Sleeve Gastrectomy is now the most popular procedure in Australia. It started as part of a procedure called the Duodenal Switch which is quite a complex procedure that has strong metabolic effect and side-effects. As a result very few surgeons around the world do the duodenal switch. But just the sleeve part of the duodenal switch was found to achieve good weight loss in the short-term and it has now become a stand-alone procedure.
The stomach is divided vertically using a stapling device. Most of the stomach, about 80%, is to the right of the staple line and is discarded. The stomach on the left is turned into a tube of stomach, which we call a sleeve, and which constitutes about 15% of the original stomach. It is always performed laparoscopically (key-hole surgery) and you are in hospital generally for one to two days afterwards.
The sleeve works as a weight loss procedure in two ways. First, you have less hunger as the “hunger” hormone, ghrelin has been reduced. This hormone comes almost totally from the stomach so removing 80% of the stomach removes 80% of the ghrelin. So, throughout the day, you are much less hungry. You don’t look for food, you don’t think about food, you don’t crave for food.
Secondly, the volume of the stomach is drastically reduced. Whereas it could easily accommodate one litre of more of food beforehand, it can now only accommodate about 100 ml. So, when you do eat, a small amount of food takes away any hunger quickly.
Good early weight loss
The first strength is good early weight loss. Because of the small stomach and the low levels of ghrelin, you will eat a lot less, typically around 1000-1200 calories per day and the weight comes down. The weight loss is usually quite rapid, more rapid than after the Lap-Band. You can expect to lose around two-thirds of your excess weight, two-thirds of the excess fat in the body. This should occur within the first year. This represents an excellent outcome. It will improve your health and it will lead to major improvements physically and psychosocially.
Easy to perform surgery
The second strength is that it is technically quite easy to perform so you find the surgeons tend to be keen on it. It is also good for you as you tend to get over the procedure more readily than a more complex procedure such as a gastric bypass.
Not dependent on close follow-up
The third strength is that it is not so dependent on close follow-up. This is quite the opposite of the Lap-Band where close follow-up is highly desirable. This can be a very attractive feature to you, particularly if getting to a follow-up clinic can be difficult. It is also an attraction to some surgeons who are not so keen on the follow-up. At CBS, we are very keen to maintain good follow-up. We do want to keep seeing you so that we can reinforce the eating and exercise rules, check on your nutritional status and make sure you are taking a vitamin and mineral replacement. And if any problems start to arise, we can address them early rather than late. Research tells us that this approach leads to better weight loss and other outcomes.
Higher surgical risk compared to Lap-band procedure
The most important weakness is the higher surgical risk of this procedure compared to the Lap-Band procedure. In particular, we worry greatly about a leak from the staple line. This is actually quite uncommon, maybe occurring in just 1-2%. But, for that 1-2%, it is 100%. And it can be a very nasty complication which could keep you in hospital for many months and needing intensive care. It can even lead to death.
Possibility of weight regain
Another weakness is the possibility of weight regain. Generally all the weight loss you will have occurs during the first year or two. After that the weight tends to creep back on. There have been no reports beyond 8 years so far. We know that the weight regain is associated with enlargement of the sleeve of stomach. We believe that eating too much or too quickly drives this enlargement. We strongly advise that you always eat small amounts of good food slowly but, at the end of the day, the control of weight regain is largely up to you. It is possibly avoidable if you are careful. For those who are becoming hungry again and regaining their weight, revisional surgery needs to be considered; we can provide options for you if need be.
Sleeve is not adjustable
If you find over time that your appetite is increasing, we are not able to do anything about it. It may be due to some enlargement of the stomach or the ghrelin levels rising. With the Lap-Band, we just add more fluid to reduce the appetite. We cannot do that with the Sleeve. If the weight regain is substantial, most often we will have to discuss one of the revisional options with you.
The sleeve is not reversible. Once 80% of the stomach is removed, it is gone for good. We do not see this as necessarily a problem. After all, removal of most of the stomach is the intention of the sleeve but it does reduce our flexibility if there is weight regain or symptoms such are reflux and heartburn develop.
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