Planning before sleeve gastrectomy   The sleeve gastrectomy has remained the most popular bariatric operation in the world in the last decade. The sleeve is recommended for the majority patients because it has good weight loss result, is safer, have less risk and complications compared to the gastric bypass   Patients who smoke cigarettes, vape or consume large volume of alcohol will not be considered for sleeve gastrectomy or gastric bypass surgery   Patients are advised against taking non steroidal anti-inflammatory (NSAIDs) tablets   Younger female patients (in the reproductive age group) need to make sure they are not pregnant before surgery and for about 12-18months after surgery Please talk to your GP about contraception for the 12 months after surgery (oral contraceptive pill, implants or Mirena IUD).   It is important to be prepared for acid or volume reflux after a sleeve gastrectomy *The reflux and weight regain are the most common concerns after a sleeve   The Delphi 2024 consensus recommendations for post op patients after OAGB include:   *Prophylactic medications such as PPI and urso-doexycholic acid be prescribed for at least 6 months to prevent acid reflux, gastric ulcer and gallstones/gall bladder issues.   *A gastroscopy check after gastric bypass surgery but the timing and interval or frequency is yet to be determined   ** Perhaps this should also apply to post op sleeve gastrectomy patients

Sleeve gastrectomy vs gastric bypass The post op side effects, risk and complications   Sleeve gastrectomy has comparative effectives and better short term safety profile, is technically easier, has less complications and much safer than the gastric bypass   Recent meta analysis in 2025 found that the sleeve gastrectomy was associated with: *lower all cause mortality and better survival advantage compared to the gastric bypass (however there may be a multifactorial cause, see below) *lower re-operation, re-intervention, hospitalization or endoscopy rates in the first few months to years (median follow up 34.4 months) *but have a higher revision rate in the long term   There have been multiple studies to prove that the RYGBP has better weight loss, improvement in glycaemic control and a better duration of diabetes remission than the sleeve *However the absolute difference in HbA1C was only about 0.3% The gastric bypass has a lot more follow up issues, side effects, risk and complications both in the short and long term *The common issues are listed below and there may be a lot more not mentioned in this section *Some of these complications are extremely serious needing hospital re-admission and is associated with a small risk of mortality *Some patients may need the gastric bypass revised or reversed due to the side effects Please do your research carefully before contemplating metabolic and bariatric surgery Some patients regret doing the gastric bypass

Sleeve gastrectomy versus gastric bypass For diabetes control and long term survival benefits A recent meta-regression analysis and some other study reported consistent survival benefits of the sleeve gastrectomy or better survival compared to the gastric bypass, however the caveats are listed below. Diabetes and baseline BMI are significant factors affecting long term survival after bariatric surgery *The duration of diabetes and level of HbA1C is inversely proportional to the remission rates of diabetes and patients with longer duration of T2DM *The number of diabetic medications used, insulin therapy and poorer glycaemic control has less favourable results, hence it is believed/assumed that the remission rates for T2DM is higher after a gastric bypass compare to the sleeve *This may be why RYGBP may offer better survival benefits than the sleeve gastrectomy for patients specifically with T2DM

The sleeve gastrectomy vs gastric bypass The post op gastro-oesophageal reflux   The most common reason for revision after a sleeve gastrectomy is for severe acid reflux *The revision rates has been reported between 2 to 6%   However recent studies have questioned that Interestingly the sleeve vs gastric bypass SLEEVEPASS trial with detail gastroscopy check up to 10 years of follow up, demonstrated similar cumulative incidence of de novo Barrett’s oesophagus between sleeve and RYGBP *This has been reported in some other larger retrospective studies as well *The association between sleeve gastrectomy, reflux and oesophageal adenocarcinoma is yet to be proven

Gastro-oesophageal reflux (GOR)   Obesity is a risk factor for GOR disease *The prevalence for GOR is up to 50% in patients with BMI >30 *It is reported that up to 73% of bariatric surgery candidates (with higher BMI) have GOR The pre-op reflux symptoms does not predict abnormal reflux or oesophageal motility disorder (achalasia or oesophageal outlet obstruction) and GOR can also occur without specific symptoms   The role of hiatus hernia repair and lower oesophageal sphincter augmentation during or after the initial sleeve gastrectomy is still being debated *A prophylactic sleeve fundoplication is not universally accepted and may be associated with a high risk of complications such as gastric necrosis and perforation

Reflux after sleeve gastrectomy   Successful weight loss helps to reduce the intra abdominal pressure and reduce GOR   However there is also reported persistent or new GOR after sleeve gastrectomy *There is reported 19-78% (worsening reflux) or 22-26.7% (de novo or new reflux) symptoms after a sleeve gastrectomy *Hence there may be a greater need for PPI medications after a sleeve which may alleviate reflux symptoms in 60-70% of patient   The pathophysiology includes raised intra abdominal pressure, impaired gastric emptying, decrease lower oesophageal sphincter pressure, more frequent transient LES relaxation from the disruption of the sling fibers and altered angle of His     Correction surgery may be indicated for sleeve stenosis (especially at the incisura angularis), rotated/twisted sleeve or fundus dilatation *Revision surgery to form a more tubular sleeve may be possible (not commonly performed) **However there is a risk for leaks due to impaired blood supply and raised intra thoracic pressure   The more common recommendation is conversion of sleeve to RYGBP may have a resolution rate of 80% for reflux symptoms *However there may be residual reflux symptoms even after a gastric bypass *The bypass may also be beneficial for some patients with weight regain *The bypass procedure has a lot more side effects, risk and long term complications compare to the sleeve

Intra thoracic sleeve migration and hiatus hernia after surgery   Sleeve migration may be difficult to diagnose on gastroscopy, Barium oral contrast swallow and CT scan (lacking sensitivity) and sometimes only appreciated during a diagnostic laparoscopy   This may represent: *Migration of the proximal end of the suture line above the hiatus *Migration of the sleeve staple line above the diaphragmatic hiatus opening *Upward migration of the Z line >2cm of the gastric sleeve   Sleeve migration has been reported in 30% of cases (range 0.4 % up to 84%) *However there is poor clinical correlation, some severe sleeve migration may have only mild reflux symptoms and vice versa   Acute migration is rare *Symptoms include vomiting, dry retching, abdominal pain and dysphagia and may lead to complications such as leak, mediastinitis, chest sepsis   Chronic migration may occur 3-5 years (or more) after the surgery, the risk may include multiple pregnancy, weight regain, raised intra-abdominal pressure, ? other procedures (abdominoplasty), etc *Symptoms are usually reflux   The management options include hiatus hernia repair, cruroplasty, bio absorbable mesh with or without conversion to gastric bypass   One study with 7 years follow up of routine gastropexy showed no significant improvement in reflux outcomes or the need for revisional procedures/surgery

Weight regain after sleeve gastrectomy Sleeve gastrectomy is the most common bariatric procedure around the world A significant amount of patients may require revision surgery for weight regain Conversion to OAGB or RYGBP produces good weight loss results Reported weight loss of 28/8% (1 year after OAGB) with remission of HPT and T2DM A systematic review and meta analysis reported weight loss of 15.8 (after RYGBP) and 39.5% (after OAGB) But revision surgery comes at a cost of increase morbidity and mortality *There is a much higher risk for marginal ulcer, anastomotic leak, bleeding and post op mortality which has been reported to be 1.1% (in the OAGB group) and 4.9% (in the RYGBP group) More revision surgery after OAGB has been reported to be 5.4% for bile reflux More revision surgery after RYGBP has been reported to be 4.9% for internal hernia and small bowel obstruction In the future more anti-obesity medications are available on the market This may be safer than revision bariatric surgery in the short and mediu term Pharmacotherapy have lower risk for adverse events and is associated with resolution of co-morbidities such as HPT and dyslipidaemia