, or we may be stimulating hormones that create a feeling of satiety, or other hormones that adjust cravings for sweetness, soft drinks, etc. may also be affected. We just don’t know yet. What is clear is that over 50% of patients feel fewer hunger cravings, and less sweet cravings.
It is also not unusual to have diabetic patients have their diabetes resolved within a month after the surgery, and not as a result of the weight loss but as a result of changes we do not yet understand. Also, studies have shown that diabetic patients with diabetes for less than five years may be cured up to 80% of the time. So yes, the gastric sleeve is simple, but it is also very complex. It is because of this combination that we feel the gastric sleeve is the most efficient operation for morbid obesity that we perform today.
How We Perform the Gastric Sleeve
We routinely use four 5mm trochars (which create very little pain and very small scars) and the 15mm trochar at the umbilicus (this scar is hidden within the umbilicus and it also creates very little pain). We measure four centimeters from the pylorus and we devascularize from this point to the gastro-esophageal junction. A 36 french bougie is then passed transorally into the antrum. An endoscopic stapler is used to transect the stomach, and the stomach is then removed through the 15mm trochar at the umbilicus. Buttressing materials fibrin glue and oversewing of the staple line are used routinely. The last thing we do before closing the incisions is an intraoperative gastroscopy to determine that there are no leaks from the staple line, no bleeding, and no strictures.
Intraoperative complications include bleeding, infections, splenectomy, converting to open procedures, staple line leaks, strictures, tube kinking, ischemia of the gastric tube. Most complications can be fixed at the time of surgery, however some may not be amenable to repair and may lead to conversion to a gastric bypass. This is rare, and we have never had to do it, but it remains a possibility.
Post-op Recovery after the Gastric Sleeve
Patients feel pain for less than 24 hours, and 90% of patients are discharged on day 1 on clear liquids. By the time they are discharged their pain has become a discomfort, and they are usually discharged on acetaminophen or non-steroidal anti-inflammatory agents. Patients are placed on anti-reflux medication for at least one month and are seen one week post-op at which time multivitamins and vitamin B-12 are started. The liquids are continued for a total of two weeks, and then patients are advanced to a puree/soft diet for another two weeks. One month post-op, patients are started on solid foods, usually chicken or fish as first regular meals. Patients are seen at one month and then routinely every three to four months for two years. Bloodwork is ordered during these visits.
Potential Complications of the Gastric Sleeve
The most devastating complication from a gastric sleeve is a leak from the staple line. Unfortunately when this happens it can be very serious, and can lead to chronic problems and, potentially, death. These are very difficult leaks to control. In our experience there are several methods to treat the leak, including drainage and hyperalimentation. However, we believe the most efficacious treatment is placement of an endoscopic stent. If all these were to fail, patients may have to be converted to a gastric bypass.
To date, we have not seen any complications from strictures, but if this were to be the case the patients may need to be dilated, stented, or may even have to be converted to a gastric bypass.
We have seen reflux worsen in approximately 10% of patients, but we have also seen it improved in many patients. Recently, we have started repairing hiatal hernias at the same time of sleeve gastrectomy. Approximately 70% of obese patients have hiatal hernias which are well known to contribute to reflux disease. By repairing the hiatal hernias, we are expecting to reduce the incidence of post operative reflux significantly. At this time we do not know who will suffer from post-operative reflux, but the treatment is proton pump inhibitors and prokinetic agents. Again, if these fail and the reflux is very severe, patients may need to be converted to a gastric bypass.
Because we are removing so much of the stomach, patients may have a problem absorbing vitamin B-12 (to absorb vitamin B-12 “intrinsic factor” is created by the antrum). To avoid this risk, we place patients on multivitamins and vitamin B-12 for at least approximately two years.
We believe that if we create a small enough stomach it will be very difficult for the stomach to dilate. The thickness of the musculature of the stomach near the lesser curvature and the antrum is the highest of anywhere else in the stomach. Thus, by staying very close to this area, using a 36 french bougie creating a small gastric tube with a small antral remnant, we feel that stomach dilatation will be very difficult.