Sleeve Gastrectomy

Indications & Mechanism - Why & Who Gets Sleeved

• Mechanism:
  • Restrictive: Reduces stomach to ~15-20% of original size (approx. 100-150 mL).
  • Hormonal: ↓ Ghrelin (fundectomy), ↑ GLP-1, PYY (satiety).
• Indications (General Criteria):
  • BMI ≥ 40 kg/m².
  • BMI ≥ 35 kg/m² with comorbidities (T2DM, HTN, OSA, dyslipidemia).
  • BMI ≥ 30 kg/m² with uncontrolled T2DM (especially Asian populations).
  • Failed supervised weight loss.

⭐ Sleeve gastrectomy's primary mechanism is restrictive, but significant hormonal effects (↓ Ghrelin, ↑ GLP-1) contribute to weight loss and comorbidity resolution.

oka

Procedure Highlights - The Gastric Trim

• Approach: Laparoscopic, typically 5-6 ports.
• Mobilization: Greater curvature of stomach, from antrum (approx. 2-6 cm from pylorus) up to Angle of His.
• Calibration: Bougie (32-40 Fr) inserted orally to size the gastric sleeve.
• Resection: Longitudinal resection using linear staplers along the bougie.
  • The fundus and body are primarily resected.
• Staple Line: Often reinforced (sutures/buttressing material).
• Result: Narrow gastric tube created.

⭐ Approximately 75-80% of the stomach is resected, primarily along the greater curvature, including the fundus (key site of ghrelin production).

Advantages & Disadvantages - Sleeve's Edge & Hurdles

Advantages (Edge):

• Technically simpler than RYGB.
• ↓ Ghrelin (fundectomy) → ↓ hunger, ↑ satiety.
• No intestinal bypass → less malabsorption (vitamins/minerals) vs RYGB.
• Good weight loss (EWL ~50-60% at 2 years).
• Staged or convertible to other procedures (RYGB, SADI-S).

⭐ Preserves pylorus (↓ dumping syndrome vs RYGB); no foreign body (vs LAGB).

Disadvantages (Hurdles):

• Irreversible (stomach removed).
• Risk of new/worsening GERD (~20%).
• Staple line issues: leak/bleed/stenosis (~1-5%).
• Potential long-term weight regain (lifestyle adherence crucial).
• Nutrient deficiencies (B12, Fe, Vit D, Ca) need lifelong monitoring.

Complications - Navigating Risks

• Early (within 30 days)
  • Staple line leak (most common site: gastroesophageal junction)
    • Incidence: 1-3%
    • Presentation: tachycardia, fever, abdominal pain
  • Hemorrhage (intraluminal or intraperitoneal)
    • Incidence: 1-2%
  • Pulmonary embolism/DVT
  • Wound infection
  • Splenic injury
• Late (after 30 days)
  • Stenosis/Stricture (most common at incisura angularis)
    • Incidence: 0.7-4%
    • Presentation: dysphagia, vomiting
  • Gastroesophageal Reflux Disease (GERD) (de novo or worsening)
    • Incidence: up to 20-30%
  • Nutritional deficiencies (Iron, B12, Calcium, Vit D, protein)
  • Gallstones (due to rapid weight loss)
  • Port-site hernia

⭐ Staple line leak is the most feared early complication; GERD can be a significant long-term issue, sometimes requiring conversion to Roux-en-Y gastric bypass (RYGB).

Post-Op Care & Outcomes - Life Post-Trim

• Immediate Care: Pain management, DVT prophylaxis, early ambulation.
• Dietary Progression:

• Weight Loss: Expected %EWL ~60-70% by 1-2 years.
• Metabolic Benefits: High rates of T2DM, HTN, OSA remission.
• Key Considerations:
  • GERD: May develop or worsen (~20%).
  • Nutritional deficiencies: Lifelong monitoring for Iron, B12, Vit D, Calcium.
• Long-term: Regular follow-up essential.

⭐ Lifelong vitamin and mineral supplementation (e.g., B12, Iron, Calcium, Vit D) is crucial to prevent deficiencies.

High‑Yield Points - ⚡ Biggest Takeaways

• Restrictive procedure; ~80% of greater curvature resected, forming a gastric tube.
• Significantly ↓ ghrelin (hunger hormone), leading to ↓ appetite and ↑ satiety.
• Pylorus preserved, hence lower risk of dumping syndrome than bypass.
• Most common bariatric procedure worldwide; technically simpler than bypass.
• Major risks: staple line leak (most feared early complication), stenosis, and GERD.
• Lifelong multivitamin, B12, iron, calcium, Vit D supplementation crucial.