Dr Leon Cohen of Mercy Bariatrics in Perth explains some very important points about the lap sleeve gastrectomy procedure also known as the gastric sleeve.
He discusses what this type of bariatric surgery entails along with the risks and outcomes you can expect.
Gastric Sleeve Video Transcription
Sleeve gastrectomy has been done around the world since about 2000 and we’ve been doing it here since 2003. And it has become the most dominant operation in Australia particularly for first-time surgeries. It represents well over 80% of the first-time bariatric operations done.
A Reductive Operation
Since 2003, we’ve done well over 1,600 sleeves. The sleeve gastrectomy I like to think of as an example of a reductive operation rather than a restriction operation which is like the adjustable gastric band or malabsorptive operation which are the bypasses.
And by reductive operation, I mean that by keyhole surgery, we staple off and permanently remove about 90% of your stomach, converting you from what is typically a one and a half litre stomach bag down to about a 100 ml stomach tube.
So your stomach starts off looking a little bit like that in shape and size. The outlet of your now skinny stomach is still the normal pyloric valve or sphincter that opens and closes rhythmically. And that means that unlike an adjustable gastric band where you have a restriction at the top part of the stomach even though it’s adjustable at any one time it is fixed, this is a dynamic sphincter that opens and closes rhythmically.
What You Can Eat & Drink
And that means that unlike a band, we would expect you to be able to eat bread and steak and chicken, all the things that a band patient struggles with you can still eat but in much smaller amounts. Typically, that will be an entrée size portion and that entrée is going to feel to you like a main course.
Also unlike a band, there is now an absolute volume limitation even to liquids. So you will get to half a mug of coffee to begin with and you will feel full. And the coffee is getting cold by the time you finished it.
That also means that you can’t go out on a hot Perth day and expect to scull a litre of water when you get home. You have to have a water bottle with you and you’re drinking small amounts frequently and that’s how you get your food in.
It also makes it a lot harder to cheat on the high-calorie liquids which band patients learn to do because you will get to a certain volume, you will feel full and you’ll need to pause.
Wrong Food Choices
The other consequence of having a small volume stomach is that it actually empties more rapidly because there’s less room and time for the food to get stored and churned up and diluted. That means that if you make the wrong choice particularly very sweet things like chocolates and lollies and milkshakes and ice cream, those high-calorie carbohydrate foods will hit the small bowel in a rush. And the small bowel does not like that. It needs to draw water in to dilute everything out and that water has to come through your bloodstream.
Blood Sugar Levels
Also, your blood sugar might climb very high and then drop very low. And so about 40 minutes after you eat a chocolate bar, you may experience that you start to get crampy or shivery or shaky and feel very tired and you may have to run to the toilet with diarrhea or lie down because you’re feeling so tired. And this is a symptom called diarrhea and dumping. And so, you learn not to eat those foods, which is a good thing.
Now, you’re fine if you eat good quality protein and complex carbohydrates. But chocolate bars are certainly going to be off the menu. And a lot of my patients who have sleeve say to me that they used to crave chocolates but after their operation they just can’t stand them.
Alcohol has a similar effect. Alcohol is primarily absorbed from the small bowel. And so, you will get twice as drunk twice as quickly on the same amount of alcohol. That means that two glasses of Chardonnay over an hour and you probably shouldn’t be driving because it could be over the limit.
Also with alcohol, it’s much harder to drink those fizzy drinks. So things like beer and champagne tend to just bubble up. And you may have to contain yourself with sipping on some Chardonnay.
You Won’t Feel As Hungry
The other way in which the sleeve works which is very different from the band is that by removing this much stomach, we get rid of an area of the stomach that makes a lot of the hunger hormone, ghrelin.
And so, patients after a sleeve almost universally report that they don’t feel hungry. They’re not thinking about food. They’re not waking hungry at night. They’re not being driven by their appetite.
Now, ghrelin is still made from this side of the stomach but in much smaller amounts. And the levels only rise very slowly over time.
The main risks to the sleeving largely come in the first one or two weeks after the surgery. And they are leak from the staple line and bleeding.
Leak is by far the most serious complication. If you were to get a leak, you will get very sick very quickly. We would always have to reoperate on you. Sometimes keyhole, sometimes open, sometimes endoscopic or radiologically, sometimes combinations of all those.
You could end up spending many weeks in hospital recovering and many months before you’re well again and you could even die. That’s how serious a leak is.
Fortunately, leaks in our series now have become very uncommon. And so for example, in the last 7 years, over 700 sleeves, we’ve had perhaps one leak in the primary series. But it remains the most important complication.
The other complication at the time of surgery is bleeding. Bleeding is much less of a problem for us because you either stop bleeding quickly and we just transfuse you up or if you don’t stop bleeding and you’re getting unstable or we feel that there’s a large clot there, we’ll take you back to theater by keyhole surgery, wash out the clot, stop the bleeding, leaver the drain. And by the next day, it’s as if it doesn’t happen. So I’d much rather get a bleed over a leak any day.
Once you’ve left hospital, and most people are in for two nights, and a week or so goes by, the staple line heals over and becomes very strong so that the risk of a leak or a bleed beyond two weeks is extremely remote.
3 Important Considerations
In the medium to long term, there are three main issues with sleeve.
1) The first is although there is no malabsorption with sleeve as there is with the bypasses, because you’re not able to eat a large amount of food particularly to begin with, you must commit to taking multivitamins probably for the rest of your life. One multivitamin a day or you could become deficient particularly in iron, calcium and B12.
2) The other issue with sleeve for some people is reflux. Now, the deal there is that if you already have reflux and it’s due to a hiatus hernia, which is a gap in the diaphragm that has become stretched where the stomach passes through to the esophagus. And if that becomes stretched, it promotes reflux. We will look for that enlargement, repair it, and then reflux actually gets better. And overall, perhaps 1-5% percent of our patients need to remain on an antacid tablet in the long term.
3) And then the third issue with sleeve and this is an issue with all the obesity surgery, it doesn’t matter what the design of operation, will the sleeve stretch up over time? Will that translate to a late weight regain? The honest answer is that all of obesity surgeries are going to fail to some degree over time. And the sleeve is no different because the sleeve does stretch a little bit and ghrelin levels too return a little bit and people slip into bad habits.
But when I say fail, what I mean is that people reach a peak weight loss typically at around two years. They remain stable for a few years. And by the fifth year, they have regained a small amount of that excess weight which they have lost.
We talk about outcomes in bariatric surgery not just as a total weight loss which the patient experiences because everyone is going to lose a different amount of weight, but more commonly as a percentage of the excess weight that they lose. So here you are with your ideal weight for your height and your current weight. And it’s the percentage of that excess weight that you lose that we report on. And that allows us to more accurately predict where you’re going to head up.
3 Factors That Contribute To How Much Weight You Lose
How much you lose to begin with and how much weight you subsequently regain seems to be dependent on three factors.
1) The first is your starting BMI weight. So the heavy you are at the beginning, the high your BMI, the more weight you’ve got to lose. The more weight in kilograms you will lose, but because you’ve got further to go, the excess weight loss is going to look smaller. If you start off down here with a low BMI, you would not lose as many total kilograms but you will get closer to your ideal. And so that percentage in excess weight loss would look larger.
2) The other factor which determines outcome is the bougie size we use to create your sleeve. The bougie is the rubber rod which determines the width and therefore the volume of your sleeve.
When I started doing the sleeve gastrectomies back in 2003, we were using a rubber rod about that wide, a 50-French bougie. And we saw typically a 65% excess weight loss at peak.
In 2006, I dropped down to a 40-French bougie, which is that wide, and then we saw a 75% excess weight loss at peak.
And currently since 2010, we’ve dropped down to a 36-French bougie. And we see now an 85% excess weight loss. Now, 36-French is about as slim as idea go and I think if we went any lower than that, we would have problems with difficulty in eating and drinking to begin with.
So there’s not a lot of difference between the 40 and 36 in terms of size but there is a 10% better excess weight loss with a slimmer bougie. And we typically only use the 40-French bougie now in people who have a very low BMI or in the elderly patients.
3) The third determinant of outcome we have found is what I like to call the “you” factors. So that’s how well you as a patient make your dietary choices after it. That’s how well you as a patient comply with exercise afterwards.
And also most importantly, how well you comply with your follow-up, because we believe that sleeve is not certain thing in operation and we need to see on a regular and structured basis following the surgery. And there are things we’re going to do with you at each visit to make sure that you maximize your weight loss.
The other advantage of sleeve is that it is an imminently revisable operation. So that if the sleeve does stretch up over time and you’ve regained some weight, there’s nothing to stop us sleeving off some more stomach to resize and reset the stomach and get your weight loss back on track. It’s also very easy to revise to other operations such as the bypasses.
Over the years, we have built up a very detailed record of our patient’s outcomes on our database lapbase. And that allows us to predict with some accuracy where we think people are going to end up based on their starting BMI, the selection of the bougie and their age.
If you go to our website and have a look at our results, you can see those graphs that help us predict where we think you are going to end up. When you come to your consultation with your bariatric surgeon, we will discuss this operation with you again and you’ll have the opportunity to ask questions to find out more about the surgery or on seeing of your concerns.
We have also used the information that we’ve gathered in our lapbase data to come up with a prediction of where we think you’re going to end up following your surgery.