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A sleeve gastrectomy can transform your life. With sustained weight loss you will find energy you didn’t know you had, aches and pains from joints can melt away, associated diseases such as high blood pressure and diabetes can improve or go into complete remission and your chances of dying before your time or having a heart attack, stroke or a cancer are greatly reduced.
Each of the weight loss operations has its strengths and weaknesses and what follows is an account of the sleeve gastrectomy.
At LapSurgery Australia we perform each of the three major types of weight loss surgery, being the gastric band, the sleeve gastrectomy and the gastric bypass. In most cases we do not recommend the gastric banding so the choice for most people lies between the sleeve gastrectomy and the gastric bypass. Studies comparing the two over five year time frames show very similar degrees of weight loss. Patients with Type II diabetes and those with gastric reflux have somewhat better results with the gastric bypass. However the sleeve gastrectomy, because of its reliable weight loss, can also achieve excellent improvement or even remission of diabetes.
The normal stomach (which is NOT enlarged in obese patients) holds about 1.5 litres of food. We reduce the size of the stomach by resecting the “bulgy” bit of the stomach – see the diagram. The resected part of the stomach is removed completely. The remaining “sleeve” of stomach holds only about 150 mls, thus the stomach capacity is reduced by 90%.
The effect of the sleeve gastrectomy is that you can eat a very small meal, feel full and satisfied and the hunger you would now feel from eating such a small meal does not occur.
By eating not more than a half cup of solid food your stomach will be full. You can’t eat any more! Food now sits at the top of the stomach. This activates nerves to the brain telling the brain the stomach is full and this causes the brain to turn off the hunger mechanism.
There is a second mechanism at work here although there remains some controversy over this. The main hunger hormone is known as ghrelin. The stomach that we resect secretes at least 60% of the body’s ghrelin. This may further reduce the hunger which would normally occur after eating very small meals.
Although the meals may be small, you can eat almost any food, just very small amounts. You will have no problem eating out.
All surgery involves some risk. Risks can be broken down into two groups, those related to surgery in general and those specific to the operation being performed. Risks of surgery in general include risks of anaesthetics, infections inside the abdomen and in the wound, lung problems, blood clots in the leg or lungs and even death. If you have other health problems such as heart or lung problems, diabetes, smoking or excess weight the general risks of surgery are increased.
These will be discussed in detail with you PRIOR to the operation by your surgeon. Possible complications include but are not limited to:
When assessing the risks of surgery you must also consider and balance the risks of NOT having the surgery and remaining significantly overweight
It is better to avoid a complication than to treat it!
People with significant weight problems in general have a higher risk of complications during any surgery. At LapSurgery, long before your operation takes place, you will undergo a comprehensive assessment of your health so that we can identify any risks and minimise these.
If, after your initial visit to the surgeon, you decide to go ahead with surgery we will arrange a comprehensive set of blood tests and an appointment with a specialist physician experienced in preparing patients for surgery and minimising any risks. Patients with significant weight problems will often have other conditions related to their weight (comorbidities) which in many cases can increase the risks of surgery. Poorly treated high blood pressure, poorly controlled diabetes, untreated sleep apnoea, vitamin D deficiency, urine infections and cardiac problems are often present and these must be treated properly before surgery. Sometimes this will involve other tests such as sleep tests, blood pressure monitoring and heart tests before we can go ahead with the surgery. The very high safety levels with which we perform this sort of surgery are very dependent on this initial thorough investigation and optimisation of treatment of comorbidities BEFORE surgery takes place.
One of the risks of this sort of surgery, often not listed in the usual complications, is the lack of education and understanding of both the preoperative preparation and the post-operative management of your lifestyle and dietary habits. We have a full time dietician at LapSurgery to educate and supervise your weight loss journey. We are also very aware that years of frustration with your weight problems and some of the prejudice you will have faced about your weight can have an effect on your mental well-being and so all patients are seen initially by our counsellor as part of the assessment. Follow up counselling is available should you wish.
The following are the commonest of the complications but please note that this is not a comprehensive list of possible complications but does cover most events.
Anaesthetic risks are extremely low because when you come to your operation any conditions which might increase your anaesthetic risk such as high blood pressure, diabetes or sleep apnoea will have been brought under control. All of our anaesthetists are experienced with dealing with the specific problems of patients with excess weight and have full access to all of the tests and information gathered during your preoperative assessment.
In any type of surgery the following risks can occur:-
Although uncommon, bleeding can occur during an otherwise routine operation and could require blood transfusion and possibly abandoning the laparoscopic (keyhole) approach and require a major incision in the abdomen. Occasionally, after a routine operation, bleeding can commence some hours after an operation and require a return to the operating theatre.
Again these are uncommon with laparoscopic surgery, but occasionally one of the small keyhole wounds can become infected and require antibiotics or drainage. Uncommonly, an infection inside the abdominal cavity or the chest can occur.
Although uncommon, during laparoscopic surgery it is possible to inadvertently damage another organ such as the spleen or the bowel. Normally this can be diagnosed and repaired during the operation but very rarely this damage may not be obvious until some hours or even days after the procedure and will then require appropriate management.
Rarely, it is not possible to complete an operation with keyhole surgery and a full abdominal incision may be necessary. This is more likely to be the case if you have had previous surgery on your stomach such as a gastric band.
Blood clots to the legs or the lungs are a very serious complication. At LapSurgery we use the maximum protection against this occurring. Shortly before the operation you will be given a blood thinning injection and have stockings placed on your legs. As well is that a further device will be placed on your legs which keeps pumping blood through your legs whilst you’re asleep to minimise the chance of a clot forming whilst you are on the operating table.
Using these precautions and early mobilisation after the surgery that is possible with the keyhole operation, these complications have been extremely rare in our patients.
When we cut the stomach we use a stapling device to seal the stomach. A triple row of titanium staples seals the cut edges of the stomach. This produces a very secure closure of the cut edges of the stomach. However, right at the top edge of the stomach there can be a failure of the staples to seal fully. If this happens there will be a leakage of stomach contents into the abdominal cavity which can give rise to peritonitis. This can only occur in the first 10 days after the operation and occurs in about 1% of patients. If you have had previous stomach surgery such as a gastric band the leak rate is significantly higher and must be discussed thoroughly with your surgeon.
This is a very serious complication and could keep you in hospital for several weeks. Further operation may be required which may not be laparoscopic (keyhole) surgery.
The leak will eventually seal by itself or by other treatments and once this occurs the operation will work just as well as if the complication had not occurred.
On occasions part of the sleeve will narrow and you may be unable to swallow foods properly. This is easily fixed in most cases by a simple gastroscopy and opening up the narrowed area with an inflatable balloon. This is painless and done just as a day case. Sometimes several dilatations may be required. In very rare cases it may not be possible to cure the problem and conversion to a gastric bypass may be necessary.
This is uncommon and mostly seen at the upper end of the sleeve in patients who have previously had a gastric band. It occurs more often in pre-menopausal women. On occasions it can be trimmed but our preferred option is to convert to a gastric bypass.
Most patients will have some reflux in the first few months after a sleeve gastrectomy which can easily be controlled with acid lowering medications such as Nexium. A very small group of patients may experience very severe reflux not controlled by tablets. In this instance conversion to a gastric bypass may be necessary to stop the reflux.
Unfortunately a small number of patients will either not lose the expected amount of weight or will at a later date put some of the weight back on. It is vital that you understand that the sleeve is a tool to help keep your weight down. It is not a procedure which can protect you forever from putting some of the weight back on. You must realise that you have a genetic predisposition to putting on weight and that long-term attention to the principles we will have taught you are essential to keep the weight off. Long-term follow-up, which we provide at LapSurgery, is absolutely essential to your long-term success. If there is any tendency to put weight back on you must see us immediately so that we can help you to reverse any weight gain. Unfortunately, some people feel they have failed if they start to put any weight back on and feel embarrassed to come back and see us. The more weight you put on before seeking help, the more difficult it will be to get the weight off. We will never make you feel embarrassed about any weight gain; we are here to help you.
Following weight loss surgery each patient has the potential of vitamin deficiency and so LapSurgery Australia recommend to all patients that they have a regular daily multivitamen in order to reduce the risks of other medical conditions such as osteoporosis, thiamine deficiency along with many other conditions. More information is given to patients at the time of consultation.
What you have read above is a summary of the operation of sleeve gastrectomy. This is not sufficient information in itself and every aspect of the sleeve, the preparation for surgery and the possible complications are always specific to an individual and must be discussed at length with your surgeon.
Good results are only achieved when you, the patient, are well informed and educated about the procedure and the operation is done by a dedicated, experienced multidisciplinary service such as we provide at LapSurgery.
We look forward to helping you.
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