Bariatric gastric sleeve

Bariatric gastric sleeve surgery Chinmay Jani Intern Doctor, Smt. N.H.L. Municipal Medical College, Ahmedabad April, 2017

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Introduction

Obesity

Obesity is a multi-factorial metabolic disorder which essentially manifests itself as a surplus of unexpected energy stored as fat. The contributing factors include genetic predisposition, eating disorders, psychological issues, poor diet, lack of exercise and co-morbid conditions predisposing to obesity.

The outcome of excess fat storage is often the development of metabolic syndrome which drives the excess incidence of associated co-morbidities.

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Bariatric Surgery:

Most bariatric are aimed at the stomach in an attempt to restrict the amount the patient can eat. Some of these procedures also add an element of gastric and small-intestinal bypass to produce a degree of malabsorption.

Types of Surgeries:

Restrictive Surgeries:

1. Gastric banding 2. Sleeve gastrectomy

By-pass surgeries: 1. Roux-en-y bypass 2. Biliopancreatic diversion - with or without a duodenal switch

Rationale for surgery: • Increase life expectancy • Decrease co-morbidities • Decrease health-care costs to society.

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Selection criteria for obesity surgery: • BMI > 40 kg/m2 or BMI 35-39 kg/m2 with serious co-morbid disease treatable by weight loss • Minimum if 5 years obesity • Failure of conservative treatment • No alcoholism or major untreated psychiatric illness • Avoid if likely to get pregnant within 2 years • Age limits 18-55 (relative) • Acceptable operative risk on preoperative assessment.

Sleeve gastrectomy procedure:

Sleeve gastrectomy was originally performed as a modification to another bariatric procedure, the duodenal switch, and then later as the first part of a two-stage gastric bypass operation on extremely obese patients for whom the risk of performing was deemed too large. The initial weight loss in these patients was so successful it began to be investigated as a stand-alone procedure.

Today sleeve gastrectomy is the fastest-growing weight loss surgery. In many cases, but not all, sleeve gastrectomy is as effective as gastric bypass surgery, including weight-independent benefits on glucose homeostasis. The precise mechanism that produces these benefits is not known.

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The procedure involves a longitudinal resection of the stomach starting from the antrum at the point 5–6 cm from the pylorus and finishing at the fundus close to the cardia.

The remaining gastric sleeve is calibrated with a bougie. Most surgeons prefer to use a bougie between 36-40 Fr with the procedure and the ideal approximate remaining size of the stomach after the procedure is about 150 mL.

In current practice, as stated above along with it used as a single procedure, it is also used mainly as the first step in a two staged procedure followed by bypass or BPD with a duodenal switch.

Laparoscopic procedure: Laparoscopic procedure is becoming more popular and acceptable in the world because of its relative less complications and better acceptance.

Following are the steps of the procedure:

• To gain access to the abdominal cavity, small incisions are created on the abdominal wall. • are placed through these skin incisions. Surgical instruments are passed through the trocars to access the abdominal cavity. • The abdomen is filled with carbon dioxide (CO2) gas to lift the stomach wall away from the small intestine and other organs. Examine the abdominal cavity using the laparoscope which is a specialized video camera. • One of the first steps of the operation is positioning the liver. The edge of your liver sits directly over part of your oesophagus and the first portion of the stomach. A is placed which lifts the liver off of your stomach. • The tissue that attaches the stomach to the omentum is then separated so that the area under the stomach can be visualized. • To cut and ligate these attachments and small blood vessels that lie on the greater curvature. This ligation of blood vessels and tissues continues extending from oesophagus to the duodenum.

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• Carry out dissection from the angle of His. This angle is opened up almost completely during sleeve gastrectomy and is therefore rendered irrelevant. • Gastrosplenic and gastrocolic ligaments are divided.

Separating the stomach by Stapling near the Angle of His

The photo demonstrates the position of the sleeve gastrectomy under the liver. The stapler is shown in one of the final stages of dividing the stomach in the area of the angle of His and the gastroesophageal junction. This portion of the operation requires a judgement with regards to amount of stomach resection and blood supply.

• Check for the presence of hiatal hernia. If hiatal hernia is present, the defect is closed with sutures anterior to the oesophagus and possibly posterior as well. • Place a bougie into the pyloric channel. • Cut the thick antrum of the stomach transversely around the bougie to create a gastric tube. The pylorusis spared along with a portion of the antrum. The stomach is divided up to the level of the gastroesophageal junction, the lower part of the oesophagus that connects to the stomach.

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Judging the size of a Sleeve Gastrectomy

The stomach is demonstrated at an early stage of being divided. Looking along the left side of the stomach, the lesser curvature, it is possible to visualize the bougie which is measuring the ideal size of the stomach pouch. The first staple line with buttress can be seen at the bottom of the picture.

• A gastric sleeve is a pouch with an estimated capacity of less than 150 ml. Stapling along the length of the stomach formed by the bougie creates a narrow tube. The staple line may be covered with material that is meant to reduce the risk of bleeding and/or leaks. • Extra care is to be taken to avoid relative narrowing at the incisura angularis. • Stomach is completely divided during sleeve gastrectomy. • The entire staple line is inspected for bleeding and visually inspected for dysfunctional staples or a leak.

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Sleeve Gastrectomy Demonstrating Divided Stomach

Laparoscopic sleeve gastrectomy completely divides the stomach into two pieces. The objective of the operation is to decrease the remaining size of the stomach as well as to resect the fundus, the portion of the stomach that is likely involved in the hunger response. The picture above demonstrates the separated stomach to the right. It appears a purple color because all of the blood supply has been cut in order to facilitate its removal.

• The resected stomach is to be placed in a specimen bag and then extracted through the site. • The port sites are then closed with non-absorbable sutures.

Sleeve Gastrectomy Shown Under Liver Edge

One of the final stages of the operation involves removing the separated stomach portion. The cut edge of the gastric sleeve can be visualized just beneath the edge of the liver. The staple line appears irregular because it is lined with surgical staple buttress material. The plastic bag used for specimen removal as well as the resected stomach can be seen in the bottom left of the picture.

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Results (Advantages) of gastric- sleeve surgery:

• Weight loss (on average) is as good as or better than gastric bypass and much better (on average) than after lap band surgery. Duodenal switch patients typically experience more weight loss than any procedure. • The overall short-term risk of gastric sleeve is similar to that of gastric bypass, higher than lap band and lower than duodenal switch. • The overall long-term risk of gastric sleeve is lower than all other procedures. • The feeling of hunger may be lower after GS than with the gastric band (lap band) or gastric bypass. • Gastroesophageal Reflux Disease (GERD) may be worse after GS than after gastric banding in 1 year following surgery, but the reverse may be true after 3 years.

In addition to benefits already covered (better weight loss and reduced risks), the gastric sleeve has a significant positive impact on health risks associated with obesity, especially…

• Diabetes • Hypertension • Hyperlipidemia

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Complications:

Sleeve gastrectomy may cause complications; some of them are listed below:

• Sleeve leaking • Blood clots and infections • Aversion to food and nausea[8] • Damage to the vagus nerve which will cause constant nausea • Gastroparesis, with a delay in moving food from the stomach to the small intestine • Vomiting • Esophageal spasm/pain

Newer approaches:

• Vagal stimulation • Endoluminal sleeve • Natural orifice endoscopic surgery

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References

1) Paluszkiewicz R, Kalinowski P, Wróblewski T, et al. (December 2012). "Prospective randomized clinical trial of laparoscopic sleeve gastrectomy versus open Roux-en-Y gastric bypass for the management of patients with morbid obesity". Wideochirurgia I Inne Techniki Mało Inwazyjne 7(4): 225– 32. doi:10.5114/wiitm.2012.32384. PMC 3557743. PMID 23362420. 2) Karmali S, Schauer P, Birch D, Sharma AM, Sherman V (April 2010). "Laparoscopic sleeve gastrectomy: an innovative new tool in the battle against the obesity epidemic in Canada". Canadian Journal of Surgery 53 (2): 126–32. PMC 2845949. PMID 20334745. 3) http://www.bariatric-surgery-source.com/gastric-sleeve- surgery.html#sthash.8MJFjlli.dpuf 4) See more advantages at: http://www.bariatric-surgery- source.com/gastric-sleeve-surgery.html#sthash.8MJFjlli.dpuf

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About the Author

Chinmay Jani

Intern Doctor at Smt N.H.L. Municipal Medical College, Ahmedabad.

PlexusMD, Management Intern

His topics of interests include cardiology, neurology and carrying out research in various fields.

Connect at: https://www.plexusmd.com/mrChinmayJani

Reviewed by PlexusMD Editorial Panel

Added by Chinmay Jani on plexusmd.com | April, 2017 Bariatric gastric sleeve surgery

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Added by Chinmay Jani on plexusmd.com | April, 2017