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Laparoscopic Sleeve Gastrectomy

Laparoscopic Sleeve Gastrectomy

Sleeve Gastrectomy (SG) is currently the most frequently performed bariatric surgery in the United States. Most patient request for this procedure and most bariatric surgeon also recommend this procedure to their bariatric patients. It is a restrictive procedure without malabsorption. 80% of the stomach is removed vertically. It is not reversible. We are converting a large stomach, about a size of a football when full, to a size of a banana. The stomach that is removed produces a hormone called Ghrelin. Ghrelin stimulated appetite. When Ghrelin level is deceased after the stomach is partially removed, patients are not so hungry and consequently they eat less. Their caloric intake thus is decreased and they lose weight. Capacity of the banana shaped stomach is about a cup per meal. SG is an easier surgery to perform, which takes around 1.5 hours compared to 2.5-3 hours for the gastric

Procedure:

Under general anesthesia, 5 trocars are made in the upper abdomen. 80% of the stomach is removed vertically. The left lobe of the liver is retracted to visualize the stomach. The pylorus (the sphincter that is normally partially closed and keeps the stomach full with food) is identified. About 2 inches from the pylorus proximally, the blood vessels of the stomach that is to be removed are cut. We use the ultrasonic shears to cut and coagulate those blood vessels all the way up to the esophagus. The vast blood supply to the inner aspect of the stomach, are not disturbed. The inner part of the stomach is also thicker and stronger, and it will be shaped into the shape of the banana. The stomach is freed from all adhesions front and back. A sizing tube (40F) is placed through the mouth and advanced to the pylorus by the anesthesiologist. The cutting is made by using of the stapler instrument, that provide 3 rows of staplers on each side and it cuts in between. A strengthening material (Seamguard) is also used to prevent bleeding and leaks.

Under general anesthesia, 5 trocars are made in the upper abdomen. 80% of the stomach is removed vertically. The left lobe of the liver is retracted to visualize the stomach. The pylorus (the sphincter that is normally partially closed and keeps the stomach full with food) is identified. About 2 inches from the pylorus proximally, the blood vessels of the stomach that is to be removed are cut. We use the ultrasonic shears to cut and coagulate those blood vessels all the way up to the esophagus. The vast blood supply to the inner aspect of the stomach, are not disturbed. The inner part of the stomach is also thicker and stronger, and it will be shaped into the shape of the banana. The stomach is freed from all adhesions front and back. A sizing tube (40F) is placed through the mouth and advanced to the pylorus by the anesthesiologist. The cutting is made by using of the stapler instrument, that provide 3 rows of staplers on each side and it cuts in between. A strengthening material (Seamguard) is also used to prevent bleeding and leaks. Those staples will remain within your stomach wall for the rest of your life. They do not rust or cause any problems. CT scans and MRI may be done in the future. They are not detectable through the metal detector at the airport.

A leak test using a blue dye is routinely done to check for leaks during surgery. Blue discoloration may be noted around the lips after surgery. The urine may turn green for about a day and that is nothing to worry about. The stomach specimen is removed through on of the left abdominal trocar site and will be sent to the pathologist for inspection. We do inject local anesthetic to all of the incisions to decrease post-operative pain. The capacity of the banana shaped stomach is about a cup of food.

Advantages & Potential Concerns

The absorption of food is near normal. All the nutrients, vitamins and minerals of the food that passed through the banana shaped stomach, goes through the normal anatomy. Absorption is nearly 100%. The passage for the food is easier tolerated by most patients. Most medications are absorbed normally. Since the small intestine is not interfered with, there are no intestinal complications seen with the SG. Long term calcium, iron and Vitamin B12 deficiency are less frequently seen. However we still check for them in the years to come. A multivitamin is suggested every day. Blood tests may be needed yearly after surgery.

A leak is the most feared complication of the SG. It occurs most frequently the first 2 weeks after the operation. Patient will experience pain in the left upper abdomen, left shoulder or back with fevers, rapid heart rate and shortness of breath. Admission is necessary to the Emergency department where a CT scan is to be done to rule out a leak. Most patients will require another operation to repair the leak or drain the area. Luckily the chance of leak is rare and is around 1%.

Narrowing of the channel may occur around 5%, which may make the patient have issues swallowing solids. If this becomes intolerable, an out-patient endoscopy with dilatation is performed to dilate the area of narrowing. This is performed under sedation or general anesthesia but takes only about half an hour to perform.

Reflux:

Since this procedure creates a tube and the pressure inside this tube becomes higher after this operation. Patients may develop gastric reflux after the SG. Usually these patients also have a hiatal hernia (HH). A hiatal hernia is when the hiatus (opening in the diaphragm for the esophagus to go through to become the stomach below the diaphragm) is born to be larger than a golf ball size opening. If this is seen before surgery through the Upper G-I X-ray or endoscopy, every effort will be done to repair this. Sometimes the HH is reported as negative but during surgery it was seen by the surgeon, the HH will be repaired and the hole is made smaller to a normal size. Patients who have severe GERD (gastro-esophageal reflux disease) or Barrett’s esophagus ( from prolonged GERD and the lining of the esophagus has changed, potential may become cancerous), the RNY gastric bypass is a better operation to control the reflux.

Inadequate Weight Loss:

The SG has a fairly good intermediate result for weight loss comparing to the gastric bypass. Weight loss is a few percentages less than the gastric bypass, but it is definitely safer than the gastric bypass. We do not have long term data (15 year or longer) for the SG. Gastric bypass 15 year US data of % excessive weight loss is 50%. That equates to losing half of their excessive weight after 15 years. Some patients do better and some less. The Lap-Band (Australian data in 15 years is 47%). All weight loss surgeries work. They are tailored to the patient’s choice, their medical conditions and eating habits. That’s why the patients go through a rigorous nutritional and psychological evaluation and learning period before their surgery. Bariatric surgery is a tool provided to the patient to help them succeed in their weight loss journey. One can make it fail if they do not follow the recommended eating program. We offer dietician and psychological follow-up as necessary after surgery.

Revisional Surgery After SG:

If the sleeve has stretched and is dilated with weight regain, a re-sleeve is often considered. One need to make sure the patients did not create the enlargement by overeating, or blame it on the surgeon that the sleeve was created too big. It may be due to the patient’s anatomy, that the stomach wall was too thin and stretchable. Insurance companies usually will cover revisions if there is documented failure of weight loss with recurrence of their life threatening co-morbidities. In depth evaluations are needed for these patients before they undergo a revisional surgery. Successful weight loss after revisional surgery usually is not as great as the original surgery.
Another alternative is conversion to another operation like the RNY gastric bypass or the Duodenal Switch. Lap-Band over the Sleeve has also been proposed. Most insurance companies do not cover for another type of bariatric procedure. They usually cover one bariatric surgery per life time. Complications after revisional surgery usually is 3-4 times higher than the original surgery. In order to comply with the insurance requirements, patient will need to undergo nutritional and psychological evaluations before the repeat surgery. Sometimes it’s a long and arduous process. Endoscopic suturing or medical weight loss may also be explored.

Bleeding and infection are rare. Hernia through the trocar site may occur but is also becoming rare. Injury to the surrounding organs like the pancreas, spleen and liver is also rare