Presentation

Sleeve Gastrectomy or Longitudinal sleeve gastrectomy is a restrictive technique proposed to patients with hyperphagia (who eat a lot at mealtimes).

It is called a ‘bariatric’ obesity surgery technique.

Its aim is to help obese patients lose weight.

Sleeve Gastrectomy reduces gastric capacity:

• We definitively remove 2/3 of the gastric volume  and we leave a stomach in the form of a tube by using staples (section) along the full length of the greater curvature of the stomach (around 25 to 30 cm).
• The surgical sample is given to the  anatomical pathologists for analysis.
• The size of the stomach left in place can vary, depending on the gastric calibration tube. This ‘bougie’ dilator is introduced, during the surgery, through the mouth into the oesophagus and then into the stomach by the  anaesthetists. We use  a 34 Fr ‘bougie’ dilator (with an approx. 2cm diameter calibre) which provides maximum regularity when making the line of staples.
• This is a reliable technique with a low repeat-operation rate  ( 1-2% )  when in the hands of operators with decades of expertise.
• The global morbidity rate of sleeve gastrectomy, both in the short and long term, is 9%.
• The mortality rate is 0.20% (mortality rate study of 143,449 patients operated in France, between 2007- 2012: data PSMI FRANCE= ω lien)

Gastric Volume Reduction:

After sleeve gastrectomy surgery the volume of the stomach that remains is around 100-150ml (the size of a banana).

The monitoring/follow-up of the patient is less onerous that with other techniques:

It consists of evaluating the results in terms of  loss of excess weight, reduction of BMI  (down to the values of normality/excess weight) and the improvement or even disappearance of other serious pathologies linked to obesity  (type 2 diabetes,  high blood pressure,  trouble with levels of cholesterol and/or triglycerides, sleep apnoea syndrome).

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Advantages

• Intervention generally completely made using laparoscopy (coelioscopy) keyhole surgery.
  • Level of security comparable with that of a gastric band with a low rate of conversion into a laparotomy (even with male super-obese patients).
• No foreign body is introduced, unlike with a  gastric band.
  • The staples used are generally well integrated after a few months: they are identical to those used in any other type of abdominal surgery.
• Sleeve Gastrectomy causes no malabsorption disorders.
  • This is a very physiological surgery technique.
  • The rest of the digestive tube is not modified, nor is digestion.
  • Sleeve Gastrectomy generates less vitamin deficiencies, notwithstanding that vitamin supplements (vitamins B1, B6, B9, B12; Iron) are recommended, as shown in the relative literature (link to bibliography).
  • There is no impact on the efficacy and dosage of your treatments (if you are taking medicines or a contraceptive pill).
  • The digestive tube remains accessible to any endoscopic investigation.
  • The risk of  dumping syndrome, whether early or late, is minimal (link).
• Food comfort is better, when compared with a gastric band (link), as there is no sensation of a blockage, with frequent vomiting.
  • With Sleeve Gastrectomy, the reduction of the calibre (volume) of the stomach is regular all along the tube: a near-normal diet is possible, even though the quantity will be reduced.  Bibliography.
• There are no risks (anastomosis) linked to intestinal suturing: no anastomotic fistulas or late-onset stenosis/ulcers, as found with the Bypass.
• There is no risk of  further surgery being required in the long term to treat an internal hernia contrary to the laparoscopic Roux-en-Y gastric bypass (LRYGBP).
• Sleeve Gastrectomy allows for the treatment of comorbidities linked to obesity with a comparable efficiency to a Gastric Bypass.
  • Disappearance and/or control of comorbidities post Sleeve Gastrectomy:
    • diabetes.
    • high blood pressure.
    • sleep apnoea syndrome.
    • dyslipidaemia (abnormal amount of lipids in the blood).
• The results in terms of weight-loss seem to be superior to those created by inserting a gastric band and are comparable with those of more sophisticated surgical interventions such as  the Gastric Bypass. Bibliography
• Sleeve Gastrectomy is an evolutive surgical procedure, at least as much as gastric band surgery: particularly relative to weight gain or insufficient weight-loss, or the appearance of Gastroesophageal reflux disease  (GERD). We can carry out the conversion to a laparoscopic Roux-en-Y gastric bypass (LRYGBP), or a Biliopancreatic Diversion (Bibliography).

Results

Public data concerning Sleeve Gastrectomy shows very interesting results in the medium term (3 years) concerning weight loss and the regression of comorbidities.

In our experience (Sleeve Gastrectomy in Montpellier 2006-2020) excess weight loss was more than 60% after 3-5 years, and the control, and even disappearance, of comorbidities comparable with a Gastric Bypass.

These figures are very encouraging, but it is worth mentioning that the real value of weight loss for all types of bariatric surgery generally increases ten years after surgery.

Quality of life after 10 years for patients having undergone SLEEVE GASTRECTOMY surgery, depends on the aggravation or appearance de novo (anew) of the symptoms of GORD, gastro-oesophageal reflux disease.

At each consultation we evaluate weight-loss in terms of:
– %EWL (percentage excess weight loss)
– %EBL (percentage excess BMI loss)

The weight loss in the medium term (3 years) is estimated at more than 60% of the excess weight (%EWL) and more than 75% of the excess BMI (%EBL).

The following is the example of a diabetic, obese patient who had Sleeve Gastrectomy surgery 3 years ago:

Now she weighs 75kg. She is no longer diabetic and is very satisfied with the results of her surgery and current quality of life.

– Her parameters prior to the Sleeve Gastrectomy surgery:

Height:  1.67m; Weight:  120kg; Ideal weight as per Lorentz:  60kg;

Excess weight (to lose): 60kg;  BMI: 43kg/m²;

Ideal BMI:  22.5kg/m²;  Excess BMI:  (43-22.5) = 20.5;

Type 2 diabetes.

– Results 5 years after surgery:

Weight: 75kg; Height: 1.67m; Weight lost: 45kg;

BMI: 26.8 Kg/m²;

%EWL = (45kg lost/60kg to lose ) = 75%.

%EBL= (43 -26.8)/20.5 = 79%.

Diabetes has disappeared.

Possible complications

A Fistula is the worst post-operative complication of Sleeve Gastrectomy:

It involves a leak of digestive fluid at a point on the line of staples (leak of oral contrast agents for opacification for an OGDT/scan).

The rate of incidence of this complication is 3%.

The formation of a subphrenic abscess in the left side of the stomach, the clinical picture of peritonitis or early haemorrhaging generally require new surgery within the first 24-48 hours.

The appearance of a fistula is an event which is difficult to anticipate. The clinical picture is variable, from a chance discovery to post-operative peritonitis.

Suggestive signs and symptoms  are abdominal pains,  pain in the left shoulder (subphrenic abscess) fever, the recent appearance of substantial difficulty swallowing (dysphagia), vomiting, and more importantly abnormally rapid heart rate, tachycardia (> 120 bpm).

Simple postoperative tachycardia for an obese person must be taken seriously: it is a very specific clinical warning sign (Federation of Visceral and Digestive Surgery=bariatric surgery risk management)

Early post-operative haemorrhaging

Rate 2.5%: Bleeding: along the line of staples, trocar holes, spleen and gastrosplenic ligament.

Stenosis:

The abnormal narrowing of the remaining stomach: this risk is estimated to be around 3%. Over time it causes prolonged vomiting.

• Notwithstanding the use of a ‘bougie’ calibration dilator, the line of staples may have irregularities (a twisted, spiralled aspect at the  gastroscopy). Although a very small rupture of the stapling may not be noticed, it may bring about a narrowing of the remaining stomach.
• If the problem of regular vomiting does not go away after an endoscopic dilation, a new remote surgical intervention is necessary.
• GORD: The symptoms of  gastro-oesophageal reflux disease are present  in 1/3 of patients but are well controlled with the available medical treatment.

Gastro-oesophageal reflux:

20% of patients can suffer from Gastro-oesophageal reflux immediately following a sleeve gastrectomy.

The symptoms are treated by proton pump inhibitor drugs  (PPIs)  (Omeprazole, Pantoprazole) with a good response.

GORD has the tendency to diminish, even disappear when the patient loses sufficient weight.

In the case of severe GORD, a Roux-en-Y gastric bypass (RYGB) can be undertaken (link to bibliography).

The mortality rate of this surgical procedure is basically zero (0.20%).

We estimate that presently Sleeve Gastrectomy surgery, if carried out by a team of experts, provides a very high level of security with low global morbidity. (Bibliography)

Late complications of Sleeve Gastrectomy:

• Dilation of the Gastric Tube:
  • Probably linked to a defect or a too large calibration in the beginning.
  • If all the large tuberosity was removed to create a narrow tube, dilation over time is unlikely or less likely as the muscle fibres  of the lesser curvature are not very extensible.
  • However, a gastric tube which is too large at the proximal level (leaving a diverticular aspect of the fundus) may, theoretically, be predisposed to this complication. This aspect is sometimes found in a sleeve gastrectomy procedure after a gastric band which did not work.
• Weight gain:
  • It is difficult to attribute weight gain to a dilation of the gastroplasty, which remains a rare event. Furthermore, substantial loss of weight was obtained with a relatively large calibration.
  • Weight gain is more likely to happen if the required diet is not followed, with hyper-caloric foods with a pasty smooth texture (milk shake) doubled by the absence of physical activity.