What Is Sleeve Gastrectomy

Overview

Obesity is the abnormal accumulation of fat in the body, associated with health risks such as diabetes, cardiovascular disease, hypertension, and hyperlipidemia. It has become a remarkable public health epidemic over the past 50 years, with healthcare expenditure exceeding $700 billion annually. Obesity is defined using the body mass index (BMI), calculated as weight (kg)/height(m). It is a complex, multifactorial disease and is the second most frequent preventable cause of death, after smoking. Treatment requires multi-faceted strategies and may be a lifelong endeavour.¹

Weight loss surgery is considered a safe and effective long-term treatment for obesity. The techniques involved in these surgeries have progressed over time, resulting in improved outcomes. Sleeve gastrectomy, initially developed in 1990 as part of a two-stage operation, became popular after the first laparoscopic procedure in 1999. Originally intended for super obesity cases (BMI>60), it was observed that patients encountered significant weight loss, leading to the publication of indications for this procedure in 2008. Compared to other weight-loss surgeries, sleeve gastrectomy is technically simpler, associated with lower illness, and has become the most commonly implemented weight-loss surgery in the United States.¹

Indications for sleeve gastrectomy

The indications for sleeve gastrectomy are generally for weight loss procedures. The traditional standards for a patient to be a candidate for any weight loss operation are¹

1. BMI greater than or equal to 40 or BMI greater than or equal to 35 with at least one obesity-related comorbid condition (hypertension, diabetes mellitus, or severely restricting musculoskeletal problems)
2. Failing non-surgical weight loss trials
3. Psychological wellness assessment
4. No medical contraindications to surgery

A BMI of 30-35 with uncontrollable type 2 diabetes or metabolic syndrome has been recently included as an indication for a laparoscopic sleeve gastrectomy.¹

Contraindications of sleeve gastrectomy

Absolute contraindications for sleeve gastrectomy include failure to tolerate general anesthesia, uncontrollable coagulopathy, and a severe psychiatric illness.¹

Barrett esophagus and severe gastroesophageal reflux disease are considered relative contraindications for this procedure.¹

Sleeve gastrectomy procedure and mechanism

During the sleeve gastrectomy procedure, the initial step entails carefully freeing the stomach from surrounding organs. Subsequently, surgical staplers are employed to excise approximately 80% of the stomach, effectively reducing its size.²

The new stomach holds less food and liquid helping minimize the amount of food (and calories) that are ingested. By removing the portion of the stomach that generates most of the “hunger hormone”, the surgery has an impact on the metabolism. It decreases hunger, raises fullness, and permits the body to attain and preserve a healthy weight as well as blood sugar control. The simple nature of the surgery makes it very safe without the possible complications from an operation on the small intestine.²

Benefits of sleeve gastrectomy

Weight loss

A morbidly obese patient would encounter a series of physical alterations after sleeve gastrectomy, including considerable long-term weight loss, conservation of excessive weight percentage loss over the long term, hunger reduction, food preference modifications, and energy expenditure increase.³

Remission of mental problems

Due to the strong link between depression and obesity, it's a prevalent issue for those chosen for weight-loss surgery. Various studies suggest a modest decline in clinical depression during the early postoperative years. Researchers observed marked enhancements in physical, psychosocial, and sexual quality of life post-surgery, resulting in substantial weight loss. Conversely, individuals with higher depression before surgery reported only modest improvements in physical, psychosocial, and sexual quality of life.³

Obesity-related diseases recovery

Type 2 diabetes

Recent studies revealed that among obese patients (BMI from 27 to 43) with Type 2 diabetes, sleeve gastrectomy plus intensive medical therapy was more efficacious and practical in decreasing hyperglycemia than intensive medical therapy solely. Following sleeve gastrectomy, insulin sensitivity increased remarkably and significantly reduced fasting blood sugar and HbA1c levels.³

Non-alcoholic fatty liver disease

Obesity is a risk factor for non-alcoholic fatty liver disease and nonalcoholic steatohepatitis. A substantial majority of patients with non-alcoholic fatty liver disease experienced improvement following weight loss induced by sleeve gastrectomy.³

Cardiovascular diseases

Morbid obesity is closely associated with the coagulation system and sleeve surgery has shown to significantly improve life expectancy and lower cardiovascular risk in individuals with morbid obesity.³

Many Reports indicate that high blood pressure often resolves after sleeve gastrectomy and even any improvement in hypertension can potentially cause a reduction in cardiovascular events

Moreover, Obesity is linked to an increased occurrence of stroke. However, the data indicates a 50 per cent lower death rate among individuals who underwent weight-loss surgery, significantly decreasing their risk of both stroke and heart attack.³

Obstructive sleep apnea 

Sleeve gastrectomy's direct impacts on obstructive sleep apnea resulted in an improvement in respiratory disturbance which consequently enhanced sleep quality in morbidly obese patients after the operation.³

Non-obesity-related diseases recovery

Gout 

Obesity is a risk factor for the development of several inflammatory and immune-mediated conditions including gout. Weight-loss surgery's impact on gout behavior beyond the immediate postoperative phase is uncertain. A recent study indicates a significant decrease in gout incidence from one month to a year after the surgery.³

Musculoskeletal pain 

Joint pain is a general musculoskeletal complaint of morbidly obese patients that can cause gait abnormalities, perceived mobility limitations, and declining quality of life. Improvements in some, but not all, gait parameters, walking speed, quality of life, and perceived functional limitations occurred three months after the weight loss procedure.³

Ovarian disorders 

Obese women face increased risks during pregnancy, including preeclampsia, gestational diabetes, cesarean delivery, and others. Some studies highlight a higher risk of neural tube defects and neonatal death in newborns of obese women.³

Several studies suggest that undergoing laparoscopic sleeve gastrectomy is associated with a reduced likelihood of miscarriage, pregnancy complications, and fetal macrosomia. Additionally, various investigations have found that sleeve gastrectomy effectively addresses amenorrhea in premenopausal females.

Visceral obesity is a key factor in polycystic ovary syndrome, the leading cause of female infertility. Sleeve gastrectomy shows promise in improving hirsutism and polycystic ovary syndrome, but further research is needed to determine the optimal weight-loss surgery technique for young infertile women.³

Pregnancy and fertility 

Despite the increased fertility rate among patients following weight loss surgery, pregnancy within 18 months is not recommended. Preferably, stabilizing the weight after sleeve gastrectomy needs to be considered before pregnancy in patients.

Urinary incontinence 

Certain studies report obesity as an important risk factor for urinary incontinence. Surgical weight loss is considered the most practical and effective method to minimize urinary incontinence symptoms and should be utilized as the initial treatment in these patients.³

Cancer 

Obesity is one of the most significant contributing factors for cancer. Sleeve gastrectomy is associated with a pronounced reduction in cancer occurrence and death.³

Risks associated with sleeve gastrectomy

Like any major surgical procedure, sleeve gastrectomy carries potential health risks.

Early complications (post-surgery) can include:³

• Pulmonary emboli
• Hemorrhage
• Chest infections
• Abscess
• Incisional hernia
• Anatomic leakage
• Wound infections
• Gastroesophageal reflux disease
• Rhabdomyolysis (in men)
• Dumping

Micronutrient deficiencies may encompass a range of essential elements, including:³

• Vitamin B12
• Iron
• Calcium
• Vitamin D
• Thiamine
• Folate
• Fat-soluble vitamins

According to certain studies, individuals undergoing sleeve gastrectomy encountered difficulties such as inadequate weight loss, ongoing weight regain, or the persistence of co-morbidities. In cases where weight loss is insufficient, consideration of a secondary procedure is recommended.

After surgery care and check-ups

• Typically, after the gastrografin leak test on day one post-surgery, oral medication in tablet or crushed tablet and liquid form is started if a nasogastric tube is present. A basic metabolic profile needs to be checked every 12 hours for the next two days, and then every 24 hours for the following three days.
• After the recovery phase and for the next 24-72 hours after surgery, the main focus is to make sure there is no leakage in the connection made during the procedure. If everything looks good, patients can begin drinking clear liquids and soft drinks.
• Most patients are usually discharged from the hospital on a full liquid diet and should be educated to keep monitoring their hydration and urine output.
• Around two to three weeks after surgery, the diet is gradually turned to soft, solid foods. Patients are encouraged to consume salads, fruits, vegetables, and soft protein daily.
• To manage epigastric pain and vomiting, patients should be counselled to eat slowly, to discontinue eating as soon as they reach satiety, and not to consume food and beverages at the same time.
• Patients have to select healthy foods, not omit meals, and visit the dietitian frequently in the first 12 months after surgery.
• Patients should generally measure their weight and blood pressure every week until the rapid weight loss phase diminishes, typically within 4-6 months, then again at 8, 10, and 12 months, and annually thereafter.
• Patients with diabetes are advised to monitor their blood glucose daily.
• Patients kept on antihypertensive or diabetic medications at discharge should be monitored carefully for hypotension and hypoglycemia, respectively, and medications should be adjusted in consequence.
• It is recommended that certain laboratory tests be carried out at three, six, nine months, and annually thereafter.⁴

Summary

Weight-loss surgery, particularly sleeve gastrectomy, has evolved as a safe and effective long-term treatment for obesity.

Indications primarily include a BMI greater than or equal to 40 or a BMI greater than or equal to 35 with at least one obesity-related comorbid condition, failed non-surgical weight loss trials, and psychological wellness assessment.

Absolute contraindications involve factors like general anesthesia intolerance, uncontrollable coagulopathy, and severe psychiatric illness.

The procedure involves freeing the stomach, excising approximately 80% of it using surgical staplers, resulting in reduced food intake and impacting metabolism.

Sleeve gastrectomy offers a multifaceted range of benefits, including substantial and sustained weight loss, remission of mental health issues such as depression, and recovery from various obesity-related and non-obesity-related diseases.

Sleeve gastrectomy poses potential health risks including post-surgical complications, micronutrient deficiencies, and the risk of insufficient weight loss.

Patients transitioning from a full liquid to a soft solid diet post-surgery should monitor hydration and manage epigastric pain and vomiting by adopting slow eating habits as well as avoiding simultaneous consumption of food and beverages.

Regular check-ups are crucial for monitoring weight, and blood pressure, and conducting necessary laboratory tests.

Patients are advised to adopt healthy eating habits, monitor their health parameters, and seek ongoing support from healthcare professionals.