Laparoscopic Sleeve Gastrectomy
1. What is a laparoscopic sleeve gastrectomy?
The larger globular stomach is reduced into a long narrow cylinder (sleeve) shaped stomach.
2. How does a sleeve gastrectomy work?
The greatest benefit of a sleeve gastrectomy is that it works on many levels:
- Restrictive component
The smaller volume (average 150-200mls) stomach sleeve tube limits the amount of food that can be consumed each time.
This stops individuals from consuming large portions of food (stops binge eating or over-eating).
Early post prandial satiety is achieved (you will feel full and satisfied after a small meal).
- Proximal gut hormonal component
With majority of the stomach removed, the gastric ghrelin hormone production is reduced.
You don’t feel constantly hungry through out the day, thus reducing the frequency of eating (reduce snacking and frequent grazing).
- Faster gastric transit and distal gut hormonal component
Digested food travels past through the stomach faster and reaches the small bowels earlier
This small bowel distension and hormonal release (GLP-1 and PYY) help to maintain the fullness sensation longer (feel full for most of the day after meals).
In other words GLP-1 and PYY-36 are anorexigenic hormones (some call it neuro-endocrine ileal brake).
- Metabolic change
It is postulated that the new body weight set point is adjusted to a lower baseline level, the physiology changes more than just simply a neuro-endocrine brake phenomenon, where the body will try to adjust the balance between appetite/hunger and metabolism in favour of a more appropriate lower body weight level.
3. What are the advantages of a sleeve over a gastric band?
- There is no foreign body in your abdomen.
- No need for repeated needle adjustments and multiple long term clinic follow ups.
- No need for future re-operations for any band, tube or port related complications.
- Eating habits and food tolerance is better with a sleeve gastrectomy (improve quality of life and better tolerated by the patients).
- Avoiding the potential for the troublesome food bolus obstruction, regurgitation or hiatus hernia formation in the future.
- Improvement or control of medical problems and excess weight loss is superior to the gastric band.
4. What are the advantages over a gastric bypass?
- The sleeve is technically easier to perform, shorter operating time and reduced length of stay in hospital.
- There are fewer complications (from leaks, internal hernia, bowel obstructions, peptic ulcers).
- The long term care is more straight forward.
- With a sleeve gastrectomy there is minimal concerns about macronutrient and micronutrient malabsorption (especially vitamins and trace minerals) or dumping syndrome (flushing, palpitations, abdominal cramps or diarrhoea after meals).
- There is often no need for long term regular blood tests, daily multivitamin or trace mineral replacements or even periodic vitamin injections.
5. What are the specific complications of a sleeve gastrectomy?
On average the staple line leak rate is 0.5-3%:
- Leaks can happen early (days from surgery) or late (2 weeks after surgery).
- The consequence of leak may be minimal or severe (which leads to sepsis, multi-organ failure or it can even be fatal).
The staple line may bleed:
- Post op bleeding tend to occur within the first 24 hours, fortunately most will stop by itself and rarely require another operation.
The other complications:
- The usual post operative complications are more likely than the specific complications (eg. pneumonia, blood clots in the legs or lungs, wound complications, etc.).
- These can be prevented by early mobilization and gentle exercise after surgery.
6. How often do you need to come for follow up?
After a sleeve gastrectomy there will be an average of 3 clinic visits in the first year.
After the first 1-2 months you should have returned to a normal solid meal and if there is no problems follow up reviews may be limited.
However visits to the GP should continue, especially if your medications (for diabetes, high blood pressure, etc.) need to be adjusted.
Do not hesitate to make another appointment to see the surgeon if there are any concerns or problems.
With a gastric band or gastric bypass you will need long term follow up with your surgeon because of the issues mentioned above (question 3 and 4).
7. How successful is the gastric sleeve?
The sleeve is quoted to have more than 50% excess weight loss.
The resolution of medical co-morbidities (diabetes, high blood pressure, high triglycerides or cholesterol level) is equivalent to the gastric bypass in the short term.
The sleeve is generally more successful than the gastric band (question 3).
- Most individuals learn to choose the correct food to eat (good food choices), eat in right quantity (controlled food portions) and develop improved eating habits (eating slowly, avoiding binge eating).
- When patient tolerate meals better and enjoy their meals, this leads to a better quality of life.
As with all types of bariatric procedure there will be some weight regain in the long term (eg. after 5 years) but you will not reach the same body weight level as before the initial operation.
8. What you may experience in the first few months after a sleeve gastrectomy?
In the first 2-4 weeks you may experience chest or upper abdominal pain with eating.
This encourage you to eat slowly, chew carefully and take your time with each meal consumption.
Some patients experience heartburn type symptoms but most will resolve within 1 year.
In the rapid weight loss phase you will often feel tired easily and dizzy sometimes (as a result of negative energy balance) or becoming dehydrated (if fluid intake is inadequate).
9. What are the issues your surgical team & dietician are most concern about?
Early complications as alluded to above.
Inadequate amount of good quality food consumed (proteins especially).
Inadequate fluid consumed (avoid dehydration especially in summer).
Although there is no malabsorption problem with the sleeve in general, you need to ensure there are adequate vitamins and minerals in your meals to satisfy daily recommended intake.
- Remember the operation is only an accessory mechanism or the first step to help you to lose the excess body weight.
- Ultimately it is the patient’s responsibility to make his/her own food choices and to maintain a healthy lifestyle for the long term.
10. In summary:
Remember the aim of the surgery is to help you to lose excess body weight but more importantly it is to improve your health and well being, teach you good eating habits, choosing the correct portions and make good food choices.
In the longer term (after the first 3-6 months) you should be able to eat like a normal healthy person but in smaller portions.
We want you to enjoy your meals and maintain a realistic healthy body weight for the duration.
The sleeve gastrectomy is chosen (over the band or bypass) in order to avoid serious potential long term side effects (alluded to above in question 3 and 4).
Don’t forget to contact your surgical team or dietician if there is any further queries.
Post laparoscopic sleeve gastrectomy diet
In the early post op period (2-4 weeks)
1. What do you do at home after surgery?
Continue on a liquid or puree diet for the first 2 weeks.
Eat slowly, chew thoroughly and have small meal portions.
Stop eating when full
- Over eating will result in abdominal or chest pain with nausea and reflux symptoms
After 2-4 weeks solid food is gradually re-introduced (in small entrée portions).
2. How often do you eat or drink?
Eat 3 meals a day + 1 protein snack/shake a day.
- Meals must include protein (>50g/day), fruits and vegetables and some grains.
- Continue with multi vitamin and mineral supplements (eg. complete the optifast drinks).
Drink plenty of water in between meals (>8 cups per day or >1.5L/day).
- Avoid water 15-30 minutes before or after a meal.
- Otherwise sip water or sugar free drinks throughout the day, avoid artificial sweeteners also.
3. What can I have in the first 2 weeks?
Types of liquid diet include:
- Soup, fruit juice, milk, custard, coffee and tea (avoid carbonated or high sugar content drinks).
- Complete your course of VLCD (optifast or other suitable alternatives which also provide extra protein as needed).
Types of puree food may include:
- Blended meat, poultry and soft poached eggs.
- Blended soft cooked or mashed vegetables or potatoes.
- Low fat cottage cheese, sugar free puddings.
- Pureed canned peaches (avoid sugar or syrup).
- Mashed bananas.
4. What should I avoid?
- Avoid alcohol.
- Avoid high calorie liquid drinks (especially soft drinks or milk shakes with high sugar contents, ice cream).
- Carbonated drinks may result in bloating and heartburn symptoms.
- Avoid fatty oily food (fried foods, skin in chicken).
- Avoid fresh or soft bread, raw vegetables or stringy fruits initially.
5. What type of lifestyle adjustment is beneficial?
Gentle exercises (especially walking) helps you keep fit and lose weight.
- This will help maintain muscle mass and core strength.
- More importantly gentle walking assist in reducing the risk of chest infection, blood clots in the legs or lungs (especially in the first month after surgery).
6. What should I eat after 2-4 weeks?
Suggested normal solid meals (in appropriate portions) include:
- Lean meat.
- Fruits and vegetables, small amounts of tofu (soy milk bean curd).
- Whole grains.
- Eat a variety of food from each food groups.
Remember to eat slowly, chew thoroughly and don’t over eat.
Remember to avoid high calorie drinks (you will regain some weight).
7. What are some examples of solid meals that may be consumed in the first 3 months?
- Thinly sliced turkey or ham.
- Lean moist beef.
- Boiled chicken (cut in small pieces) in broth.
- Low fat cheese.
- Unsweetened canned or cooked fruit, mashed potatoes.
8. What tend to happens in the longer term?
After 3 months it is expected you will return to a full normal healthy diet.
Examples of food consumed include:
- Lean moist red or white meat (veal, beef, pork, poultry and fish).
- Some crunchy fruits and vegetables (including salads).
Basically you may return to all normal food but
- Remember choose foods that are high in protein and low in fats.
- Low in refined sugars and carbs/starch.
In summary simply follow the basic advice:
In the first 2-3 weeks consume only fluid or puree type meals
- Eat slowly, chew carefully and thoroughly.
- Stop eating when full (don’t over eat).
- Plenty of water to sip in between meals.
- Food choices include protein first, then fruits and vegetables, then grains.
- Regular simple exercise and constantly educate yourself regarding a healthy lifestyle will keep you motivated to lose weight and stay in good health.
In the longer term continue with your re-learnt new healthy lifestyle
- Eat good quality food, balanced meal in the right portion size, adequate multi vitamin and mineral supplement.
- Avoid snacking or grazing throughout the day.
- Regular simple exercises.
- Follow up with your surgeon, dietician and local general practitioner is essential especially when your medications (for diabetes, high blood pressure, etc.) need to be adjusted.
The above is only a simple guide and for general information . For any specific questions and for individual cases please consult a qualified bariatric dietician. Remember to attend follow up appointments and be reviewed regularly by your local GP, especially if your diabetic or cardiac medications need to be adjusted in accordance with your blood sugar or blood pressure levels.