Section: UGI Sub-section: Bariatrics Curriculum: Curriculum, page 83
Principles
- Can be either staged or definitive procedure
- Can convert to Bypass, DS, BPD later
- Results
- 70% EWL at 3 yrs but only 50% at 6 yrs
- May be comparable to bypass, but with less morbidity
- Mortality rate 0-3.3%
- Major complications 12%
- Antrum divided 2-6cm from pylorus
- Sleeve formed over Bougie, size 32-40F
- Mechanism of action
- Restrictive
- Hormonal
- Remove Fundus, main location of Ghrelin-secreting cells
Pros and Cons
- Pros:
- Technically easier than RYGB
- No anastomosis
- No risk of internal hernias
- Normal intestinal absorption
- No risk of malabsorption
- No foreign device
- Pylorus preserved
- Prevents dumping
- Options remain for revision procedures
- Cons:
- Long learning curve (50 surgeries)
- Irreversible
- Weight gain eventually, less durability
- Less effective for T2DM than RYGB GORD rates high (20%)
Procedure
- Laparoscopic access is variable/surgeon dependent.
- The Liver is retracted and a bougie inserted into the distal stomach (usually 34Fr +)
- The hiatus is inspected to evaluate for a hernia.
- The greater curvature is devascularised and mobilised 4cm proximal to the pylorus to the OGJ using Ligasure. The gastrocolic ligament is taken off
- As the dissection heads caudally you will encounter the gastrosplenic ligament and the short gastric vessels.
- The hiatal fat is then mobilised and the angle of His taken down.
- There are often adhesion between the posterior aspect of the stomach and lesser sac which have to be divided.
- The gastric sleeve can then be created by firing consecutive staplers 5cm proximal to the pylorus up to the OGJ along the bougie. Care must be taken when heading towards to OGJ to not ‘catch’ the oesophageal sphincter.
- The stomach can then be removed via one of the 12mm ports. https://www.sages.org/video/sleeve-gastrectomy-for-morbid-obesity/
Complications
- Staple line leak 2-3%
- Bleed from staple line
- Stricture/Stenosis
- Volvulus/torsion
- GORD