DR. ROY HOPKINS: GASTRIC SLEEVE
Laparoscopic Sleeve Gastrectomy
What is a Gastric Sleeve?
In a laparoscopic sleeve gastrectomy, surgeons shrink the stomach by cutting and removing a part of it. This creates a smaller stomach, often called a 'gastric sleeve.'
What does a Gastric Sleeve do to the Body?
A sleeve gastrectomy can be considered a “restrictive” procedure as it restricts the volume of food you can eat comfortably. Typically the volume the stomach can hold after a sleeve is about 200ml (compared to 2-4 litres normally). This therefore limits the amount of calories and nutrients you can eat and process.
With a sleeve gastrectomy, food still travels through the intestines normally. This means your body absorbs all the calories and nutrients from what you eat just like before. In contrast, a bypass does exactly what is says – it bypasses part of the small bowel, meaning the calories and nutrients can’t be absorbed fully because most of the absorption occurs in the first half of the small bowel.
The sleeve gastrectomy works by 3 major mechanisms:
1. Restriction: By reducing the stomach's capacity, the sleeve limits the amount of food an individual can eat in one sitting. This restriction helps control calorie intake and promotes weight loss.
2. Hormonal Changes: The surgery alters the production of hormones involved in appetite regulation and metabolism, such as ghrelin. Ghrelin, often called the "hunger hormone," decreases after sleeve gastrectomy, leading to reduced feelings of hunger and increased feelings of satiety.
3. Improved Metabolism: Beyond weight loss, sleeve gastrectomy has been shown to improve conditions related to obesity, such as type 2 diabetes, high blood pressure, and sleep apnoea. These metabolic improvements can have profound effects on overall health and quality of life.
How I do a Sleeve Gastrectomy
The sleeve is usually created over a “bougie”, a tube of a particular size to make sure the right size sleeve is created. This tube is usually 32-40 French. A 32fr bougie has a circumference of 33.51mm and a 40Fr has a diameter of 13.33mm. By using these like a stencil a standardised tube can be created.
The really technical bits:
There are important steps and considerations in creating a really good “sleeve”.
The 4 major factors I consider are:
1) The distance from the pylorus (the muscle at the end of the stomach between the stomach and first part of the small bowel). The closer the
sleeve staple line starts from this, the more antrum of the stomach is removed and therefore more weight loss. However the closer the staple line is to the pylorus the higher the pressure becomes in the distal stomach and there is an increased risk of a leak or other complication. Most surgeons, therefore start between 2-6cm away (I measure 4cm and start there)
2) The distance around the incisura. The incisura is the bend on the lesser curve of the stomach (the right side). If the staple line is too close here it can lead to narrowing (“stenosis”) and the effect is like bending a garden hose acutely so creates higher pressure above this p-0 which can lead to reflux and other issues). The current idea is to be at least 4cm away from incisura top avoid this (again, I measure this with a marking pen).
3) The distance from the gastro-oesophageal junction (GOJ). The top part of the sleeve should end >1cm away from the GOJ. If the staple line is too close to the bottom of the oesophagus, where it enters the stomach there is an increased risk of leak
4) A straight staple line. It is important to have a straight staple line, rather than one that twists or spirals as this also increases pressure within the stomach.
SEE PICTURE ATTACHED
Differences in Weight Loss and Complication Rates between Different Operations
There is a lot of information around about all of these. It is always best to look at local information to see how this will affect you. We are lucky in Australia and New Zealand to have the Bariatric Surgery Registry. This has been around for over 10 years now. Approximately 90% of all weight loss surgery data is submitted (de-identified) to the registry. The registry now has information on over 140,000 patients in Australia and over 6000 patients in New Zealand so it gives us a really accurate picture of our outcomes in Australia and New Zealand. The following data is from the 2022 Bariatric Surgery Registry Annual Report:
Average Weight Loss in Australia:
Surgery Type 1 Year Post-Op 3 Years Post-Op
Total Body Weight Loss Total Body Weight Loss
Sleeve Gastrectomy 31% 30%
Roux-en-Y Bypass 32% 33%
One Anastomosis Bypass 34% 35%
Therefore based on local data, the difference in weight loss at 3 years is only 5% of starting total body weight between a sleeve and an OAGB.
Complication Rates to Consider:
Sleeve Gastrectomy 1.3%
One Anastomosis Gastric Bypass 3.7%
Roux-en-Y Gastric Bypass5.3%
Importance of Routine Bloods and Vitamins
Because weight loss surgery changes the amount of calories and nutrients that can be absorbed, either by reducing the amount that can be eaten or by reducing the amount that can be absorbed, it is extremely important to monitor the levels of vitamins and nutrients in the blood. Vitamin and nutrient deficiencies can cause a variety of long-term issues. For example B1 deficiency can lead to Wernicke’s encephalopathy (eye-movement disorders, unsteady gait and confusion – a medical emergency). Iron, folic acid (Vitamin B9) and Vitamin B12 deficiency can lead to anaemia. Vitamin D and calcium deficiencies can lead to issues with muscles and bones.
Simple over-the-counter vitamins are not good enough and if you have surgery, you really need to take a daily multivitamin that is tailored to the procedure. There are a variety of different brands. They differ slightly in their composition so you need to have your bloods checked regularly (every few months after surgery for the first couple of years and then annually for life). The type of multivitamin can then be changed as necessary in response to your individual needs.
A Gastric Sleeve is a Tool!
A successful operation is just that - an operation. It gives you a tool to improve your life – not a magical outcome (there are no such things as unicorns….). It is always possible to either sabotage the weight loss (by eating and drinking high energy foods) or regain weight again (by slipping back into old habits).
A good analogy is a lawn mower – you can buy the most expensive lawn mower with all the extras but unless you maintain it well (and also take care of your lawn by weeding it and fertilising it properly) you will not get the result you really want. So it is very important to “maintain and service” your sleeve and also be taught how to use it in the first place. This is why seeing your Surgeon but also a Dietitian and Psychologist is so important. They can give you the right information and education and teach you how to care for your “tool” and get the most out of it.
A good program will include regular follow up with your Surgeon, Dietitian and also a Psychologist (as necessary) for a period of time (typically 1-2 years) so that you can start to create and embed new “good habits”. This is what creates long-term success, not just a good operation!