Bariatric Surgery

Initially, the Gastric Sleeve was the restrictive part of the biliopancreatic diversion duodenal switch operation. Then, the gastric sleeve became the first stage operation for very obese patients who underwent duodenal switch operation to reduce the perioperative risks. Some patients lost enough weight after the gastric sleeve surgery and did not undergo the planned second stage duodenal switch operation. These findings prompted bariatric surgeons to consider the gastric sleeve surgery as a standalone bariatric procedure. The first laparoscopic Gastric Sleeve was performed in 2000.

Over the past decade, the number of gastric sleeve surgeries continue to increase nearly every year. Now, more than half of all bariatric surgeries performed in US are gastric sleeve procedures.

On average, people lose about 60-70% of their excess weight

The first 2 weeks: 10-20 pounds; most patients lose about one pound a day

The first 3 months: 35-45% of excess weight loss

The first 6 months: 50-60% of excess weight loss

The first year: 60-70% of excess weight loss

Most people reach their lowest weight 12-24 months after surgery

The Gastric Sleeve success rate is approximately 80-90%

Large clinical trials and studies have proven gastric sleeve surgery lead to resolution or improvement of many obesity related health problems such as:

Type 2 diabetes: Most studies indicated that 60-80% of patients with type 2 diabetes could achieve disease remission or improvement after gastric sleeve surgery

• Hypertension
• Fatty liver disease
• High cholesterol
• Sleep apnea
• Decreased cancer risk
• PCOS
• Asthma
• Migraine
• Join pain
• Depression and other psychosocial problems
• Infertility
• Low testosterone: Gastric sleeve can naturally lead to increased testosterone level
• Urinary incontinence
• Gout

BMI more than 40 without comorbidities

BMI 35 to 39.9 with at least one serious comorbidity including diabetes, hypertension, sleep apnea or limitations in the quality of life

BMI 30 to 34.9 with metabolic syndrome or diabetes that is uncontrolled with medical therapy

It is important to note that upon entrance to a bariatric surgery program and before proceeding with surgery, patients should participate in a guided weight loss program with exercise and lifestyle modifications; this will help ensure that the patient can make the commitment necessary to undergo the postoperative nutritional restrictions of the procedure.

A BMI of 20 to 25 kg/m2 identifies a subject with a normal weight, whereas a BMI of 26 to 29.9 kg/m2 is considered overweight, and a BMI of 30 to 39.9 kg/m2 is considered obese. A patient with a BMI over 40 kg/m2 is called extremely obese; a patient with a BMI over 50 kg/m2 is superobese, and with a BMI greater than 60 kg/m2 is super-super obese.

The surgery takes approximately 40-70 minutes

Discharge from hospital typically occurs after 1-2 nights

All patients are encouraged to walk as early as 3-4 hours after surgery

In general, the pain is easily manageable after surgery. Most patients take less than the recommended pain medication

Most patients go back to work and/or school after 2-4 weeks. Fatigue is common the first 2 weeks due to low calorie intake from liquid diet. However, the majority of patients do not feel hungry during this stage of the diet. The energy level improves quickly after the introduction of the soft diet, which is approximately 2 weeks after surgery. On occasion, we allow patients to work from home 2-3 days per week after surgery.

Patients can begin exercising 4 weeks after surgery

Over the past decade, with the improvement of surgical techniques and surgeons’ experience, the gastric sleeve has become an overall safe bariatric surgical procedure. However, complications can still occur during and after surgery. Below are the main complications and risks of the gastric sleeve surgery:

Leakage from the staple line – this is a rate but serious complication of the gastric sleeve surgery. The reported leak rate is between 0.7-3 percent. At UCLA, we pay paramount attention to our surgical techniques to minimize all the complications. At this point, we have never had a leak from the gastric sleeve surgery at UCLA.

Stricture/stenosis – In the past, we had one stricture among our first 20 gastric sleeve procedures. We have not had any strictures within the past 5 years.

Bleeding

Blood Clot

Heart Burn – This is a very controversial topic in bariatric surgery and the data from different centers is inconsistent. In our experience, most patients with heartburn before surgery see improvement of symptoms after surgery due to weight loss. Some patients may develop new heartburn, which is treatable with over-the-counter anti-acid medications, in most cases.

Nutrient or vitamin deficiency

Weight Regain – After 1-2 years, slight weight regain is common among all bariatric procedures and about 10-20% of patients can have significant weight regain after gastric sleeve surgery. After 5 years of follow up, many centers collected data to show that the majority of patients can maintain their weight loss after the Gastric Sleeve Surgery.

Excess skin due to rapid weight loss in a short period.

After the operation of the sleeve gastrectomy, the patient needs a special diet for a period of thirty-five days, and this diet is divided according to time into several patterns or stages, which are the clear liquids phase for a period of ten days, the phase of full fluids and pureed foods for another ten days, then the phase of soft meals for ten days, and finally Back to the natural food system, and at each stage there are specific types of foods that are allowed to be consumed.

The first day: to follow a liquid diet. Some surgeons allow patients to drink water a few hours after surgery

Clear fluid phase (10-14 days)
The patient can drink at this stage liquid soups such as broth, apple juice or filtered carrot juice without drinking citrus juice, and herbs such as flowers, anise or chamomile can be drunk, in addition to water, tea and coffee.
Full Fluid Phase (10 days)
This stage contains pure or thick soups mashed in a blender, such as vegetable soup, lentils, vermicelli, etc., and watermelon, melon or carrot juice can be drunk, and yogurt and low-fat milk are consumed, in addition to other liquids.
Pureed Food Stage (10 days)
The patient can, at this stage, eat any type of liquid present in the previous two stages, in addition to eating well-mashed fruits in an electric mixer, as well as drinking fruit cocktails, grilled or boiled vegetables that must be mashed, or eating starches such as rice soup or breakfast cereals with milk low fat. At this stage, it is forbidden to eat meat from fish or white and red meat, as well as eating bread and all kinds of soft drinks like Pepsi and coca cola , for a period of three to six months after the operation.

The normal diet phase after 30-34 days
It is possible to return to eating various foods and eating meat and solid foods, and at this stage the next tips must be followed to avoid any stomach imbalance: Eat slowly and chew well. Refrain from eating as soon as you feel full. Not to eat and drink at the same time. Distribute food to different times and eat six to eight snacks.

After surgery, all patients should take multi-vitamin and B complex

Be careful not to neglect the sport after the operation; In addition to diet, exercise helps to lose weight in a healthy way, and the intensity of exercise must be gradually increased after the sleeve, where the patient begins to walk for a period of half an hour or more, then after a week he starts swimming, then after a month it is possible to ride a bicycle, and after three months he begins With stomach-tightening exercises and aerobics.

Laparoscopic gastric banding (Lap-band) was once very popular. However, due to its high rate of long term complications and inferior weight loss, the number of Lap-band surgeries went down every year in the US and worldwide. Most of the US large academic Bariatric Surgery Centers rarely perform the Lap-band procedure at this time.

Laparoscopic Roux-en-Y Gastric Bypass Surgery is the gold standard of bariatric surgery. However, Gastric Sleeve has replaced the Gastric Bypass Surgery as the most popular bariatric surgery in recent years due to its technical simplicity and fewer long-term complication rates.

Advantage of Gastric Sleeve versus Gastric Bypass Surgery

Technically, the Gastric Sleeve is a much simpler surgery. The operating time for gastric sleeve is usually 40-70 minutes, while gastric bypass surgery takes approximately 2-3 hours to complete.

There is a much lower chance for nutrient or vitamin deficiency with the Gastric Sleeve procedure. In addition, there is no mal-absorption for Gastric Sleeve patients.

Some long-term complications could occur with the Gastric Bypass patients including bowel obstruction, marginal ulcer, and internal hernias. The chance of Gastric Sleeve patients developing these complications is exceedingly rare.

There is no consensus regarding the imaging modalities that should be obtained before a bariatric procedure

An abdominal ultrasound is necessary for patients undergoing gastric bypass to identify possible liver pathology and cholelithiasis due to the high prevalence of the latter in this patient population.

patients with symptoms of acute or chronic cholecystitis or symptomatic cholecystitis should have their gallbladder removed during the bariatric procedure, as weight loss will only worsen their symptoms.

Esophagogastroduodenoscopy (EGD) is not routinely a recommended procedure in the workup for bariatric surgery. The American Society of Metabolic and Bariatric Surgery advises the use of endoscopy only for patients with significant gastrointestinal symptoms.

Certain basic tests are done prior to surgery:

• A complete blood count
• Urinalysis
• Chemistry panel
• Gallbladder ultrasound
• The chemistry panel gives results of about 20 blood chemistry values. Many surgeons also ask for a gallbladder ultrasound to look for gallstones.

Other tests may be requested when indicated and include:

• Chest X-ray
• Electrocardiogram
• Pulmonary function testing
• Echocardiogram
• Sleep studies
• GI evaluation
• Cardiology evaluation
• Psychiatric evaluation

An accurate assessment of your health is needed before surgery. The best way to avoid complications is to understand their potential in the first place. It is important to know if your thyroid function is adequate since hypothyroidism can lead to sudden death post-operatively.

If you are diabetic, special steps must be taken to control your blood sugar. Because surgery increases cardiac stress, your heart will be thoroughly evaluated.

These tests will determine if you have:

• Liver malfunction
• Breathing difficulties
• Excess fluid in the tissues
• Abnormalities of the salts or minerals in body fluids
• Abnormal blood fat levels

Patients with significant gastrointestinal symptoms such as:

• Upper abdominal pain
• Heartburn
• Belching
• Sour fluid

They may be symptomatic of underlying problems including:

• Hiatal hernia
• Gastroesophageal reflux and/or
• Peptic ulcer
• Up to 15 percent of reflux patients may show early damage in the lining of the esophagus, which could predispose them to cancer of the esophagus. It is important to identify this so a suitable surveillance or treatment program can be planned.

The sleep study detects a tendency for sleep apnea. The abnormal stopping of breathing usually associated with airway blockage when the muscles relax during slumber. This condition is associated with a high mortality rate.

Sleeping after bariatric surgery

After surgery you will be sedated and will receive pain narcotics, which further depress normal breathing and reflexes. Airway blockage also becomes more dangerous at this time. It’s important that your surgeon has clear expectations of the procedure so he can decide how to handle possible irregularities.

Medical problems such as serious heart or lung problems can increase the risk of any surgery. Conversely, if these problems are related to the patient’s weight, they also increase the need for surgery. Severe medical problems may not dissuade the surgeon from recommending bariatric surgery if it is otherwise appropriate, but those conditions will make a patient’s risk higher than average.

There are several contraindications for bariatric surgery procedures which include:

Major depression or uncontrolled mental health problem

Current substance misuse, including alcoholism

Patients determined to be non-compliant with nutritional requirements and supplementation after bariatric surgery

Underlying eating disorders

Severe coagulopathies

Patient-related contraindications to undergo surgery (cardiovascular risk, anesthetic risk)

A relative contraindication to sleeve gastrectomy procedure is gastroesophageal reflux disease which can become significantly worse after a sleeve gastrectomy

Patients are advised to avoid pregnancy 12 months before the operation and up to 18 months after the operation.
In the event of pregnancy, it is recommended to closely monitor the patient’s weight and fetal health
Non-hormonal contraceptives are recommended as they are less likely to gain weight

The American Society for Metabolic & Bariatric Surgery (ASMBS) guidelines for postsurgical tests following bariatric procedures in the USA have remained unchanged for the last decade.
The ASMBS guidelines recommend postoperative blood testing every 3 months for the first year, every 6 months for the second year, and annually thereafter regardless of the type of bariatric procedure performed.
other bariatric guidelines (other than USA) recommend less frequent postoperative lab testing.
We usually ask on routine follow up visits for:
CBC, KFT, LFT, TSH, Lipid profile, Zinc, Mg, Ca, Vit B12, Vit D, Uric acid, Folic acid, Iron, Ferritin and HbA1c.