Surgery is the most effective long term treatment for morbid obesity and some comorbidities related to this prevalent condition.  The laparoscopic Roux en Y gastric bypass is considered the gold standard for weight loss surgery, but in recent years the Gastric Sleeve has become the most commonly performed bariatric surgery procedure in the United States.  The Gastric Sleeve was first described in 1988 as part of the biliopancreatic diversion and duodenal switch.  The Gastric Sleeve became the initial step in the management of superobese or in patients with high operative risk or multiple prior operations.  Following the initial weight loss, a second stage more definitive procedure was performed, but researchers found that most patients achieved significant weight loss within 12  months after surgery.  Subsequently, the gastric sleeve became a single-stage procedure for the treatment of morbid obesity.  In recent years the Gastric Sleeve gained significant traction after most medical insurance companies including Medicaid and medicare added coverage to this procedure. You can find the requirements for surgery CLICK HERE.

The gastric sleeve is also known as:

• Vertical Sleeve Gastrectomy
• Sleeve Gastrectomy
• Vertical Sleeve Gastroplasty
• Gastric Stapling Surgery
• Greater Curvature Gastrectomy

The gastric sleeve is performed laparoscopically or minimally invasive by most bariatric surgeons.  I know of several surgeons that to this date continue to perform this procedure using open techniques.  In my opinion, no patient should be undergoing an open gastric sleeve in the 21st century.  In my hands, 99.9% of these procedures are done laparoscopically even in superobese patients or patients with prior abdominal surgery.  So if your surgeon scheduled you for an open gastric sleeve, please look for a second opinion.

Before Gastric Sleeve:

You will be seen in my office at least twice before surgery. On the first visit, we will go over your medical history and we will determine which procedure is best for you. You will get a checklist with all the things you need to do prior to surgery.  Some of these items include a psychological evaluation, nutritional evaluation, etc. I will discuss this in detail in another post.

On the second visit, we will go over all the items on the checklist and make sure that you are ready for surgery. Most of the time during this visit you already have a date for surgery.  We will weight you and we will make sure that you have not gained weight.  Gaining weight before surgery in my practice is a big NO, NO.  If you gain weight I will postpone your surgery until you lose the weight you gained. Yes, I have done it several times before.

You need to quit smoking at least 3 months prior to surgery. READ HERE to see why smoking and bariatric surgery don’t get along.

You will need to be on a liquid diet for 2 weeks prior to surgery.  Don’t worry is not as bad as it sounds. Every patient goes through, trust me you can too. Most patients lose between 10-20 pounds during these 2 weeks… Yes… I will discuss the details on another post.

You will be scheduled to go to a preoperative class with the bariatric coordinator.  This is gold, many of your questions will be answered at that time. Yes, it is mandatory.

The Operation:

I perform these procedures using five small incisions, the largest incision is 15 mm in size and is usually the one that hurts the most after surgery.  The other four incisions are 5 mm in size.

Using a laparoscopic camera and some special instruments approximately 3/4 of the stomach is removed.  A calibration tubing called a Bougie is used to make the sleeve gastrectomy the same size every time.  The procedure takes between 45-90 minutes in most cases and is done under general anesthesia.  I do most cases with my Physician Assistant which you will meet in the office. After the stomach is divided and endoscopy will be performed to evaluate the sleeve and to identified any leaks.

The complication rate is very low but not unheard of, nationwide the leak rate is around 2 % and the mortality rate is approximately 1%. The risk of any other complications is around 15-20%.  These complications include urinary tract infection, pneumonia, wound infection, hernias, etc.

The procedure generates weight loss by reducing the stomach capacity to accommodate food.  The average weight loss reported is approximately 60% of the excess body weight between 1-2 years after surgery.  In order to take full advantage of the procedure, the patient is required to follow a diet and to exercise as much as possible.  On average patients tend to lose around 40-50 lbs on the first 3 months after surgery, the second-trimester weight loss is usually half of the first-trimester weight loss.  So if the patient lost 50 lbs in the first 3 months, he/she should lose around 25 lbs by the 6 months mark.  For this reason, I always encourage the patients to lose as much weight as possible for the first 3 months after surgery because this is the period of most weight loss.  Obviously this is dependent on the patient’s compliance with the diet, exercise program, and initial weight.

After Gastric Sleeve:

The usual hospital stay is 2 days, so if you have surgery on a Monday, you should expect to be discharged on Wednesday.  The first 24 hours are the worst in terms of pain, you will get IV pain medication to control your pain.  The second most common complaint in the first 24 hours is nausea, this is usually controlled with IV medications as well, most of the nausea is gone within 24 hours.

You will be encouraged to get up and out of the bed immediately after surgery to prevent a blood clot in your legs.  Morbid obese patients are at high risk for deep venous thrombosis (DVT) and the most effective preventive treatment is early ambulation.  Early ambulation is also helpful in preventing pneumonia.  An incentive spirometer will be given to you to prevent respiratory complications after general anesthesia.

Immediately after surgery, you will be completely NPO (nothing by mouth).  The first day after surgery you will be doing sips of water only (30 ml every hour).  On day number two you will graduate to protein drinks. You will get 60 ml of protein drink (Carnation Instant Breakfast) every other hour and 30 ml of water in between.  After discharge, you will start the high protein liquid diet for 2 weeks. I will explain the liquid diet in more detail in another post.

Most patients should expect 2-3 weeks off work to fully recover.  If you do heavy lifting or high-intensity work you might need 4-6 weeks in order to perform all your working duties.  You can start exercising 2-3 weeks after surgery but you need to start slowly and stay hydrated.  I usually tell my patients to limit the lifting to 15-20 pounds for 6 weeks, after this period most patients are clear to do any type of activity. Every patient is different so use your commonsense, if you are doing something and is causing pain then you are not ready for that activity yet.

Most patients will see me in the office 2 weeks after surgery, then at 3 months, 6 months, 9 months, and 12 months.  After the first year, I will see you on a yearly basis.  Some patients see me more often depending on the weight loss, knowledge of the diet, and overall success.  I want you to succeed so if you need to come to see me more often, then that will be your follow up plan.

Vitamin supplementation is a must-do after gastric sleeve surgery.   You will need to take a multivitamin daily.  You will also need Vitamin B12 supplementation for life.  I will explain Vitamin B12 in another post but in a nutshell, you need either a sublingual, nasal, or injection dose of vitamin B12 either daily or every six months depending on the route.

You will have to take an anti-acid medication (PPI) for 12 months after surgery even if you don’t have acid reflux or heartburn. This is to prevent any ulcers after surgery. We will stop it after one year unless you have acid reflux.

Most likely your medications will have to be adjusted after surgery, most patients require only half of the diabetes medications after surgery.  This will be discussed with you prior to discharge from the hospital. You will get a prescription for pain medication, anti-acid, and anti-nausea medication. You will have to crush tablets or open the capsules while you are on the liquid diet. Once you advance the post-op diet to a regular diet you can take your medications without crushing them.

Conclusion:

A gastric sleeve is a great option for many individuals, but you still need to put work into it… Weight loss surgery is like anything else in life, the more work you put into it the better the reward. In the Ocala/Gainesville/North Central Florida nobody has better outcomes in bariatric surgery than I do.

If you are one of our patients reading this post, I want to Thank You for your trust in me and my staff.  Thank you for selecting our program to regain control of your life.  If you are new to this whole process, Thank you for taking the time to read this post and we will be happy to see you in the office and help you regain control of your life.  We will help you win the fight against obesity. So remember to Take Action and Get Moving.

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