Op. Dr. Cemal Kara

SLEEVE GASTREKTOMY

Detailed information about stomach tube.



  1. What is Sleeve gastrectomy?

Sleeve gastrectomy is a surgical procedure in which weight loss of obesity patients is provided by the removal of most of the stomach. The remaining stomach is named as stomach tube because it is in the form of a tube. The first Sleeve gastrectomy was performed as a part of the duodenal switch operation in 1988. In 1999 it was performed as a closed surgery for the first time. After 2001, it was started to be performed as a first-line surgery before the gastric bypass surgery in very obese patients. After 2009, its popularity started to increase and it started to be applied as a surgical method on its own. Especially with laparoscopic initiation, this operation became very popular due to the shortening of the hospital stay, shortening of recovery period, fewer scars and reduced surgical site hernia.

  1. Which Patients are treated with Sleeve gastrectomy?

It can be applied to patients with obesity who are unable to lose weight or who have weight-related insulin resistance, joint problems, etc.  Up to ten years ago, it was performed as a first step surgery in very obese patients before gastric bypass surgery. In this case, the patients lost weight and then bypass surgery was performed. However, later observations and studies showed that there was no need for a second surgery in the majority of the patients and that adequate and permanent weight loss was achieved. Likewise, the frequency of its use increased gradually as it was seen to be as effective as bypasses on the diseases such as diabetes and blood pressure. It is now the most common bariatric surgery today.

  1. Do diseases such as diabetes, asthma, blood pressure prevent Sleeve gastrectomy?

On the contrary, these are diseases caused and exacerbated by obesity. These diseases are not an obstacle for the surgery but they are the reason.

  1. How to prepare before Sleeve gastrectomy? Which examinations are done?

First, the following tests and examinations are applied to each patient before surgery

  1. Blood biochemistry tests
  2. Hemogram
  3. Hormone tests
  4. Hepatitis tests
  5. Whole abdominal ultrasound
  6. Gastrointestinal Endoscopy (with anesthesiologist)
  7. ECG (Electrocardiography)
  8. Chest radiography
  9. Pulmonary function test
  10. Effort test and ECO (Echocardiography) if required

After all these tests, necessary examinations are carried out by Anesthesia, Internal Medicine, Cardiology, Chest Diseases and Endocrine specialists. As a result of these examinations, firstly it is checked whether the patient has any other underlying disease that may cause weight gain. If there is no such disease, the patient will be examined for anesthesia like every patient who will be operated. Relevant specialists will make recommendations about pre-operative treatments if necessary. Thus, the problems that may arise during and after this significant surgery are reduced to the minimum.

  1. How is Sleeve gastrectomy performed?

All procedures are done by laparoscopic (closed) operation method. Laparoscopic surgery is performed with a large number of small incisions. The ports placed from these incisions are used to reach the abdomen by the hand tools. One of these is a surgical telescope connected to a video camera and others are for the insertion of specialized surgical instruments. The surgeon monitors the operation from a video monitor. With experience, an experienced laparoscopic surgeon can perform many procedures as laparoscopically as in open surgery.

The first Sleeve gastrectomy was performed as a part of the duodenal switch operation in 1988. In 1999 it was performed as a closed surgery for the first time. After 2001, it was started to be performed as a first-line surgery before the gastric bypass surgery in very obese patients. After 2009, its popularity started to increase and it started to be applied as a surgical method on its own. Especially with laparoscopic initiation, this operation became very popular due to the shortening of the hospital stay, shortening of recovery period, fewer scars and reduced surgical site hernia.

The abdomen is inflated by giving CO2 gas to the abdomen, and then reached into the abdomen through special tools called trocar. First, a guide silicone tube is inserted from the mouth to the stomach exit to adjust the remaining stomach width. The stomach is separated from the surrounding fat, from the veins and from the adjacent spleen. Then, with the special devices called stapler, the excess part of the stomach is cut off and separated. About 80-150 ml of stomach volume remains. The separated part is removed from the abdomen and sent to the pathology. Bleeding is then controlled in the section cut and stapled. Additional metal clips may be used for this, or additional stitches may be used if necessary. Again, some special medications may be applied to the wound area to reduce bleeding if needed. Then a silicone drain is inserted into the surgical area to remove the fluids that accumulate inside. The wound is aesthetically closed and the operation is terminated.

  1. Is the brand of materials used during Sleeve gastrectomy important?

There are many different products in the market. The materials of the two leading American companies are the best quality products currently on the market and used all over the world. However, their costs are much higher than Chinese products used for the same purpose. Safety, not cost, is of first importance in health. Each product used has its own barcode with serial number. The barcode of each used material is placed in the patient file. Absolutely ask for the material used.

  1. Is there a leak test on Sleeve gastrectomy?

Leak test is performed during the revision surgery and then on the 2nd day. The purpose of the leak test in the operation is to determine if there is a problem with the staples, whether there is leakage at the suture line. If there is leakage, additional suture is added to prevent leakage. It is also possible to take the necessary measures on time and to intervene by conducting a leak test before starting the liquid nutrients after the operation.

  1. Is there suture in Sleeve gastrectomy?

In bariatric surgery, additional suturing in addition to special materials called staples is controversial. Some surgeons think that suturing reduces the possibility of bleeding and leakage and that every patient should be sutured. Some surgeons say that suturing reduces the chance of bleeding to some extent but does not reduce the risk of leakage; in contrast, it may lead to more leaks and bleeding after vascular injury while suturing. We are among the two of them as a clinical approach. Although we do not use additional stitches to each patient, we will definitely add extra stitches if the stapler line is not safe enough for us. The fact that our results are much better than the average of the world suggests that our method is more successful. The most important point here is that the surgeon who performs the surgery must have the ability and experience to intervene and correct any problems.

  1. Why is blood thinner used in Sleeve gastrectomy?

During each surgery, there is a possibility of blocking blood vessels with          intravascular blood clots. This can lead to serious problems when it is a vessel that feeds vital organs such as the heart, lungs and brain. As the weight of the patients increases, the risk of embolism increases. For this purpose, blood thinners are given to these patients regardless of the surgery. Although the risk of bleeding is slightly increased, the benefit is much higher. The use of blood thinners begins before surgery and continues for two weeks. The duration of use may be even longer in high-risk patients, such as those with cardiovascular disease or previous embolisms.

  1. Will there be pain after Sleeve gastrectomy?

Since revision surgery is done laparoscopically (closed), by entering through millimetric holes, postoperative pain is much less than open surgery. Still, the phrase “she/he had a surgery, of course there will be pain” is extremely wrong. No patient should feel pain in the 21st century. Pain is completely avoided by administering post-operative analgesic to each patient. The important point here is this: Pain threshold of each person is different. Again, drug tolerance and bioavailability from the drug are different. Therefore, treatment cannot be standard. The pain relief treatment should be regulated separately depending on the needs of each patient.

  1. Will there be a scar after Sleeve gastrectomy?

Since the incisions are very small, the aesthetic results are also fairly good. After a few months, these lines will become almost invisible. After the wound heals, you will be recommended a cream for less scar appearance. You will get much better aesthetic results if you use it for three months.

  1. When does nutrition start after Sleeve gastrectomy?

On the 2nd day of the surgery, you will start taking liquid food after the leak test. You will have soft (puree style) food for two weeks following the first two weeks of fluid feeding. You will be in constant communication with our dieticians throughout this entire process.

  1. How will nutrition, vitamins and mineral supplements be provided after Sleeve gastrectomy?

During the first 15 days, protein supplements are provided for the patients. Especially in the first year of the disease various vitamin and mineral supplements are provided. Protein and vitamin usage times differ according to the type of surgery. These are not standard for every patient but are determined according to what the patient needs and how much they need after the examinations performed on the routine controls.

  1. Is it possible to get up and go back to work immediately after Sleeve gastrectomy?

Since surgery is done laparoscopically (closed), you can get up and walk after a couple of hours of surgery. Even during the period when you are in the hospital you will not be cared for, you will be able to do your own selfcare. Patients who work on desk and patients who do not require heavy effort can start back to work within a week. Patients who require heavy effort should stop working for at least one month. The resting report is given for as long as required to the patients after the surgery.

  1. When are the stitches removed after Sleeve gastrectomy?

It is not necessary to take the stitches as dissolvable stitches are frequently used. If a non-dissolvable stitch is used for a different reason, the stitch is checked and removed when you arrive for a follow-up on the tenth day.

  1. When can you have a shower after Sleeve gastrectomy?

You can take a shower when you’re out of the hospital. There is no problem with the sutures getting open and wet. After showering, dry with a clean towel, apply batticon on the sutures and wait for them to dry. Batticon does not cause permanent stain in your clothes. There is no need to use batticon after the tenth day.

  1. Can I use medication after revision surgery?

During the first month, do not use any medications except the ones we prescribe. If a medication is suggested by another physician, you should definitely consult us. You can use any medications after the first month. Nevertheless, try not to use too much painkiller and take plenty of fluid after taking the medication.

  1. How Sleeve gastrectomy (tube stomach) surgery works?

Sleeve gastrectomy surgery, contrary to what is believed, is working not only by restricting food intake, but also surgery has very important hormonal and metabolic effects. First of all, as the volume of the stomach decreases, less food is taken. But this is not the diet. You will not be hungry, you will feel totally full. Even food in small quantities is enough for you. The hormone called Gharelin, also known as the appetite hormone, is secreted from the fundus part of the stomach. With the removal of this part of the stomach, the appetite also decreases seriously. The mechanism of action, which is also secreted from the stomach and acts on the intestines, has different hormonal effects that are still under investigation. Although the exact nature of this effect is unknown, the final effect is a dramatical improvement in problems such as diabetes and blood pressure even when the weight loss has not started yet. There will not be a significant increase in the volume of pouch in the long term unless you seriously force the stomach. The first response when the patient takes a small amount of food is to strain the wall of stomach pouch and to warn the nerves that inform the brain about the fullness of the stomach. The patient feels a sense of satiety as if she/he ate a big meal, but it is actually a few spoonfuls.

  1. Will there be weight gain after the sleeve gastrectomy?

The risk of weight gain after a sleeve gastrectomy is very low. In order to maximize the benefits of this physiology, the patient only needs to eat at meals, take 2-3 meals a day, and avoid snacks between meals. This surgery requires changing the eating habits acquired over a long period of time. In almost all cases where weight gain was observed again in the late periods of surgery, there was no increase in the meal capacity. The reason why you gain weight again is especially high calorie snacks between meals. There is no known operation to overcome the side effects of this type of eating habit.

  1. What are the advantages of Sleeve gastrectomy compared to Gastric Bypass Surgery?

It causes less vitamin, mineral deficiencies (especially vitamin B12 deficiency, iron, calcium and folate deficiency).
Less lifelong vitamin-mineral supplementation and follow-up is required.
Intervention options that can be done again with weight gain are extremely variable.
When there is a problem, endoscopy has the chance to intervene in the bile ducts and the pancreatic duct. The procedures such as ERCP and biopsy can be done easily.
Since there is no stomach tissue that is closed and left, there is always a chance of control by endoscopy.
The decrease in appetite is greater because the part of the fundus that secretes Ghrelin (appetite hormone) is removed.

  1. What is the cost of bariatric surgery? Is it an expensive surgery?

Our clinic has an agreement with social security institution (SSI) and serves as affordable as possible. You can get detailed information from our contact numbers.

The prices of bariatric surgery are slightly higher than other surgeries. However, a few titles are extremely important here.

  1. The materials used are an important cost item. There are many different products in the market. The materials of the two leading American companies are the best quality products currently on the market and used all over the world. However, their costs are much higher than Chinese products used for the same purpose. Safety, not cost, is of first importance in health.
  2. The operating room and the hospital where the surgery is performed must have certain equipments and standards. It is necessary to have sufficient number of intensive care beds and a full-time physician in all branches. All equipments from the operating table to the patient bed should be suitable for obese patients. Therefore, it is not appropriate to perform the procedure at every hospital.
  3. Bariatric surgery is not completed only with the surgery; there should be a support team with specialist dieticians whom you can reach for 7 days 24 hours.
  4. The cost of testing and preparation steps required for revision surgery is higher.

 

Meeting all these requirements increases the cost of surgery by a little more than other surgical procedures. Even if putting aside the quality of life, obesity is the actual cost considering in the long term.  The amount of money to be spent on the treatment of health problems caused by obesity such as joint erosions, diabetes, asthma, sleep apnea and blood pressure is several times higher.





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