Sydney Metabolic Surgery  Sydney Metabolic Surgery

 
 

   Sleeve Gastrectomy

The Surgery   Recovery   Long Term Issues

Currently is the most common type of surgery performed in Australia and is gaining momentum in other countries as well. The surgery was discovered accidentally, as it was the first stage of laparoscopic duodenal switch surgery. Due to technical difficulties in patients with a BMI 60 and over, some cases of surgery were cut short after finishing the first stage, which was to sleeve the stomach. Many patient didn’t go back for the second stage as they lost enough weight and maintained it, and the idea of sleeve gastrectomy (SG) as a stand-alone procedure for weight management developed around year 2000.

Sleeve gained popularity over lap band due to higher success rate and better life style. Medium term complications are much less than lap band, currently significant number of lap band patient experience the treble effect of the band on the esophageus, severe dilatation and reflux, acid and non-acid reflux. Popularity of sleeve gastrectomy has accelerated since 2010, as it can be performed even in patients with previous multiple abdominal surgeries, as compared with gastric bypass or other surgeries which would necessitate conversion to open surgery.

The principle of SG, is to reduce the size of the stomach down to 100 – 150 ml. In practice this size goal serves only as a guideline, and is slightly different between practicing surgeons. Although the principle of the operation is consistent between different surgeons there is variation in the finer points of surgery with a SG such as the amount of stomach removed and the exact shape which will optimise outcomes. My own technique have also undergone some changes throughout my years of practicing.

Sleeve works by altering size / shape of the stomach, decreasing Ghrelin hormone and altering vagal nerve signals to the brain. This is to counteract against the second strongest signal in our brain, the hunger signal which is the main cause of diet failure. This signal together with breathing signal are vital to keep us alive. Food and oxygen are important element in energy production ( calories) which keeps our body alive and kicking. So it is our survival instinct which push us to eat.

How the Sleeve Works

Size: Generally 100 – 250 ml is an acceptable size. We are producing one size fits all, and have only a few pre-operative hints with some patient to lean toward smaller size stomach, but otherwise we are trying to produce same size for all comers. Too small a size might produce severe food intolerance and poor life style, although the patient could lose all the excess weight and in short period of time. It is very important to strike the balance right, which is easy to say but hard to achieve sometimes.

The size of stomach which allows you to eat close to entire size and any food you like, I think this is the ideal size. Desperation or the push to lose more weight and gain more patient satisfaction could have led some surgeon to produce excessively small stomach. The smaller the size the higher the leakage rate and other complications.

Stomach will never regrow but could stretch slowly. Nobody knows what is the maximum stretching ability our stomach has, but shouldn’t double in size. Up to 250 ml is acceptable size.

Shape: attention to shape is gaining more interest as it plays very important role in combination with size in the determination of patient progress. The ideal shape is gradually increasing size from the cardia to the antrum. Axial rotation, angulation and narrowing at the mid stomach (the incisura) are important issues that needs special attention by the surgeon.

Leaving or retaining some fundus (the upper thin part of the stomach), could lead to weight regain as this part could stretch and allows the patient to eat more. It also affects the number of remaining Ghrelin producing glands.

Leaving too much of the antrum (the lower portion of the stomach), again allows bigger portions of foods and could also stretch needing redo-surgery.

Ghrelin Hormone: is a hunger producing hormone located in microscopic glands inside the flesh of the stomach and very concentrated at the upper part. Surgery will not remove it all but majority will go with proper sleeving of the stomach.

Grehlin vs Appetite

About 30% of patients have to remind themselves to eat due to complete loss of hunger signals, whilst the other 70% still feel hunger but no where near the intensity prior to surgery. Other non-consistent changes could be encountered, like for example losing interest in your favourite food and being unable to tolerate smoking

Ghrelin has multiple effects on our body including bone mineralization, muscle growth, and repair of intestinal cells.

Vagus Nerve: this nerve conveys direct information to the brain about status of the esophageus, mainly the speed the food bolus travelling down to the stomach. Usually if the stomach is empty, it will take 4-8 sec for the bolus to reach the stomach once swallowed. With a sleeved stomach, the new tube like stomach is not as welcoming and fills up with a few mouthfuls, leading to significant slow down of the passage of food bolus. Signal through the nerve then will tell the brain that the stomach is full and should urge us to stop eating.

Other possible mechanism, could play part in the weight loss following sleeve gastrectomy, like producing dumping syndrome, which is not as common as in gastric bypass surgery.

 The Surgery go to top of page

The operation performed laparoscopically, (keyhole surgery) almost all the time, with few exceptions like patients with previous multiple complex open surgeries.

Pre-operative preparation:

Patient should be assessed for suitability for bariatric surgery and anaesthetic risks:

We will need to know every single details of your general health, medications, previous surgeries, allergies --- etc.
Blood tests, ECG and other investigations as needed
Medication review and adjustment might be needed. blood thinning medications should be dealt with properly depending on the individual patient circumstances
Diet prior to surgery is important to plan, some patient might not even need any diet while others might not proceed unless planned % of weight loss prior to surgery achieved. All these plans will be decided upon during the consultation. Aim of diet is to make the surgery safer, by softening the liver, improving heart and lung functions --- etc.
Planning your work, family and social commitments
Psychological issues should be discussed, medication management pre and post surgery is important.
Setting plans about managing diabetic medication
Cardiac and blood pressure medication should be continued, you could even have them at the day of surgery with small sips of water.
Cardiac stents, and management of aspirin and plavix should be discussed.
Fasting before surgery, for patient on morning list, should fast from midnight the night before surgery. For patient in the afternoon, could have liquid in the morning and water up to 4 hours before surgery, unless issues with lap band and oesophageal dilation is contemplated.
Diabetic medication should be omitted on the day of the surgery
Brisk walking for few hours every day before surgery will improve recovery post surgery.
Smokers should attempt quitting few weeks before surgery, otherwise should expect breathing difficulties and frequent coughing which is quite painful following surgery.
Alcohol together with weight put more burden on liver and increases the severity of fatty changes.
Should inform us of any significant previous anaesthetic reactions or any significant allergies.

The day of the surgery:

Hospital will contact you about your approximate time of surgery
Formal paper works and nursing check
In the operating theatre, few formal check ups and anaesthetic review
positioning on operating table, intravenous cannula inserted, O2 by mask, and other preparation
once anaesthetic medication given, it will be a matter of 30 – 40 sec and you will be fully anaesthetised.

The procedure:

position on the table and proper strapping ensured
operation site cleaned with antiseptic and proper drapes used
the first incision for camera insertion is just under the left rib cage (anterior axillary line)
other working ports inserted under direct vision and the anatomy checked as below

Port Positions
Stomach

The yellow fatty tissue in the bottom of the picture is the greater omentum (abdominal policeman or lady), will be dissected off the stomach as you could see were the arrows are in the next picture. This will allow the resection of the lateral border of the stomach following the insertion of calibration tube (Bogie).

Bogie Insert

Next picture shows the bogie in black / blue inserted by the anaesthetist.

Border Restriction

Next step of the surgery is to resect the left lateral border of the stomach using stapler device and trying to leave stomach of 100 – 150 ml size, apart from experience there are no other definitive ways to measure the size at the time of surgery, so surgeon’s experience will play important part in this surgery.

Stomach Shape
Stapler Device

The other important point is the shape of stomach, this area is the current interest as we think it has a lot of influence in weight lost, quality of life and complications.

Stapled Stomach

As you could see above in the dark lined shape, this is the final shape of the remaining stomach. Nice and narrow at the top and slowly curving and increasing in size as we go towards the lower end. I also fold and stitch the lower end using non-absorbable stitches to prevent future stretching / dilatation and possible weight regain.

Once the stapling finished, the next step will be the re-enforcement of staple line by bringing back the fat layer, (omentum) and stitching it to the staple line. This process will also stabilize the new stomach prevent twisting and bleeding from the staple line. The last quarter of the staple line will be folded to re-shape the lower part of the stomach were stapling is difficult and could lead to complications.

Reinforcement of Staple Line

By finishing this step the operation is almost finished. Final inspection, instillation of local anaesthetic and retrieval of the excised stomach through the largest port site are the remaining steps. Wound cleaning and closure using dissolvable stitches under the skin. Steristrips and water proof dressing are applied.

The anaesthetist will slowly reverse the anaesthetic and will remove the breathing tube once the patient is wake enough. You wouldn’t remember or recall any of these events, due to the heavy sedation on board at the time.

 Recovery from anaesthetic and Further management go to top of page

Rest of the recovery will be at the recovery unit and once awake enough you will be transferred to surgical word or high dependency depending on individual cases.

On the day of surgery, you will be nil by mouth, feeling some pain and discomfort. The pain response following surgery is different with different patients, and is dependent on a vast range of factors including age, comorbidities, social demographics and also psychological factors. Generally laparoscopic or keyhole surgery is much less painful than traditional surgery. Fluid is introduced through intravenous cannula and oxygen is given through mask or nasal tube.

Day one post surgery, you will be assessed in the morning checking your suitability to start water trial and progression to liquid. Should be able to come off the bed and move around.

Medication will need special attention:

Diabetic medication: during pre-operative diet period, usually you will need half of the dose; you should stop all diabetic medication on the day of the surgery; your blood sugar will be monitored post-surgery and we could give you small frequent doses of rapidly acting insulin for short period of time if needed. Majority of patients will not need medication, as the amount of calories ingested is very small. If you are on long acting insulin, the dose will be slowly decreased aiming at stopping them once suitable. Your individual plans will we discussed with you. If you are on a combination of oral medications and subcutaneous insulin, we will try to get you off insulin first whilst keeping oral medications until ready to stop all medication if suitable.

Blood thinners / anticoagulant: scenarios are different depending on individual patients circumstances and plans will be set before surgery. Almost every patient will have Clexane injection, to prevent clots. Some will need to have it for few weeks if previous history of deep venous thrombosis.

Blood pressure medication: depending the blood pressure, as some will go the other way, low pressure. If needed majority of blood pressure medication could be swallowed.

Antidepressant, and other psychiatric medication: most of these medication could be used on the first day, but if suitable we will try to delay the use for few days, or if liquid alternative present, some could be crushed. All medications are designed to dissolve, so even if the tablet stuck in the middle of new stomach, should eventually dissolve and pass down.

Arthritis medication: it is very important to stop these medication until full diet allowed. Using alternatives and suppositives might be needed

Cholesterol medication: no need to restart these medication , and if needed might be started few weeks later.

Other medication should be discussed and stopped or restarts as needed.

Herbal medications should be stopped, as we don’t completely understand their effect if any.

Oral intake:

Usually by midday day one post surgery, trial of water starts, you will put to plan, 20 ml of water to drink every hour, for few times and if you passed the test with no vomiting or excess nausea then you will progress to clear fluid diet and will continued for five days.

Examples of clear fluid:- ( water, juice, electrolyte drinks, sport rehydration drinks like powerade, clear broth of meat and chicken, will try to avoid jelly)

How much you will need depends on many factors, difference between individuals and seasons. Basically the gauge will be the level of your thirst and the colour of urine. If dark, then you will need to increase your oral intake.

Will need to drink slowly, chest pain and discomfort is good sign that indicate difficulties of smooth passage of liquid through, so you should slow down and swallow even smaller mouth full at a time.

If you couldn’t tolerate liquids and urine is becoming darker or you are feeling lethargic, you will need to contact us or the hospital to arrange hydration.

Diet will be progressed slowly, with gradual increasing of thickness of fluid until four weeks when soft diet could be started. Basically no food that needs chewing should be consumed in the first four weeks post surgery.

Oral intake

Day 1 - day 5 – week 1: water trial, if successful will proceed to clear fluid ( no Jelly), which includes, tea, coffee, clear broth, powerade, --- by day 5 should be able to have shakes, like optifast, protein shakes / drink up to week one

Week 2: puree diet could be started, but very thin to start with, and mostly vegetable legume. Basically could boil small amount of rice, lentils, and others and once ready cooked turn off the fire and add vegetable and blend in few minutes time.

Week 3: Puree diet with addition of meat or chicken to the blend

Week 4: thicker puree with more consistency closing up to mashed food.

Subsequently soft food could be started, like casserole, steamed fish, boiled egg --- for one week and then to full diet by about week 6.

Vitamins and protein supplements

Daily multivitamins is very important to cater for our body needs. Even people with a full stomach might need vitamin supplements as our current food is very poor in vitamins due to fruit harvesting and current storing practices. Wide variety of products are available and our dietician will advise you about good brands.

Vitamin B12, usually injectable preparation is needed. The absorption of this vitamin needs a special protein produced by the stomach, and since the stomach is smaller, less protein is produced leading to less vitamin B12 absorption.

Vitamin D, majority of us have low levels which becoming an epidemic. This vitamin very important for bone mineralization, immune system and over all wellbeing. Adequate level is needed to prevent hair loss

Calcium, adequate calcium especially in pre and post menopausal ladies is very important to avoid early osteoporosis..

Silica and other hair and nail preparations: supplement helps to stabilize and prevent excess hair loss.

Protein, average of 60 – 70 gm of protein needed daily, to keep lean body weight, sense of well being and help to prevent hair loss.

Iron, iron usually in the best circumstances is difficult to absorb and needs adequate acid to facilitate absorption. Smaller stomach, less acid and eventually less iron absorption. Supplement could be oral or through infusion if severe deficiency encountered.

Fibre, good % of patients suffer from constipation due to insufficient fibre from inadequate fruit and vegetable intake. We usually recommend benefiber to help with bowel movement.

Pain relief

Pain is not a big issue and majority of our patients are pleasantly surprised, saying "we expected much more pain than this, did you actually operate on us”

Injectable pain relief used during hospital stay and script will be given when discharged home. Majority won’t need more than dissolvable panadol. Endone and targin are stronger pain relief medication options.

Lower front chest wall pain could be related to fast eating and drinking very quickly. Pain around the wound usually due to muscle stretching and bruising from the surgery. Shoulder tip pain might be significant in patient whom had hiatus hernia repair.

Excessive pain with other symptoms should prompt you to contact us for advice.

Unusual pain in the chest, leg should be investigated for possibility of deep venous clotting and pulmonary embolism ( clot going to lung).

Acid medication

Acid medication is administered through the drip whilst you are in hospital. On discharge, you will be given a script for pariet tab 20 for 2 weeks, mainly to help you stomach wound to heal, and will help if you had acid reflux.

Acid reflux might persist with majority setting down in about 3 month. If it persists a for long period and is not responding to medication then formal assessment and investigation is needed. Some might need surgical intervention.

During initial surgery we try to make sure a few boxes are ticked to prevent or lessen the impact of possible post-operative acid reflux. Difficulties encountered may include a very large fatty liver which obscures the hiatus making it difficult to assess or repair hernia during the initial surgery. Although it is not ideal, some do come back for second surgery but it is much safer once some weight is lost.

Dressing and wound management

You will have water proof dressing covering the wound. It could stay up to 7 – 10 days. Some bruising in and around the wound is expected in some patients. Minor blood oozing might happen too, only excessive bleeding leaking through the dressing needs attention.

Infection is not very common and not very troublesome as we don’t have foreign body inside to worry about. Occasionally some of the stitches might poke through before they are completely dissolved. It will eventually dissolve and shouldn’t be too much of a bother.

You may shower from the first day, but you do need to pat the wound dry.

Level of physical activities and daily living

You will need to take it easy in the first 5 – 7 days. Some could go back to office type of duties one week post surgery, but some might feel week, depending on how much initial restriction they had. If calories are too restricted the body will switch into severe starvation mode to decrease energy expenditure making you feel like you have no power even to move around. The body eventually will let stored energy out ( stored fat) to supply the body.

Should be able to drive after 5 – 7 days, and could return to office type of duties 1 – 3 weeks post surgery depending on overall recovery. From 3 – 6 weeks post surgery, could go back to work on light duties, meaning not pulling or pushing hard and not lifting over 5 kg.

In term of exercise, normal walking is allowed for up to 2 weeks. On the 3rd week you may start brisk walking and gentle jogging. Full sport activities could be started 6 weeks post surgery.

Could start physical intimacy roughly by 3 weeks, but do be gentle to start off with. If you have children at the age where you need to lift them and change nappies, you may need help for few weeks.

Heavy lifting or physical activities of any sort could lead to the development of abdominal wall hernia, but no untoward effect on the actual sleeved stomach unless extreme activities or direct accidents.

When to call / what are the signs of concern / complication

Although there are great variation between different patients experience, but few points should raise concerns if happened.

- ( STAPLE LINE LEAKAGE)

Rate of leakage of %1 or less depending on the unit. Usually causes temperature and Severe sudden pain, following food especially if you were not following diet instruction. If you start eating solid food early, it will be like poking your finger through the staple line trying to break it. You might get away with it, but if leakage happened you should remember that your life is at stake. It can be quite a painful experience . At best you will be in hospital for a few months with multiple surgical procedures. Outcome depends on clinical situation.

Us perfecting the procedure and you following instructions will minimize leakage, but unlikely to reduce it to zero. If it happens, it should be managed by us, because we understand the procedure you have had and can manage its complications. Nobody should operate on you or do anything without consulting us.

Most of the time when patient call in worried about leakage, they don’t have it. We don’t mind you calling us. We would rather know of issues early, because it allows us to make treatment decisions early before you deteriorate further. If you have any concerns - even if it turns out to be a completely benign issue we are very happy to offer advice and reassurance.

Other more common causes of pain include localized bleeding, normal post-operative pain but in patient with low pain threshold, psychological issues, lung clots, infection, splenic infarction ( sharp decrease In blood supply to the spleen), lung collapse, back related pain if you already suffer from chronic back pain, severe acid reflux and inflammation of the lower esophageus, and multiple other related and incidental non-related causes.

- (severe acid reflux)

One of the areas of great interest is in understanding the causes of acid reflux following surgery and whether changing our technique may stop or at least decrease the severity of reflux. Most of the acid reflux is manageable at home with acid medication. Only in extreme cases when the sleeved stomach is pulled up into the chest where semi-urgent surgical intervention is needed. Again with proper stitching and plication this shouldn’t happen. Other causes like severe narrowing in the mid portion of the stomach, like hour glass deformity also may contribute. Thankfully most of the time it is due to much simpler causes.

- (recurrent vomiting and dehydration)

Vomiting is not uncommon following sleeve gastrectomy, and causes of vomiting are many. Vast majority will settle down, although some going on for a few days may even need readmission for hydration. The most common cause of prolonged vomiting is usually due to severe inflammation and oedema of the newly sleeved stomach as shown in the picture below. If there is some unavoidable angulation in the gastric tube, it might lead to complete blockage .

Bleeding

To counteract and decrease the oedema and the inflammation we usually use Dexamethasone which is strong steroid to help and usually suffice.

- Bleeding

Some blood loss is unavoidable. It could range from negligible to a level that we might need blood transfusion. Thankfully the rate of significant bleeding is low. Bleeding is usually from the newly formed staple line, and stitching usually is the best way to control it, which we routinely do. But bleeding from other sites is also possible including, liver, spleen, greater omentum and from the port sites. Routine blood check is done after surgery to check for significant drop in the blood level.

- Deep venous thrombosis

Obesity is one of factors which encourages clotting of the blood in the deep veins. We do take due precautions, like routinely inject clexane and putting on stocking and pneumatic calf compressors during surgery. For higher risk patient we might need about 2 weeks of clexane injection, which the patient could inject themselves at home. The risk of clotting is the highest in the first 3 weeks and fades away gradually. Long distance travelling obviously not advisable if possible in the first 4 weeks.

- Hypoglycaemia

Occasional severe attack which could lead to fainting. This is usually due to a much higher level of insulin production in an insulin resistant individual. Once weight lost occurs, the insulin sensitivity improves but the level of secretions still the same and will lead to severe hypoglycaemia if the oral intake was inadequate. It could take a few weeks until sugar level stabilizes. One of the best way to prevent these attacks is pre-operative dieting and weight loss which is basically training your body and getting it ready for the post-operative period.

 Long term issues go to top of page

- Diet, vitamin and mineral sufficiency or deficiency

Balanced diet with enough protein, essential elements and vitamins is important to maintain long term healthy body. Good recipe books specifically put together for bariatric patient are available, like the example below is important to have.

Your Guide

Consulting an experienced dietician is essential and will help preventing long term nutritional deficiencies. Self education about food, calories, additives and chemicals added can be helpful . Your stomach is not just smaller but its function is affected, less acid affecting calcium and iron absorption, quicker stomach emptying in some patient leading to dumping syndrome. This is not as significant compared with bypass surgery . Vitamin B12, deficiency is common, mainly due to a decrease in protein produced by the stomach to facilitate the uptake of the vitamin in the small bowel. Vitamin D, deficiency is quite common amount the public , and it is worse with obesity, as higher doses of inactive Vitamin D needed to produced enough active Vit D compare to none obese person. Once weight loss is achieved this becomes less an issue.

- Eating and chewing technique effect on the long term health of the esophageus.

Sleeve produces resistance to food passage although not as severe as lap band surgery, but it is important to consider. Basically you will need to chew your food properly and not to push it too hard or too quickly even if you feel hungry.. This behaviour could lead to severe stretching and dilatation of the esophageus. It could become another stomach and could accommodate as much or more than the sleeved stomach.

Chewing Food

Eating in a hurry and trying to push down with water or other liquid could cause a lot of damage to the esophageus. It is very important to look after the health of the esophageus otherwise long term suffering might be encountered and you might need a bypass to decrease the pressure on the esophageus.

- Sport and physical activities.

The importance of physical activities cannot be overstated. Exercise won’t help with weight loss but helps to maintain it and significantly improves your health. Loosing weight alone doesn’t make you healthy. Our body is dynamic and our tissues like muscle and bone will changes with the levels of activities. If we don’t exercise, our muscles gets weaker and our bone becomes brittle which leads to all sorts of problems, ranging from back pain, disc prolapse, osteoporosis and associated fractures, muscle and tendon issues. Our heart and lungs becomes less efficient and our immunity drops--- all to the harm of our body.

Our unhealthy modern living is harmful, and the more advanced we are the less activities we engage in. We don’t play games using our body but only our fingers facing computers. Most of us have no idea about building simple things, planting or cooking from scratch--- we all want something readily made and don’t want to wait.

We need to keep moving and expose our body to higher and higher levels of physical challenges. Of course starting slowly, otherwise you could harm yourself if you jump from a fully sendary life to doing extreme activities. Consulting personal trainer and or exercise physiologist might optimise your quest for very healthy body.

- Changing the management of your pre-existing medical morbidties.

Very important to evaluate the need of your pre-existing medication regularly, especially early on. The effect of weight loss have a variable effect on pre-existing medical conditions, mostly positive. You will need to see our bariatric physician to take you through the changes

- Skin laxity

If you loose enough weight regardless of the methods used , skin folds and sagging could become a significant issue that might need surgical intervention. Through our clinic we offer abdomino-plasty (tummy tuck) at an affordable price for our patients.

- Pregnancy

Usually advised our ladies to avoid pregnancies in the first 12 month,

- Weight maintenance / weight regain

This is one of the most important issue that most of us think about it. We must remember the way our body works and how the surgery works to convenience the body to stay satisfied with a lower weight which is against its inherited survival instinct built into our brain. This surgery is a strong tool given to you, that you need to understand well and maintain. This tool doesn’t and can’t block or stop all our bodies tricks to regain weight. We are giving you the upper hand but you could tip the balance against yourself. You have to put some effort yourself.f You can’t depend 100% on the operation, the percentage of effort unfortunately might need to increase as years passes by.

Having said all that we don’t pretend to understand all the reason beyond some of the weight regain. We are constantly reviewing the effect of the surgery, patient response and adjusting to tackle issues as we discover them.

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