Sleeve Gastrectomy

What is sleeve gastrectomy?

Sleeve gastrectomy is the permanent removal of part of the stomach. What remains is a narrow tube shaped like a banana. The volume of that tube corresponds to a small fraction of the former stomach.

The effect of the procedure appears along two routes. The first is a restriction in volume: a small stomach fills with less food and a feeling of fullness begins early. The second is hormonal: the part that is removed is the area where the hormone that increases hunger is secreted. Removing that area reduces appetite.

The operation is carried out by the keyhole method. A camera and instruments are placed through several small openings in the abdomen. The stomach is divided and closed with special stapling devices. The abdomen is not opened with a large incision.

How does it differ from the other obesity operations?

In sleeve gastrectomy the route through the bowel is not altered. Food passes in the normal order from the stomach into the duodenum. In gastric bypass the route food takes is rearranged. That difference changes the effect on absorption and the profile of vitamin deficiency.

Options that are not surgical are set out separately. A gastric balloon is a temporary method and its effect ends once it is removed. Weight-loss injections are given under medical supervision and weight regain is common once they are stopped.

What it does and what it does not do

The operation is a tool that starts the process of losing weight and makes it sustainable. Portions become smaller, hunger is reduced and weight loss becomes marked in the first months. Improvement is often seen in type 2 diabetes, high blood pressure, sleep apnoea and joint complaints.

The operation does not produce a result on its own. If eating habits do not change and physical activity does not increase, weight loss falls short of what is expected. The volume of the remaining stomach is limited, but high-calorie liquids pass that limit.

The operation is not a cosmetic procedure. Excess skin may appear after weight loss. That situation requires a separate surgical assessment.

The outcome varies from person to person. For that reason no promise of a result is given on this page.

Who is it suitable for?

Assessment of a candidate is not reduced to a single number. The body mass index is the starting point; the accompanying conditions, the weight history and any previous attempts are assessed together.

The following headings are examined at the assessment:

• Body mass index and how long the weight has been carried
• Accompanying conditions such as type 2 diabetes, hypertension and sleep apnoea
• Previous attempts at weight loss through diet and exercise
• Eating behaviour and psychological assessment
• Willingness to comply with long-term follow-up after the operation

The operation is not carried out in the following situations:

• Pregnancy and breastfeeding
• An untreated eating disorder
• Uncontrolled alcohol or substance use
• Severe liver failure or advanced heart failure
• An inability to understand the operation and what follows it

In people with serious reflux, sleeve gastrectomy may not be the first choice. In that group the endoscopy findings before the operation are decisive and an alternative method may come onto the agenda.

How is the operation carried out?

The process begins with a consultation. A history is taken, a physical examination is carried out and laboratory tests are requested. The inner surface of the stomach is assessed by endoscopy. Respiratory and cardiac assessment is carried out for the safety of the anaesthetic.

A preparatory diet is followed before the operation. Its purpose is to reduce the volume of the liver and improve the view of the operative field. That diet usually lasts two weeks.

On the day of the operation the following steps are carried out in order:

1. General anaesthesia is given.
2. Between four and five small openings are made in the abdomen.
3. The camera and the surgical instruments are placed.
4. The greater curve of the stomach is separated from its vascular attachments.
5. A calibration tube is placed in the stomach and the staple line is marked out.
6. The stomach is divided in the shape of a tube and stapled.
7. The staple line is checked for leaks.
8. The removed part of the stomach is taken out and the openings are closed.

The total duration is usually between 60 and 90 minutes. The stay in hospital is two to three days in most cases.

The recovery period

In the first hours after the operation the patient is helped to stand. Early movement is an important measure in reducing pulmonary and vascular complications.

Feeding advances in stages:

• The first days: clear fluids, in small and frequent sips
• The second week: fluids and food of a puréed consistency
• The third and fourth weeks: a move to soft food
• After the fifth week: a gradual return to solid food

A daily protein target is set and followed. Fluid is taken at times separate from meals; fluid drunk with a meal shortens the feeling of fullness.

Return to daily life is within two to three weeks for most people. Return to desk work may be earlier. Heavy lifting and movements that strain the abdominal muscles are deferred for the first six weeks.

Reviews are carried out at the first, third, sixth and twelfth month. At each review the weight, the blood results and the eating pattern are assessed. Vitamin and mineral supplementation is adjusted according to the blood results.

Risks and possible complications

Sleeve gastrectomy is a major operation and it carries risks. Most of the risks appear in the early period and are managed by intervening in good time.

The early complications are these:

• A leak from the staple line
• Bleeding
• Clot formation in a vein and pulmonary embolism
• Wound infection

The situations that may be seen later are these:

• The onset or worsening of reflux
• A narrowing at the staple line
• Vitamin and mineral deficiencies
• Weight loss below what was expected, or weight regain
• Excess skin after weight loss

In the event of fever, increasing abdominal pain, a rising pulse, shortness of breath or an inability to take fluids, medical help should be sought without losing time. Those findings may herald a leak or bleeding in the early period.

Preparation before the operation, early movement, treatment to prevent clots and regular follow-up are decisive in reducing the risks.

Frequently asked questions