Starting from the top we will explain the anatomy of the digestive system to understand how the operation works:
1.- Mouth: Entry point for food; teeth and tongue chew food and move it to the back of the throat for swallowing. The enzyme amylase starts digestion of starches and sugars (carbohydrates).
2.- Esophagus: Carries food to the stomach. It has no digestive function.
3.- Stomach: Holds food and mixes it with acid and saliva. It has not absorptive function!.
4.- Pylorus: The valve that controls the emptying of the stomach. It helps prevent “dumping syndrome”.
5.- Small bowel: This tube 5 meters (15-30 feet) in length, lies in between the pylorus and the large bowel (the colon). 95% of all digestion is carried out here and it is the most important part of the digestive system. It is divided in 3 parts:
- Duodenum: Two feet long (60 cm). Bile from the liver and pancreatic enzymes (the digestive juices) enter this segment.
- Jejunum: The middle portion of the small bowel.
- Ileum: The lower portion.
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How the stomach is divided with stapler’s |
Final drawing of the LSG after stomach removal |
The jejunum and ileum are the sections where carbohydrates, proteins and fats are absorbed, as well as vitamins and minerals. Iron and Calcium are absorbed in the duodenum.
6.- Large bowel: Starts at the end of the small bowel. Its main function is the absorption of water and holding the stools. Nutrients are not absorbed here. The appendix joins the bowel at its beginning.
7.- Liver: Nutrients absorbed from the small bowel go the liver via the portal veins. It secretes the bile necessary for fat digestion.
8.- Pancreas: Secretes the enzymes necessary to digest carbohydrates, proteins and fats.
HOW DIGESTION WORKS IN A NORMAL PERSON
Digestion stars in the mouth with saliva’s amylase. Food travels to the stomach where it is held, and mixed with acid, it starts to break down here. Stomach emptying is regulated by the pylorus. Digestion and absorption happen in the small bowel when food is acted upon by bile from the liver and pancreatic enzymes. Water is absorbed in the colon and waste is excreted through the rectum.
HOW THE SLEEVE GASTRECTOMY IS PERFORMED?
BY LAPAROSCOPY. How the Sleeve Gastrectomy Works
This procedure generates weight loss solely through gastric restriction (reduced stomach volume). The stomach is restricted by dividing it vertically and removing more than 85% of it. This part of the procedure is not reversible. The stomach that remains is shaped like a banana and measures less than 2 ounces (50 cc.). The nerves to the stomach and the outlet valve (pylorus) remain intact with the idea of preserving the functions of the stomach while reducing the volume. By comparison, in a Roux-en-Y gastric bypass, the stomach is divided, not removed, and the pylorus is excluded. The Roux-en-Y gastric bypass stomach can be reconnected (reversed) if necessary. Note that there is no intestinal bypass with this procedure, only stomach reduction.
Sleeve Gastrectomy (Vertical Subtotal):
The restrictive part:
The stomach is transected and removed at the greater curvature, leaving the functional inner portion of the stomach at a capacity of 50 cc. or 2 ounces. The Pylorus, the valve that regulates stomach emptying, is preserved. The stomach will probably double in size with time. No bands or rings are used to narrow the stomach.
To cut the stomach, we use surgical linear staplers. These are instruments apply staples and cut the bowel, both, at the same time. The staples make the operation safe, so bleeding and leakage are prevented! Besides, we suture the edges of the stomach together on top of the staplers as a second layer to prevent bleeding or leaks.
Advantages of this operation: The small stomach restricts the intake because the patient feels full easily. But there is not any restrictive band to act as a foreign body to make you vomit. Not one inch of the small bowel is removed, it remains untouched! The removal of part of the stomach is not reversible, but with time the stomach enlarges enough to allow fairly normal intake and have no serious long-term consequences
IMPORTANT FEATURES OF THE SG
- The stomach: It will be small, 1.5-2 oz. (50 cc.) in size, like a small juice glass (in the shape and size of a small banana); it will slowly enlarge so you can eat a small normal meal. Not a large meal. It is basic that the stomach has to be small! Some surgeons had had to re-do the operation because weight regain if the stomach was too large! (over 75 cc.). The segment of stomach removed is not reversible but it has very little clinical significance since the stomach is not a “noble” organ and many patients (for other conditions) have a normal lifetime and life span many years even without the whole stomach!.
- Reduced incidence of marginal ulcers: Ulcers occur when the small bowel is joined to the stomach in the gastric bypass. Because the acid production has been decreased by the removal of part of the stomach the chances of ulcer formation is minimal.
- No dumping syndrome:This complication is caused by liquids and foods high in sugar content emptying into the small bowel as in the gastric bypass. It causes dizziness; sweating and such bad sensations that patients tend to avoid eating sugars.
- The pylorus: It is not removed or bypassed. It continues to function normally, controlling stomach emptying, preventing the “dumping syndrome” that occurs with the gastric bypass. It also allows complete and effective reversal of the small bowel no normal, if needed.
INDICATIONS:
The Sleeve Gastrectomy is done in:
- Super-Super-obese patients (BMI > 50-60) on whom the risk of extensive surgery is too great. Then when they do loose weight the second part of the operation can be done.
It is done to try to reduce the overall risk of weight loss surgery. Once a patient BMI goes above 60Kg/M2, it is increasingly difficult to perform a Roux en Y gastric bypass or a Duodenal Switch laparoscopically. In addition, a Roux en Y gastric bypass tends to yield inadequate weight loss for patients with a BMI greater than 60Kg/m2. The Duodenal Switch is very effective for high BMI patients but unfortunately it can also be quite risky and may by safer if done open.
The Sleeve Gastrectomy is a reasonable solution to this problem. It can usually be done laparoscopically in patients weighing over 250 Kilos = 500 pounds. The stomach restriction that occurs allows these patients to lose more than 100 pounds and in many patients more than 200 pounds. This weight loss allows significant improvement in health and effectively "downstages" a patient to a lower risk group. Once the patients BMI is lower (35-40) they can return to the operating room for the "second stage" of the procedure, which can either be the Duodenal Switch, Roux en Y gastric bypass or even a LapBand®. Currently, results of the second stage are very limited.
- Low BMI patients (BMI 35-45 Kg/m2): A procedure similar to the SG called the M & M (Magenstrasse and Mill) but without the removal of the stomach was also started in England over 5 years ago as a stand alone weight loss procedure for anyone with a BMI greater than 35 Kg/m2 (Johnston D. Obesity Surg 2003; 13:10-16). It proved to be quite safe and quite effective even at 5 years. 10% of the patients did fail to achieve a BMI below 35 at 5 years and these tended to be the heavier patients. The same ones we would expect to go through a second stage as noted above. But…The Sleeve Gastrectomy is more effective since it removes the Ghrelin, (a hormone producing hunger) so SG patients loose their appetite. Low BMI individuals who should consider this procedure include: bypass such as intestinal obstruction, ulcers, anemia, osteoporosis, protein deficiency and vitamin deficiency.
- Those who are considering a LapBand® but are concerned about a foreign body. Lap-band patient’s vomit almost everyday. NO SG patients have severe vomiting and only sparingly!
- People who need to take anti-inflammatory medications may also want to consider this. Usually, these medications need to be avoided after a gastric bypass because the risk of ulcer is higher.
- Those who are concerned about the potential long term side effects of an intestinal bypass such as the DS
- Patients with severe medical conditions such as liver cirrhosis, intestinal chronic diseases such as Crohn or ulcerative colitis, transplanted patients on medications, AIDS patients, etc. Those who have other medical problems that prevent them from having weight loss surgery such as anemia, extensive prior surgery, and other complex medical conditions.
- Patients who need to have the lap-band removed or other bariatric operations. bypass such as intestinal obstruction, ulcers, anemia, osteoporosis, protein deficiency and vitamin deficiency.
- Adolescent patients. Patients under 18 with morbid obesity and comorbidities are good candidates for a LSG. WE have a 10 years old operated on with a BMI-42 and 9 months later he is BMI-27
- The elderly
Its advantages are:
- The stomach is reduced in volume but functions normally, so most food items can be consumed, albeit in small amounts.
- Eliminates the portion of the stomach that produces the hormones that stimulates hunger (Ghrelin).
- No dumping syndrome because the pylorus is preserved.
- Minimizes the chance of an ulcer occurring.
- By avoiding the intestinal bypass, the chance of intestinal obstruction (blockage), anemia, osteoporosis, protein deficiency and vitamin deficiency are almost eliminated.
- Very effective as a first stage procedure for high BMI patients (BMI>55 kg/m2).
- Limited results appear promising as a single stage procedure for low BMI patients (BMI 35-45 kg/m2).
- Appealing option for people with existing anemia, Crohn's disease and numerous other conditions that make them too high risk for intestinal bypass procedures.
- Can be done laparoscopically in patients weighing over 500 pounds.
- No foreign body;
- Less operating time and Easy recovery;
- Few, if any, side effects;
- It is done by Laparoscopy;
- A very good alternative to adjustable band and gastric balloon and
- If there is no enough weight loss then the BPD can be added by lap.
- It is a very good operation for Adolescent patients who have severe obesity, but should not be exposed to a more aggressive surgery
Disadvantages of the Sleeve Gastrectomy Weight Loss Surgery
- Potential for inadequate weight loss or weight regain. While this is true for all procedures, it is theoretically more possible with procedures that do not have an intestinal bypass.
- Higher BMI patients will most likely need to have a second stage procedure later to help lose the rest of the weight. Two stages may ultimately be safer and more effective than one operation for high BMI patients. This is an active point of discussion for bariatric surgeons.
- Soft calories such as ice cream, milk shakes, etc can be absorbed and may slow weight loss.
- This procedure does involve stomach stapling and therefore leaks and other complications related to stapling may occur.
- Because the stomach is removed, it is not reversible. It can be converted to almost any other weight loss procedure.
- Considered investigational by some surgeons and insurance companies.
- It is a disadvantage that we do not have long-term results with this technique.
SUPPLEMENTS REQUIRED AFTER SURGERY
VITAMINS: Only Vitamin B12 and folic acid may be necessary. NO extra calcium or iron are required
CHILDBEARING
Women of childbearing age who are having weight reduction surgery should use some type of birth control during the period of rapid weight loss (18 to 24 months). Maternal malnutrition may impair normal fetal development. All patients who are losing weight, at a rapid rate, are in some way suffering some form of malnutrition. Pregnancy should be postponed until your weight has become stable for some time. Patients have become pregnant after SG without any difficulty.
Folic acid, one of the B vitamins, has been found to prevent neural tube defects (NTD). Increased intake of folic acid reduces the risk of NTDs such as anencephaly and spina bifida (open spine) by as much of 50 to 70 % if women take enough of it before conception and in the early months of pregnancy. Take your multivitamins containing 400 mg of folic acid (the standard in most multivitamins) every day. Many morbidly obese patients also have fertility problems, but after WLS they will frequently be able to become pregnant. Do not get pregnant until your weight has stabilized.
Viamin B-12 it may also be required
RISKS AND COMPLICATIONS
Most patients do very well with the operation but there are risks. Short-term risks are the one seen in the hospital or during the first month after WLS. The risks of all surgeries are infection, blood clots, bleeding and pneumonia. All of them are important to us.
The complication we surgeons are very concerned about is a possible “leak”. A leak is a perforation of the stomach or the bowel from any place where a suture or staple is. The places where the stomach is sutured are tested during the operation for leaks using a special dye called “methidine blue”. No patient exits from the OR with a leak since we test it several times. But leaks may occur thereafter. Not all leaks need reoperation if they are well drained. But you may require reoperation, prolonged hospital stay and important medical treatment. Fortunately this complication is not common. One month after WLS the risk of these complications is gone.
Wound abscess or pus is very uncommon unless you had a leak. Special measures are used to prevent wound infection or drainage during surgery. Some patients may develop a wound seroma made of the subcutaneous fat that becomes oily after WLS; the treatment is partial opening of the wound and drainage.
We cut stitches on the second or third day, and use strips of tape to hold the wound closed to decrease scar formation.
Some patients have difficulty takings fluids in the very beginning because there may be swelling around the operated areas. You will stay on liquids the first 21 weeks, then 1 week on mashed/pureed food, and then after two weeks you may go on a normal diet.
As with any surgery, there can be complications. The list can include:
- Deep vein thrombophlebitis 0.5%
- Non-fatal pulmonary embolus 0.5%
- Pneumonia 0.2%
- Acute respiratory distress syndrome 0.25%
- Splenectomy 0.5%
- Gastric leak and fistula 1.0%
- Postoperative bleeding 0.5%
- Small bowel obstruction 0.0%
- Death 0.25%
BLOOD LOSS
Blood transfusions in primary WLS are very rare.
LONG –TERM COMPLICATIONS
There are should not be any long-term complications. No diarrhea, fouls smelling stools or flatulence.
FOLLOW UP
After surgery you will be given discharge information for your primary care physician and your self.
WEIGHT REGAIN At this time there is no long-term follow up with the SG operation for more than 3 years all over the world!
Our experience:
We initiated this procedure 12.02.2002 for our high risk and high BMI patients almost 4.5 years ago. The results have been very impressive. One patient with several co-morbidities and BMI 74 died due to heart organ failure. All the rest had awesome good results, even over 65 years’ old patients! No patient had deep vein thrombophlebitis, pulmonary embolus, pneumonia, acute respiratory distress syndrome, splenectomy, gastric leak and fistula, small bowel obstruction. One patient required laparoscopic exploration for postoperative bleeding without undue consequences and was discharged on the third day.
Our paper published at the Obes Surg 15:1124-1128, 2005 (available upon request) is the first dedicated exclusively to the LSG and is the largest updated publication in the world.
We have operated on 135 patients at this time. All patients are having weight losses as good as the DS. Only 3 patient of the 9 super-obese ( BMI >60) patienst has required yet a second stage operation.
Patents with low BMI had excellent QoL (quality of life) and very, very good weight losses and no side–effects!
Sleeve Gastrectomy Weight-Loss Surgery Patients. Post-Op Dietary Plan for Vertical
As with all surgical weight-loss programs, it is imperative that SG patients adhere to a strict postoperative diet. Patients must stick strictly to a liquid-based diet for 2 weeks after surgery; 1 more week on mashed (baby) food, patients graduate to a 600-800 calorie/ day solid diet. Once goal weight is achieved, usually 1-2 years after surgery, most patients can consume about 1000-1200 calories per day.
Long-Term Weight-Loss Results
On average, patients who undergo Sleeve Gastrectomy surgery experience a 60-80% loss of excess weight.
Lap Sleeve gastrectomy video
