Gastric Sleeve Options

Sleeve gastrectomy is a new procedure that induces weight loss by restricting food intake. With this procedure, the surgeon removes approximately 60 percent of the stomach laparoscopically so that the stomach takes the shape of a tube or "sleeve." This procedure is usually performed on superobese or high risk patients with the intention of performing another surgery at a later time. The second procedure can either be a gastric bypass or duodenal switch.

Expected Weight Loss

This combined approach has tremendously decreased the risk of weight loss surgery for specific groups of patients, even when the risk of the two surgeries is added. Most patients can expect to lose 30 to 50% of their excess body weight over a 6 - 12 month period with the sleeve gastrectomy alone. The timing of the second procedure will vary according to the degree of weight loss, typically 6 - 18 months

Why Consider Surgery

Patients who are morbidly or severely obese are at increased risk for health problems and tend to have a shortened life span. There is also added potential risk from continued weight increase. The risk of severe obesity is greater than that of its surgical treatments. Persons eligible for gastric bypass surgery include the following:

Persons at least 100 pounds above ideal body weight.

Persons who are at least 80 pounds over weight and have life-threatening obesity related problems such as diabetes, hypertension, sleep apnea, etc.

Above persons who have failed non-surgical attempts at weight loss, specifically a combined regimen of diet and exercise.

Surgical Options

Roux-en-Y Gastric Bypass

LAP-BAND System

Deuodenal Switch or also known as Duodenal Switch

Gastric Sleeve

Mini Gastic Bypass

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Surgery has become an acceptable method of treatment for clinically severe obesity because it appears to be the only option which can provide long-term maintained weight loss in-patients with clinically severe obesity. In fact, the number of patients having surgical treatment of obesity has doubled in recent years. Stomach, or gastric operations, have been preformed since 1969. Currently, the two leading approaches to weight-loss surgery in the United States are Roux-en-Y gastric bypass and adjustable gastric banding system, or LAP-BAND®. Vertical banded gastroplasty, or stomach stapling, is less commonly performed today. Obesity surgeons should be skilled in more than one surgical approach as the specific procedure needs to be carefully matched to the individual patient.

How Surgery Causes Weight Loss

Procedures for weight loss are either restrictive and /or malabsorptive: they restrict the intake of food and/or cause some of the food to be poorly digested and absorbed, and therefore eliminated in the stool. The LAP-BAND®, Sleeve Gastrectomy and Vertical Banded Gastroplasty are "restrictive" surgeries, whereas the Roux-en-Y Gastric Bypass, Banded Gastric Bypass and Duodenal Switch are "combination" type procedures resulting in both a restrictive and malabsorptive effect.

In surgery for obesity management your stomach is divided into two portions: the small portion is your new stomach, or reservoir for food. As you eat the food enters your pouch and empties slowly. Since your stomach pouch is very small, you will feel full very quickly. Overeating can be very uncomfortable and may result in vomiting. Your eating habits will therefore change drastically and you will likely never be able to eat the quantity of food that you can currently eat. For example, a typical size lunch for most patients is half a sandwich and a piece of fruit.

In addition, after gastric bypass surgery, most patients develop a phenomenon called "dumping syndrome". When sweets are eaten the patient experiences sweating, fatigue, lightheadedness and diarrhea. This unpleasant experience helps patients avoid sweets and many patients report losing their desire to indulge in sweets. Furthermore, eating large amounts of fats may lead to poor absorption and result in diarrhea and abdominal cramping.

Weight Loss

Weight loss varies widely, depending on many factors, such as the patient’s age, starting weight, ability to exercise and the type of operation used. On average, patients lose one half to two thirds of their initial excess weight at the end of one year. Initially heavier patients tend to lose more actual pounds, but lighter patient are more likely to come close to their ideal weight. The average patient in our program loses 70% of their excess weight and over 95% of the patients lose at least half of their excess body weight with gastric bypass. Lap Band patients average 50% of their excess weight although 70% of excess weight-loss is possible depending on patients' motivation.

Surgery's Effect on Other Health Problems

The degree of improvement of various obesity-related problems depends on the extent of the illness and the length of time the patient has had it. The longer the patient has had the condition, the less likely it is for it to completely resolve after surgery. In general, more than half of the surgery patients find an improvement of their high blood pressure associated with diabetes. Nearly 80% of non-insulin dependent diabetes is controlled without medication after surgery. Obesity related respiratory problems, including sleep apnea and shortness of breath with minimal exercise, will become asymptomatic, improve or completely resolve. Joint and back pain associated with obesity, urinary incontinence, venous problems in the legs, acid reflux, menstrual irregularity, and certain types of headaches are also improved with weight loss after surgery.

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Issues with Tube gastrectomy

1. Stomach tube may stretch up over time leading to late weight regain. The extent of this is currently unknown

2. The amount of weight reduction is in the region of 40-60% of excess wt lost over the first 1-2 years.

3. There is no malabsorbtion to nutrients

4. If weight is regained the second stage of Duodenal Switch or Gastric Bypass can be added laparoscopically.

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DIETARY INSTRUCTIONS

The Gastric Sleeve Resection operation is often the first step towards intestinal bypass for high cardiopulmonary risk patients. Fortunately a majority of patients do benefit from Sleeve Resection alone.

The following 6 rules are very important eating habits:

1. Only eat small quantities: The capacity of the stomach has changed. Also the amount of food intake has to change. Nevertheless it is not always easy to stop eating at the right time. What do we mean, if we say small quantities? For example one slice of bread for breakfast or 2 potatoes and a small piece of fish for lunch.

2. Chew well and swallow food only completely mashed: You need more time for chewing and also not all food is possible to chew well. The list of “unsuitable food” will show you the products which are usually not easy to chew.

3. Never eat and drink at the same time: The reduced capacity of the stomach will no longer permit to take in both: liquid and food at the same time. The usual amount of beverage, 2-3 litre liquid per day, are desirable. It´s better to drink between or before meals.

4. Do not lay down or rest after eating: because in a horizontal position reflux is more likely. The food also remains longer in the prestomach and leads to a very uncomfortable accumulation of mucus.

5. Eat five times a day: This is important, because if you only eat 2-3 times a day, it is not possible to have a great variety of food. Consequently, as you can only eat small amounts, you do not get enough proteins, minerals and vitamins. In addition, when eating 5 times daily, it is less likely that you are overpowered by sudden hunger attacks where you probably forget the new eating habits.

6. Watch for beverages rich in calories: In our experience, many people take in a lot of their calories with soft drinks, hot chocolate and milk shakes. This is also possible after the operation, so consider this before drinking high calorie liquids. The type of liquid should be varied and include tea or coffee, diluted fruit- or vegetable juice, light drink with artificial sugar, low fat variants of butter milk, mineral water without gas. 

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Eating program in the hospital:

1. The operation day, you get only tea in little sips. The remaining need for liquids is given by infusion

2.The first day after the operation you get tea, as much as you want, and for lunch and dinner soup.

3. The second day you get your first breakfast with tea or coffee, crisp bread with butter and jam. For lunch we serve mashed potatoes, mashed vegetables and mashed meat – only small portions. Please eat with a tea-spoon to enforce slow eating. Between breakfast and lunch and between lunch and dinner you get a snack – pureed fruits or yogurt. For dinner you can choose between several kinds of porridge with applesauce or a sandwich with cream.

Possible beverages are: coffee, tea, mineral water without gas, diluted orange or apple juice.

after the third day, if you respond well to this diet, you get solid food like: potatoes, vegetables, fish, minced meat, dumplings e.g. – well done cooked but not mashed.

After the time in the hospital, you can start to make up your own menus. It is still important, that you eat little, often and chew the food thoroughly.

If you comply with all advices given on your diet, you should have no problems with the healing process. You should not lift any heavy objects for two weeks after your operation, as this may cause abdominal pain.

You must not take aspirin or any other drug such as non-steroid anti-rheumatic drugs, that may irritate your stomach, without gastric protection. Therefore you must inform your doctor of this advice
(gastric mucosal prophylactic).

What are the risks associated with gastric sleeve resection?

The risk of postoperative complications average out between 3-5%. This includes infections, pneumonia or bleeding. Severely overweight patients run a higher risk of incurring operative complications. The risk of mortality is, according to literature, below 0.3%.

It is also possible to regain weight after some time, because snacks and high calorie food could make the band ineffective.

The main goal is to make radical changes in your lifestyle after gastric sleeve resection. You must learn to have five meals a day and no snacks in between. Also, high calorie drinks such as coca cola, ice-tea or any other soft drinks must be avoided.

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Possible risks specific to gastric sleeve resection and their frequency according to statistical data found in the literature and in our series:

- Stomach mucus irritation and swelling due to vomiting or antiinflammatory drug use - Wound infection - Blood loss after surgery

DOCTOR APPOINTMENTS

After surgery you must undergo regular outpatient check-ups. Initially, these check-ups will be carried out after 3 month and after 6 months. Once your weight has stabilized, check-ups will be necessary on an annual basis.

PHYSICAL ACTIVITY

It will be important to alter not only your eating habits, but also your level of physical activity. Patients are generally recommended to start exercising slowly. As weight loss is achieved, physical activities will gradually become easier.

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Duodenal Switch is a procedure that induces weight loss by gastric restriction with decreased food absorption. With this procedure, the surgeon removes approximately 60 percent of the stomach so that the stomach takes the shape of a tube. The lower intestine is then divided much further downstream than with gastric bypass so that more intestine is bypassed.

Duodenal switch preserves the outlet muscle that controls emptying of the stomach. It also offers the ability to eat larger portions than after gastric bypass or adjustable gastric banding and has reliable and long-lasting weight loss. Since this operation induces a state of decreased absorption, you may experience more bowel movements, and need to be closely monitored for vitamin, mineral and protein levels.

Expected Weight Loss

Most patients can expect to lose 60 to 80 percent of their excess body weight over a 2-year period. Clinical trials have demonstrated durable weight loss beyond 10 years.

Today, there are several surgical procedures used for achieving weight loss. The most common are the Roux-en-Y gastric bypass, or simply, the gastric bypass and the Lap-Band, or adjustable gastric banding system.

Roux-en-Y Gastric Bypass

Lap Band Procedure

Gastric Bypass is the most common form of weight loss surgery in the United States because it results in reliable weight loss with acceptable risks and minimal side effects. In gastric bypass surgery, the surgeon staples off a large section of the stomach, leaving a tiny pouch. Patients simply can't eat as much as they did before surgery, because this small pouch can only accomodate a few ounces of food at a time, and they subsequently lose weight. Additionally, because most of the stomach and some of the small intestine has been bypassed, some of the nutrients and calories in your foods will not be absorbed. Appropriate candidates for this surgery are those who are 100 pounds or more overweight.

It is important that patients who have had a gastric bypass procedure make a lifelong commitment to making the necessary changes in their diet. This includes maintaining an adequate intake of protein, taking vitamin and mineral supplements including a multivitamin, B12, iron and calcium, and avoiding sweets and fatty foods.

Laparoscopic Gastric Bypass Surgery

Since 1997, the Center for Obesity Surgery has been performing a laparoscopic gastric bypass procedure. In laparoscopic surgeries, surgical instruments are inserted through small incisions rather than a large one. Patients benefit by having a faster recovery time than with traditional surgery, a lower risk of hernia, and less scarring. Laparoscopic surgery also protects the patient's immune function, whereas open surgery can compromise the immune system and even promote the growth of any existing tumors. Possible complications of bowel obstruction and leaks should be discussed with your physician.

Success Rates for Gastric Bypass Surgery

Weight loss surgery is considered successful when 50% of excess weight is lost and the loss sustained up to five years. For example, a patient who is 100 pounds overweight should lose at least 50 pounds; a patient who is 200 pounds overweight should lose at least 100 pounds. And they should be able to maintain loss successfully for the following five years.

Estimated weight loss in the first 1- 2 years after a Roux-en-Y Gastric Bypass is approximately 1/2 to 2/3rd of excess weight . 50% excess weight loss has been documented 10 years and more after Gastric Bypass.

Risks of Gastric Bypass Surgery

Gastric Bypass Surgery achieves weight loss by decreasing intestinal absorption of food; instead of following its usual path, food bypasses a portion of the stomach and small bowel. In addition to surgical complications, some people experience long-term deficiencies of vitamin B12, folate, and iron. "Dumping syndrome," in which the consumption of sugar causes abdominal cramping and diarrhea, can also occur. Some people will also regain some weight in subsequent years.