Laparoscopic Sleeve Gastrectomy Surgery

This surgery turns the stomach into a narrow tube (“sleeve”) so the amount eaten is significantly reduced and patients feel full after eating a small amount of food. The stomach can no longer expand after a meal (like blowing up a balloon), rather your stomach becomes a tube shape which cannot distend much.

Removing part of the stomach also reduces the level of the “hunger hormone” (ghrelin) produced by the stomach so people will feel less hungry between meals, and people often choose to avoid unhealthy foods. Swallowed food still passes in a normal fashion through the bowels for absorption.

This is usually recommended when alternative weight loss options have not been successful and the person’s health is at risk. It can help individuals gain control over their weight. Official statistics from Australia’s National Bariatric Surgery Registry show that in 2020 sleeve gastrectomy was undertaken for 82% of all bariatric surgery patients.

A balanced assessment is made by a bariatric surgeon when determining an appropriate type of surgery for you. The doctor will factor in the risks of obesity, the amount of weight you need to lose, other medical conditions you have, the chances of success and the possible side effects of surgery.

You should consider it a serious decision for you to have sleeve surgery. After your consultation you need to consider what you have been told and read. During surgery, you will be having a general anaesthetic and have 5 keyhole surgery incisions. Surgery takes about an hour and most of your stomach will be permanently removed (a small stomach remains and the bowel beyond the stomach itself is unaffected). You will wake up in the recovery room and soon later taken to the ward for recovery, often discharged back home the next day or day after.

Yes. Most of the stomach organ will be removed and this cannot be reinserted at a later time. You will still have a small stomach tube remaining which still provides the necessary functions like the whole stomach does (the difference being it doesn’t allow much distention to hold large portions of food, and the ghrelin hunger hormone levels in the blood drop).

This tends to be around 80%. Under anaesthetic a narrow plastic tube is passed down your mouth into your stomach and this is used to calibrate the size of the sleeve. Almost always the width of this tube stomach is the same size in everyone, although may be slightly longer in taller people. The stomach that is removed can frequently be found to be able to distend to hold 1-1.5L of liquid (so you can see that without this, your portions will drop substantially).

The stomach itself is not an essential organ (sometimes a patient with stomach cancer will need the whole stomach removed and they can still eat and live a normal life). In any bariatric surgery the whole stomach is never removed.

The stomach serves a few different functions, including storage of a whole meal which can be eaten all at once rather than over hours, digestion of food so it becomes mushy and can then be passed into the small bowel for absorption, and secretion of chemicals that help with B12 absorption and also send hormone signals throughout the gastrointestinal system. For the gastric sleeve, a small tube stomach remains in order to preserve these latter functions whilst being very small so a large meal cannot be ‘held’ by the stomach and reducing secretion of the hunger hormone ghrelin.

You may discuss this with your doctor, and any variations are likely to only be subtle. It is important for the new stomach to be narrow enough to cause you to fill up very early. A plastic tube placed under anaesthetic and removed at the end is used to achieve the correct size. A wider sleeve may not produce the restriction required, and a narrower tube may cause poor food tolerance and vomiting.

You will be advised of the dietary stages over the first 6 weeks after surgery whilst the sleeve is healing. As the swelling reduces and the sleeve softens up the idea is you can eat any type of food, just in vastly reduced portions. The long term goal and expectation is that at meal times, you can eat any type of food but much less, more like a bread and butter plate size.

What each person calls a “normal” diet can differ. Often people struggling with obesity try very hard to eat a healthy diet but are not always aware of calorie dense foods and maladaptive eating habits. The surgery and aftercare help to more align a “normal” and a “healthy” diet.

For two weeks you will be on a fluid diet, followed by 2 weeks of pureed food then progressing gradually from soft foods to all foods. It is ultimately recommended you eat a broad range of foods including vegetables, meats, fruits and fluids, ensuring you eat healthy food first which you fill up on. Three small meals a day with a health snack in between is often best.

Most people get early signals when their sleeve is filling up and then choose not to eat that extra mouthful. As someone is learning their portion size after a sleeve, the occasional person may take that extra mouthful and may vomit this. Usually it is then clear to someone how much their stomach can take. Whilst this won’t cause a problem for the sleeve once, it is preferable to avoid doing this and make the choice to ‘put the fork’ down as you are starting to feel full.

The stomach does not ‘grow’ back as such. The narrow tube stomach can ‘stretch’ and it is normal for it to do so somewhat. Most weight is lost over 6-9months and portions gradually increase over the ensuing years, whilst remaining small. Despite this the weight tends to remain stable in this time. The goal remains an excellent weight loss and health outcome long term.

Yes. It is your eating habits that will change which is the necessary effect to improve your weight and health. After leaving hospital after a day or so, you will be assisted in adapting these habits. You may walk freely as you tolerate and partake in exercise and usual activities after a couple of weeks. We want your life and lifestyle to become more ‘normal’ and ‘balanced’ after the sleeve.

The day after surgery we provide a pain and nausea relief which usually settles mostly within 24 hours. You start to slowly drink fluids in this time. On discharge (usually the next day) you take oral pain relief as you need it, which tends to be for a few days, and walk quite freely around the house or around the block. In the first few weeks most people feel more energised with less weight they are carrying around. Sometimes people feel more tired as the weight loss occurs (so everyone is different). The goal remains the same that following the weight loss stages – more energised, healthier, easier to get around and sleep and able to engage more in physical activities and lead an otherwise normal life.

It is recommended you do not in the early stages after sleeve gastrectomy. The effects of alcohol can come on sooner, and alcohol tends to contribute to dehydration. Long term, you can consume alcohol. It is obviously recommended to do in moderation as for anyone, and remember there are substantial calories in alcoholic drinks.

Given a substantial part of the stomach is removed in surgery, this is really a permanent effect. It is normal for the sleeve to stretch/dilate a little and despite this, the weight loss outcome is quite consistent for people and long standing. Studies reveal that the majority of sleeve gastrectomy patients keep the majority of the weight off long term, and in far superior way to the average person with chronic obesity undertaking dieting alone.

It is quite consistent and substantial for the weight loss over the first 2 weeks, 3 months and 12-24 month timeframes. Studies show that some weight can gradually come back on beyond this time. The surgery has its strong effect in its own right, and to get the most out of your surgery it is important to try to relearn and readapt healthy eating and lifestyle habits during this time of weight loss to set yourself up for success. We provide a program to assist you with this over 2 years.

As far as health problems associated with your weight, there are high changes of reversing such problems as high blood pressure, diabetes, sleep apnoea and translating long term to improved health and life expectancy. These have been proven by multiple scientific studies.

It depends on the nature, severity and regularity of your reflux. It is quite normal for anyone to experience the occasional reflux after eating a triggering food such as a spicy meal and in this case you can have a sleeve gastrectomy. Sometimes people get reflux more regularly, may find it is worse as they put on weight and may take occasional or regular reflux medication. Your surgeon can advise and in many circumstances a sleeve gastrectomy can still be performed and often reflux improves. Sometimes a hiatus hernia is found and this should be repaired at the time of the sleeve gastrectomy which can improve the reflux. For severe cases a gastric bypass may be recommended.

The first step is to identify and avoid triggering foods. Waiting a number of hours after eating before exercising or lying flat is important. You may take antacids and if needed common reflux medications which can even be bought over the counter. You should see your doctor about this. If reflux becomes very common or problematic your surgeon can assess if any correctional surgery is needed.

You are usually discharged from hospital 24-48 hours after surgery and be advised to start a liquid diet. Your surgeon and dietitian will see you at around 2 weeks which is when the stomach has mostly healed. A pureed diet is taken for 2 weeks then progressing onto soft foods and eventually solids. Over the next 3-6 months, you will have further follow-up consultations as you progress through the dietary phases.

Keyhole surgery allows you to walk the same day as surgery. Light cardio exercises like jogging can be done after 2 weeks while strenuous gym exercises or sports should wait 4-6 weeks. You are usually able to return to work after 2 weeks, depending on your type of work.

Psychological and dietary support can assist you in adapting to the changes you will experience with your eating and lifestyle, and allow you to address long-standing, problematic eating habits.

The bulk of the healing occurs in the first 4-6 weeks. You are put on a fluid diet for 2 weeks followed by a pureed diet for 2 weeks to avoid pressurising the sleeve while it is healing. Healing is an ongoing process and usually doctors advise that healing generally in the human body is mostly achieved by 6 weeks.

It is recommended to be 2 weeks. This is while the rapid healing phase of the staple line taking place. You will usually be then seen by Dr Le Page and are usually able to then progress to a pureed diet. You need to be mindful of only taking sips and to do so regularly to avoid dehydration.

This assessment is determined on an individual basis by your surgeon whereby your weight, duration and other treatments tried are taken into account. The Body Mass Index (BMI) is the standard tool for categorising the degree of overweight and obesity. Obesity is defined when the BMI is greater than 30, and a person may be eligible for surgery depending on the impact the condition has on their health.

Original consensus guidelines were introduced in the early 1990’s and suggested a BMI above 35 with weight related problems or a BMI above 40 alone is adequate. Select patients with BMI 30-35 may also be eligible.

This procedure involves no ‘replumbing’ of the bowel nor insertion of a foreign object like the gastric band. Patients tend to have a good eating quality in that any type of food can be tolerated, just in dramatically reduced portions. This, along with altered hunger signals allows patients to work on improving poor eating habits. The weight loss achieved, and the resulting health benefits, are quite reliable and predictable.

Sleeve gastrectomy results in an average excess weight loss of around 70% (total body weight loss of up to 30%). The amount of weight you lose depends on several factors including whether you adopt and maintain healthy eating habits and regular physical activity.

As with any medical procedure, sleeve gastrectomy carries potential rare health risks including infection, bleeding or leakage of fluid from the stomach, and blood clots. It is recommended to take long-term vitamins or other supplements. Patients may develop acid reflux after surgery.

It is very uncommon for an “unsuccessful” weight loss during the weight loss phase. Usually around 70% of excess weight loss is achieved over a 6-12 month time frame. If this is not achieved it would usually be because the diet taken by a patient is inappropriate, such as regular consumption of liquid calories such as soft drinks, alcohol or ice-cream.

Once the target weight loss is achieved, over the years a small amount of weight can be regained with some mild dilation of the sleeve. Some patients may put on more weight afterwards, often due to consumption of excessive liquid calories or always overeating leading to sleeve stretching. We provide assistance to avoid this and Dr Le Page will keep a close eye on your progress. The majority of people undergoing sleeve gastrectomy keep the majority of the weight off long term.

This would usually be a new pain in the left upper or central abdomen occurring usually between 5-14 days and generally associated with a fever or feeling unwell. Fleeting feelings of discomfort after eating are normal early on after sleeve, it is more concerning if the pain persists. At any stage if you are unsure you should consult with you surgeon.

Many people experience this in the first 6 months or so by noticing more hair in a hair brush or in the shower. It is very rare for this to be noticeable to anyone else based on the someone’s appearance.

Yes. You will be seen in hospital straight after your surgery, then usually at 2 weeks, 3months and between 6-12months thereafter. This is to ensure you are adapting well to the sleeve, developing good habits and to ensure your nutrition is adequate.

Dr Le Page will be seeing you most regularly, but you will also have input from the dietitian, your own GP, post-op coaching sessions and sometimes other medical specialists.

• Regular exercise
• Improving your diet on a sustainable basis (usually with the assistance of a dietitian)
• Lifestyle alterations to encourage regular, healthy mindful eating
• Short term medications can be prescribed by your GP
• Endoscopic gastric balloon or stitching (not approved by Medicare)
• Laparoscopic gastric bypass (single-loop or Roux-en-Y) and gastric banding

Both have their advantages and disadvantages. The sleeve is often preferable as it is well tolerated, reliable and keeps things simple with the arrangement in your abdomen. The bypass usually has a slightly higher degree of weight loss and long term more sustained, however there are more likely to be issues with nutrition, usually the food tolerance is not quite as good and there remains very small risk of the bypass long term of an ulcer or a bowel twist. This is best explained by the experienced bariatric surgeon in a consultation.

If you are concerned about your weight, it is advised to first discuss with your GP regarding your weight loss options. GPs can help identify suitable patients who could benefit from bariatric surgery and then write a referral to see a bariatric surgeon.

What are some helpful links for other information on gastric sleeve ?

• Australian Government-Department of Health
  • https://www.health.gov.au/health-topics/overweight-and-obesity
• The Science of Obesity
  • https://www.thescienceofobesity.com.au/speak-to-your-gp/