Laparoscopic Sleeve Gastrectomy (LSG)

“Love yourself enough to live a healthy lifestyle!”

Laparoscopic sleeve gastrectomy is a surgical procedure for weight loss in which the stomach is divided longitudinally. This leads to the formation of a long narrow banana shaped stomach with a much smaller capacity for food intake. Laparoscopic sleeve gastrectomy surgery works mainly on the principle of food restriction. Gastric sleeve surgery also increases the rate at which the stomach empties and leads to an increase in the levels of certain gastro-intestinal hormones. These along with a reduction in “Ghrelin” which is the hunger inducing hormone lead to weight loss and other metabolic benefits post sleeve gastrectomy surgery.

Laparoscopic sleeve gastrectomy leads to about 65 to 75% excess weight loss over 12 to 18 months. Laparoscopic sleeve gastrectomy also leads to a significant improvement in associated co-morbidities like type 2 diabetes, high blood pressure, high cholesterol, gout, obstructive sleep apnoea, joint diseases etc.

Laparoscopic sleeve gastrectomy is one of the most popular procedures being performed in India presently.

 

Eligibility for laparoscopic sleeve gastrectomy

The IFSO- APC (International Federation for Surgery for Obesity and Metabolic Disorders – Asia Pacific Chapter) guidelines for weight loss surgery are as under:

  • Bariatric surgery/obesity surgery/weight loss surgery must be considered for the treatment of obesity for acceptable Asian candidates with BMI ≥ 35 Kg/m2 with or without any associated diseases.
  • Bariatric surgery/metabolic surgery must be considered for the treatment of type 2 diabetes or metabolic syndrome for patients who are inadequately controlled by lifestyle alterations and medical treatment for acceptable Asian candidates with BMI ≥ 30 Kg/m2.
  • Bariatric surgery/metabolic surgery may also be considered as a non-primary alternative to treat inadequately controlled type 2 diabetes or metabolic syndrome for suitable Asian candidates with BMI ≥ 27.5 Kg/m2.

We recommend laparoscopic sleeve gastrectomy surgery for relatively younger patients who are committed to follow a good diet and exercise regime post the surgery.  Laparoscopic sleeve gastrectomy surgery also works well for volume eaters and obese patients with recently diagnosed diabetes. It can also be performed as a first stage procedure for super-super obese patients and then converted to another bariatric procedure such as Roux-en y gastric bypass, SADI-S, Sleeve with DJB or a duodenal switch. Laparoscopic sleeve gastrectomy surgery is also a part of some metabolic procedures like the ileal transposition.

Preparation before the procedure

  • First step is a consultation with the doctor and the team to decide on your eligibility for gastric sleeve surgery. A detailed medical history, diet recall and a complete physical and psychological assessment will be performed at this time.
  • Once we have decided to go ahead with gastric sleeve surgery, you will need to undergo a battery of tests. You may also need to see a diabetologist, endocrinologist, nephrologist, chest physician etc based on your clinical profile and associated co-morbidities.
  • A pre-operative upper GI endoscopy is a must before all bariatric procedures.
  • You will also need to be on a high protein liquid diet for a period of 5 to 7 days prior to the procedure. Most obese patients have fatty and enlarged livers. Swelling on the liver makes the surgery difficult for the surgeon. Pre-operative high protein liquid diet helps to shrink the liver and makes the surgery easier for the surgeon and safer for the patient. It has been seen that patients who sincerely follow the pre-operative liquid diet, tend to achieve better weight loss results post bariatric surgery.

In the hospital

  • Once all the tests have been done and you are medically fit to undergo gastric sleeve surgery, you will need to get admitted to the hospital one evening before your scheduled surgery.
  • All pre-operative medications including prophylaxis for venous thrombo-embolism will be taken care off at the hospital.
  • You will be fasting for 6 to 8 hours prior to the surgery.
  • Sleeve gastrectomy surgery typically takes about 45 minutes to an hour to perform and is done under general anaesthesia.
  • You will be encouraged to walk around on the same day and can go to the washroom yourself.
  • You will be started on liquids on the next day after the surgery. If all is well, you will be discharged to go home on the day after surgery.

Mechanism of action of laparoscopic sleeve gastrectomy surgery

  • Gastric sleeve surgery entails dividing the stomach longitudinally. This results into a long narrow banana shaped tube of the stomach. The other half of the stomach is removed out of the body. This surgery is permanent and cannot be reversed.
  • After gastric sleeve surgery, patients tend to feel full and satiated much earlier and with much smaller quantities of food.
  • Sleeve gastrectomy surgery also leads to a decrease in the levels of the hunger inducing hormone “Ghrelin”. This decreases the sensation of hunger and patients do not feel uncomfortable even though they are consuming very small quantities of food.
  • Sleeve gastrectomy surgery also leads to increased rate of gastric emptying which results into an early release of certain gastro-intestinal hormones like GLP 1 and PYY. This has a favourable effect on diabetes.
  • Gradual mobilization of fat stores from the body results into weight loss.

What to expect after sleeve gastrectomy surgery

  • You will be started on a clear liquid diet on the day after your surgery.
  • If you are able to tolerate liquids and do not have any other clinical problems you will be discharged on the day after your surgery.
  • All medications including prophylaxis for venous thrombo-embolism will be explained to you before discharge.
  • After sleeve gastrectomy surgery, you will be on a liquid diet for about 15 days followed by soft and mashed diet for the next 15 days. You will be able to consume normal home cooked food after one month of surgery but it will be restricted in quantity.
  • You will also need to take nutritional supplements as advised by the team and the team will guide you at every step about the nutritional supplementation and diet.
  • It takes a few months to adjust to new eating habits. Please do not worry. We are available at all times to answer your queries.

Expected weight loss after sleeve gastrectomy surgery

  • Patients may lose up to 65 to 75% of their excess weight after sleeve gastrectomy. Weight loss is dependent on many associated factors such as initial weight of the patient, age, gender, associated co-morbidities, behavioural modification made by the patient etc.
  • Patients who embrace the lifestyle change and comply with behavioural modification guidelines as suggested by the team, tend to do better after any weight loss procedure including gastric sleeve surgery.
  • Please note that weight loss procedures must not be perceived as a short cut. High level of commitment is needed from both, the doctor and the patient. It is mandatory to follow the diet prescribed by the team and to put in atleast 30 to 45 minutes of exercise every day to achieve best results.

Improvement in co-morbidities

  • Laparoscopic sleeve gastrectomy also leads to a significant improvement in associated co-morbidities such as type 2 diabetes, high blood pressure, high cholesterol, obstructive sleep apnoea, gout, PCOD etc.
  • Improvement in the above components of metabolic syndrome eventually leads to a considerable decrease in the risk of developing heart disease.
  • Overall weight loss secondary to bariatric surgery leads to a significant improvement in quality of life and confidence levels of the patients.

Upsides

  • Sleeve gastrectomy is a relatively easy procedure to perform.
  • There is no alteration or re-routing of the gastro-intestinal anatomy. Food passes along the normal physiological route. Nutritional supplementation is definitely required post sleeve gastrectomy but the incidence of nutritional deficiency is relatively lower.
  • Stomach remains available for endoscopic surveillance. This is important for countries like Japan and Korea where there is a high prevalence of stomach cancer.
  • Relatively lesser incidence of dumping syndrome.
  • Sleeve gastrectomy can be easily converted to other bariatric/metabolic procedures such as Roux en y gastric bypass, duodenal switch, sleeve with DJB, SADI-S and so on.

Downsides

  • Gastric sleeve surgery must not be performed in patients suffering from hiatus hernia and acid reflux disease. Sleeve gastrectomy is a refluxogenic operation and in such patients, it can increase the reflux levels. This can be especially troublesome if the patient is a smoker.
  • Varying degrees of weight regain has been observed in some patients in the long term after this surgery. The importance of embracing lifestyle change and behavioural modification is paramount after any bariatric procedure. Surgery is just a tool that leads to massive weight loss but for weight maintenance in the long term, effort has to be put in by the patient and the team.
  • In terms of complications, this surgery is as safe as any other surgery. In this age of internet and Google doctors, you will come across a lot of unnecessary information on the internet. We sincerely urge you not to get influenced by half-baked information on the internet. Doctor and the team will honestly discuss the complication rates of all procedures with you during your consultation.
  • If you are a smoker, please stop smoking atleast 3 weeks before your surgery. It is advisable not to undergo any bariatric procedure if you will continue to smoke after the surgery.

Long term follow up

  • Bariatric surgery leads to best results in patients who follow up regularly. Follow up schedule will be given to you at the time of discharge from the hospital and we urge you to follow this schedule strictly.
  • You will need to see the doctor and the team on a regular basis in the first year and once every year there-after for life.
  • Please get your tests done as advised by the team. This goes a long way in preventing nutritional deficiencies.
  • It is mandatory to get an upper GI endoscopy done once every year after any bariatric procedure.

Cost of laparoscopic sleeve gastrectomy

Dr. Aparna Govil Bhasker has one of the highest experiences in performing this surgery in the country. Laparoscopic sleeve gastrectomy cost depends on many factors. Laparoscopic sleeve gastrectomy surgery cost depends on the disposable equipment used. Gastric sleeve surgery cost also depends on the type of room category selected by the patient. Sleeve gastrectomy surgery cost varies a little depending on the duration of stay in the hospital. Cost of laparoscopic sleeve gastrectomy is not routinely covered by insurance companies. Off late there has been some movement on this front and some of the insurance companies have started covering the cost of laparoscopic sleeve gastrectomy surgery. Some of these insurance firms charge a higher premium to their customers. Cost of gastric sleeve surgery is covered for central government employees in India under the CGHS health scheme. Nowadays there are some companies that have started giving interest free loans and cover the cost of sleeve gastrectomy surgery in affordable EMIs. The doctor and the team will guide you about the cost after assessing and evaluating all the above details.

Last but not the least

We understand that by taking the decision to undergo this surgery, you have taken a major life decision. The objective of the above information is not to overwhelm you but give you a detailed and honest account of how your life will change. This decision will propel you into a better and healthier life. We are your equal partners in this journey and having a positive frame of mind is extremely important before taking this step. We are here to take care of you and solve your tiniest query. We urge you to stay positive, because at the end of the day, your body hears everything that your mind says.

“Motivation is what gets you started, habit is what gets you going.”