Overview
Definition:
Sleeve gastrectomy is a restrictive bariatric surgical procedure that involves removing a large portion of the stomach along its greater curvature, creating a smaller, sleeve-shaped stomach
This significantly reduces stomach volume, leading to decreased food intake and subsequent weight loss.
Epidemiology:
Obesity is a global epidemic, with a rising incidence of severe obesity requiring surgical intervention
Sleeve gastrectomy has become one of the most frequently performed bariatric procedures worldwide due to its effectiveness and relatively lower complication rates compared to earlier procedures like Roux-en-Y gastric bypass in certain patient populations.
Clinical Significance:
Sleeve gastrectomy offers significant benefits for patients with severe obesity, leading to substantial and sustained weight loss, improvement in obesity-related comorbidities such as type 2 diabetes mellitus, hypertension, sleep apnea, and dyslipidemia
It also plays a crucial role in improving quality of life and reducing mortality associated with obesity
Understanding its indications, techniques, and potential complications is vital for surgeons preparing for DNB and NEET SS examinations.
Indications
Primary Indications:
Body mass index (BMI) of 40 kg/m² or higher
BMI of 35 kg/m² or higher with one or more significant obesity-related comorbidities (e.g., type 2 diabetes, hypertension, obstructive sleep apnea, cardiovascular disease).
Secondary Indications:
Failed medical therapy for obesity
Patient preference and understanding of the risks and benefits
Absence of contraindications.
Contraindications:
Inflammatory bowel disease (e.g., Crohn's disease of the stomach)
Uncontrolled gastroesophageal reflux disease (GERD) or Barrett's esophagus
Significant hiatal hernia that cannot be repaired
Inability to tolerate major surgery
Substance abuse disorders
Unrealistic patient expectations.
Preoperative Preparation
Patient Evaluation:
Comprehensive medical, surgical, psychological, and nutritional assessment
Evaluation of comorbidities and optimization of their management
Smoking cessation
Review of medications, especially anticoagulants.
Endoscopy:
Upper gastrointestinal endoscopy is recommended to rule out peptic ulcers, hiatal hernias, and other gastric pathology that may contraindicate or necessitate modification of the procedure.
Nutritional Counseling:
Preoperative counseling on dietary changes, lifestyle modifications, and the importance of long-term adherence to a healthy diet and exercise regimen.
Informed Consent:
Detailed discussion with the patient about the procedure, its benefits, risks, potential complications, alternatives, and expected outcomes.
Procedure Steps
Approach:
Laparoscopic approach is the standard
It involves several small incisions for port placement, allowing visualization with a camera and manipulation with surgical instruments.
Stomach Mobilization:
The greater curvature of the stomach is mobilized from the retroperitoneum and spleen
Care is taken to preserve the vascular supply to the remaining gastric sleeve.
Stapling:
A linear surgical stapler is used to divide the stomach from the pylorus proximally to the gastroesophageal junction distally, creating a narrow tubular sleeve
A bougie (calibrated tube) is often used to ensure a consistent diameter of the gastric sleeve (typically 36-40 Fr).
Reinforcement And Leak Testing:
The staple line may be reinforced with sutures or bioabsorbable materials to reduce the risk of leaks
A leak test using methylene blue or air insufflation is performed before completion of the procedure.
Completion:
The resected portion of the stomach is removed through one of the port sites
Hemostasis is meticulously achieved
Drains may be placed.
Postoperative Care
Immediate Care:
Close monitoring of vital signs, pain control, and fluid balance
Intravenous fluids are administered
Nasogastric tube may be kept for drainage.
Dietary Progression:
Diet is advanced slowly, starting with clear liquids on postoperative day 1, progressing to full liquids, pureed foods, soft foods, and finally to regular solid foods over several weeks, guided by tolerance.
Mobilization And Activity:
Early ambulation is encouraged to prevent deep vein thrombosis and pulmonary complications
Gradual return to normal activities is advised.
Medications:
Pain management with analgesics
Prophylaxis for deep vein thrombosis with subcutaneous heparin
Acid suppression therapy (e.g., proton pump inhibitors) is usually continued long-term to protect the gastric staple line and reduce GERD symptoms.
Follow Up:
Regular follow-up appointments with the surgical team and a dietitian to monitor weight loss, nutritional status, and manage any emerging complications
Blood tests for vitamin and mineral deficiencies are performed periodically.
Complications
Early Complications:
Bleeding from staple line or vessels
Gastric leak from staple line (most serious, requires prompt diagnosis and management, often surgical re-exploration)
Stenosis of the gastric sleeve
Injury to adjacent organs (spleen, esophagus)
Deep vein thrombosis (DVT) and pulmonary embolism (PE).
Late Complications:
Gastroesophageal reflux disease (GERD) or worsening of pre-existing GERD
Stricture formation within the sleeve
Nutritional deficiencies (e.g., iron, vitamin B12, vitamin D) if not adequately supplemented
Gallstones
Weight regain if dietary and lifestyle changes are not maintained.
Prevention Strategies:
Meticulous surgical technique with careful dissection and hemostasis
Staple line reinforcement and rigorous leak testing
Early and aggressive mobilization
Appropriate DVT prophylaxis
Long-term nutritional supplementation and regular follow-up
Careful patient selection and preoperative optimization.
Prognosis
Factors Affecting Prognosis:
Preoperative BMI
Presence and severity of comorbidities
Patient adherence to dietary and lifestyle changes
Surgical technique and experience of the surgeon
Management of postoperative complications.
Outcomes:
Sleeve gastrectomy typically leads to 50-70% excess weight loss within the first 1-2 years
Significant improvement or remission of type 2 diabetes, hypertension, dyslipidemia, and sleep apnea is common
Long-term weight loss maintenance requires sustained lifestyle changes.
Follow Up:
Lifelong follow-up is recommended to monitor weight, nutritional status, and manage potential long-term complications
Regular consultations with the bariatric team, including a dietitian and potentially an endocrinologist, are crucial for optimal outcomes.
Key Points
Exam Focus:
Key indications and contraindications for sleeve gastrectomy
Understanding the laparoscopic approach and critical steps of stomach mobilization and stapling
Recognizing and managing early complications like gastric leaks and staple line bleeding
Long-term nutritional deficiencies to monitor
The role of sleeve gastrectomy in managing obesity-related comorbidities.
Clinical Pearls:
Use of a bougie is critical for achieving a consistent sleeve diameter
Meticulous hemostasis along the greater curvature is paramount
Preoperative GERD assessment is important as it can be exacerbated post-operatively
Postoperative dietary progression must be strictly adhered to
Long-term vitamin and mineral supplementation is non-negotiable.
Common Mistakes:
Inadequate stomach mobilization leading to tension on the staple line
Failure to adequately reinforce or test the staple line for leaks
Aggressive dietary progression leading to nausea, vomiting, or staple line complications
Underestimating the need for long-term nutritional monitoring and supplementation
Poor selection of patients with uncontrolled GERD or significant eating disorders.