Gastric Sleeve / Stomach Reduction / Longitudinal Gastrectomy / Vertical Gastrectomy

For doctors

The gastric sleeve (stomach reduction) is a new procedure that induces weight loss by limiting the consumption of food. Through this procedure, the surgeon removes about 75% of the stomach so that the new stomach is in the form of a tube or sleeve. The remaining stomach will have a volume of approximately 100-150 ml.

Gastric sleeves candidates are those with a body mass index (BMI)> 40 or BMI> 35 that have other obesity-related disorder such as: type II diabetes mellitus, hypertension, sleep apnea, severe arthritis, asthma, hypercholesterolemia and cardiovascular diseases.

Studies have shown that the production of glargine, a hormone regulating hunger, is diminished significantly after gastric sleeves. This is due to the removal of a stomach segment that is responsible for producing this hormone. Higher weight loss after the gastric sleeve, as compared to the effects of a stomach ring, is due precisely to the lack of hunger.

Gastric Sleeve Benefits

  • The metabolic intervention in surgical patients with the best risk/benefit ratio
  • Improvement / healing of obesity through maximum, stable and long-term weight loss
  • Improvement / healing of comorbidities associated with obesity (e.g. diabetes mellitus, hypertension, hypercholesterolemia, sleep apnea)
  • Short hospitalization period, minimal postoperative pain, rapid social reintegration
  • It increases the quality of life
  • The feeling of hunger decreases significantly

Laparoscopic surgery

The Gastric Sleeve (stomach reduction) surgery is performed laparoscopically and is proven to be safer and with comparable results to the gastric bypass procedure. Because there is no malabsorption component in this surgery, the requirement of vitamin and protein supplements after the surgery is diminished as compared with gastric bypass surgery. Moreover, the possibility of intestinal occlusion and dumping syndrome is near zero. Unlike in the case of the gastric band, there is no implantable component in the gastric sleeve, eliminating the need for adjustment or the risk of complications caused by a foreign body. Unlike the gastric ring intervention, the gastric sleeve isn’t, however, a reversible operation.

For patients

Preparing for the Gastric Sleeve Surgery

1st stage

Consultation at the surgeon at the Provita Medical Center on Monday and Wednesday - between 17:00 and 20:00.

For appointments call: 0799 112 578.

2nd stage 

If after this consultation with the doctor, you decide to go ahead with the surgery, you will be given a diet that should be kept for 14-21 days before surgery. This is a high protein diet designed to prepare the liver for surgery, eliminating fat and decreasing its size. The actual preparation consists in specific medical tests and investigations. They last for 1-2 days and take place within 2-10 days prior to surgery, depending on the location and schedule of the medical team. On the day of the tests, the anesthetist is also consulted. If after this stage the results of the investigations do not contraindicate surgery and the anesthesiologist concludes that the patient is ready, surgery follows.

Day before the surgery

The high protein diet is discontinued on the day before the surgery. On this day it is recommended that you consume only LIQUIDS. Also on this day, between 18:00 -20:00, you will be given an anticoagulant injection, as indicated by the anesthetist. This can be done at home or at the hospital. It is a subcutaneous injection that can be administered in the shoulder or in the abdomen, and the anticoagulant will be provided by the hospital.

Day of surgery

In the morning of surgery, you mustn’t eat or drink. If the surgery takes place in the afternoon, you will benefit from hydrating infusions. It is very important for the stomach to be absolutely empty at the time of surgery.

Gastric Sleeve Complications

The gastric sleeve intervention, as all surgeries, can lead to complications that may occur both during and after the procedure itself. The first 24 to 48 hours are critical in terms of non-specific complications, while the following 30 days for the most feared complication, the gastric fistula. The first ten days are the most critical, with the risk of complications falling substantially after this initial period.

The most common complications of gastric sleeves and their associated symptoms include: 

SURGICAL

Internal bleeding

If a patient begins to bleed, it will usually take place in the first 24 to 36 hours.

Symptoms include:

  • Breathing difficulty
  • Increased heart rate
  • Pale skin
  • Dizziness after minimal effort
  • Insufficient urination
  • Rectum bleeding (might require prolonged hospitalization)

Gastric fistula after gastric sleeve surgery

A serious infection can result if a hole appears in the stiching of the stomach. The gastric juice, which is very acidic, can reach the abdominal cavity causing peritonitis. This can lead to a condition known as Sepsis (a complication that spreads the infection throughout the body). If the measures aren’t taken on time, the general condition deteriorates and death may occur. Therefore, the physician will monitor the patient post-surgery for various signs that may suggest the occurrence of gastric fistula.

Signs that may suggest the appearance of a stomach fistula after the gastric sleeve surgery:

  • Fever for no apparent reason
  • Stomach ache
  • Swelling of the abdomen
  • Difficulty in breathing
  • Fast and shallow breathing
  • Fatigue

The gastric fistula is a rare, but very serious complication if not discovered in time. Currently there no medical test can fully confirm the appearance of this complication. Therefore, it is necessary for the patient and the surgeon to pay attention to any symptoms occurring within the first 30 days after surgery.

The surgeon will evaluate all of the patient's symptoms and decide, based on experience, the need for a new operation to confirm and treat the gastric fistula. The rate of occurrence of these complications is 1-3% depending on the literature cited.

If you do not feel well or have any of the above symptoms, do not hesitate to contact your surgeon.

  • Wound infections
  • Eventrations
  • Gastric stenosis

Nonsurgical

Blood clots (deep vein thrombosis, thromboembolism)

Appear in less than 1% of the gastric sleeve operations. Blood clots can block the flow of blood (even leading to death), thus posing a high risk risk for obese patients undergoing any type of surgical procedure. This is why administering anticoagulant injections and installing special sockets are common practice in gastric sleeve surgeries. The most important measure to avoid this complication is early mobilization post-surgery. Even on short walking distances, early postoperative mobilization proves to be useful after surgery. Walking should take place as soon as possible after surgery, as soon as two hours, but this is the case for each patient.

  Pulmonary:

  • Pneumonia, atelectasis
  • Respiratory insufficiency

Cardiovascular:

  •  Heart failure
  •   Arrhythmias
  •   Strokes

Kidney and liver:

  • Kidney failure
  • Liver failure

Psychosocial:

  • Anorexia, bulimia
  • Postoperative depression, social dysfunction
  • Psychosis

Death

Other complications:

  • Small wound infections, scars
  • Urinary infections
  • Drug allergies
  • Nausea, vomiting, intolerance to certain foods, eating disorders
  • Esophagitis, Gastroesophageal reflux disease
  • Hypoglycaemia, hypotension
  • Stenosis or later enlargement of the stomach
  • Anemia, temporary deficits of vitamins or minerals
  • Constipation, diarrhea, bloating
  • Gallbladder
  • Gastritis or gastric ulcer
  • Insufficient weight loss

Post-surgery diet, in the hospital and immediately after discharge

A. Week 1 (first 7 days after surgery)

Liquid diet. While still in hospital and after the medical team allows you to, you will have to drink cold, unsweetened liquids. Useful information:

  • Drink water, tea, soup, Gatorade, coffee
  • Drink in small sips
  • Avoid drinking straight from the bottle, as it can cause gas

Gases are a common post-operative occurrence, so try not to make things worse by following the advice above. If you have diarrhea or if you vomit, replenish your electrolytes (sodium, potassium, chlorine) by drinking Gatorade to rehydrate and rebalance.

B. Week 2 (7-14 days after surgery)

Mashed foods (puree). Your diet will consist in no-fat, sugar-free food:

  • Red meat / poultry, potatoes, unsweetened marmalade (apple jam)
  • You will not be able to eat more than a few spoons of food
  • You are the only one in control of how much you eat
  • A good option is baby food

C. Weeks 3 to 4

You will follow the below diet, until your doctor decides otherwise, i.e. for about 2 weeks:

  • Red and poultry (pureed in blender), soft boiled eggs
  • Light cottage cheese, puddings without sugar
  • Unsweetened marmalade, preserved peach puree (not in syrup!), ripe banana puree
  • Steamed and blended vegetables
  • Oatmeal, corn, flour porridge

Solid foods - If you tolerate the above diet, after 2 weeks you can gradually introduce solid foods in your diet, such as weak protein, fruit / vegetables and whole grains, and limits fats and sugar.

This diet needs to be customized. It’s normal to develop temporary intolerance to certain foods. Try to reintroduce these foods into your diet, slowly, at a later time and don’t forget: eat slowly, chew well and don’t eat excessively! You will eventually end up tolerating various foods in each food group.

  • There are general indications as to when you can introduce various foods in your diet. The pace of adaptation to diets differs from individual to individual
  • The diet should be rich in protein and poor in refined carbohydrates (such as white flour). Recommended order: protein, fruit and vegetables, whole grains
  • Drink Gatorade in the hospital, but stop after discharge. If you have diarrhea or you vomit, drink Gatorade for rehydration
  • Baby food. If you don’t want to cook, eat baby food. Choose those with less sugar and rich in protein (red meat and chicken)

Basic principles for successful weight loss

In order to success with your weight loss, it’s important to adjust your lifestyle and behavior:

1. Eat three meals a day and limit unnecessary in-between snacks

This surgery is a restrictive procedure, which means that your weight loss depends very much on what you eat. Snacks in-between meals (pretzels, peanuts, cakes, biscuits, etc.) or frequent eating can slow weight loss or even cause weight gain due to the calory excess.

2. Eat slowly and chew food until it becomes pasty

Not chewing food properly can lead to stomach aches, nausea, vomiting, etc. It’s important to chew your food wel, until it becomes pasty

Avoid sugar. Read the product label carefully.

Ingredients are listed in order of quantities, so try to buy products which don’t have sugar listed as one of their first 3 ingredients. Try to eat less than 15 grams of sugar at a meal, to limit "empty calories" (with no nutritional benefit).

Simple sugars can be found on labels as: sugar, dextrose, corn syrup, sucrose, glucose, molasses and honey.

You can use artificial sweeteners such as:

  • Nutrasweet -> Egual
  • Saccharin -> Sweet & Low
  • Sucralose -> Splenda

4. Cut on high-fat foods

Low fat content means that the food contains less than 7% fat. Examples of high fat foods: chips, fried foods, fast food, bacon, sausage, hot dog, cold cuts, cheese, butter, whole milk, donuts, cakes, biscuits and other pastries.

5. Stop eating when you feel full

Overeating can cause nausea, vomiting, and affect the stomach size (it can stretch it). The stomach size stabilizes in approximately 6-9-12 months after surgery.

6. Drink adequate fluids to prevent dehydration

Your objective is at least 6-8 glasses of liquid per day. Drink slowly, with small sips. Avoid carbonated drinks, beverages containing sugar and alcoholic drinks. Carbonated drinks can increase stomach due to the build-up of additional air in the stomach. It’s recommended not to drink alcohol (at least during the first year) or limit the amount, as it’s absorbed rapidly and you will light headed very easy. In addition, alcoholic beverages are excluded from most diets due to their high sugar content.

Choose sugar-free beverages: flat water, fruit compote with sweeteners, skim milk, unsweetened coffee (preferably without caffeine), tea with sweeteners, natural juices (without added sugar). Tips:

  • Stop drinking carbonated beverages and caffeine and smoking before surgery.
  • Choose drinks with 10 calories or less per 100g
  • If it's hard to tolerate simple plain water, add a sugar-free flavor (a slice of lemon, orange, etc.)

The main signs of dehydration: dark urine, headaches, dizziness, lethargy, a white layer on the tongue.

7. Don’t drink while eating!

This dilutes the gastric juice and hinders digestion. Drink 30 minutes before eating. Wait 30-45 minutes after your meal to drink (meat is harder to digest).

8. Choose wisely what you eat

Firstly, every meal should include proteins. Then your daily nutrition should include vegetables and fruits, then whole grains.

9. Exercise!

Your goal is to exercise at least 30 minutes each day. This helps you lose weight and maintain it on the long-term. You can start with 5 minutes and increase the time as you gain strength.

During the first four weeks, walking should be your main exercise. After four weeks try to introduce more complex exercises (weight lifting, moderate aerobics, dancing, jogging, etc.). Always discuss this with your doctor beforehand, if you heven’t exercised before. An effective physical exercise is where you sweat abundantly. Choose the type of physical exercise you enjoy, so you won’t be tempted to quit.

10. Proteins. 

You need to eat at least 60-80 grams of protein per day, as food and / or supplements. Proteins are the most common substance in the human body after water. Unlike other substances, proteins can’t be stored in the body, therefore daily intake is essential. Among other things, proteins accelerate wound healing, increase metabolism to burn fats, and protect the muscles (thus helping you lose weight only from the adipose tissue).

Problems that may occur in the long run: 

  • Hair loss: 3 to 6 months after surgery; the hair regenerates afterwards. There can be can multiple reasons: surgery related stress, rapid weight loss or long-term deficient diet (protein, iron, zinc, essential fatty acids, etc.). Vitamin H supplements (Biotin) can help. Also make sure you drink plenty of fluids, eat enough protein, and check that the iron and zinc levels are good.
  • Nausea and vomiting: usually the cause is eating too fast, too much or drinking while eating. If it's not food related, call your doctor.
  • Bad taste in the mouth: it’s common right after surgery and should disappear in a few weeks.
  • Dehydration: appears if you don’t drink enough (1 liter in the first days after surgery, then increase the amount up to 2 liters). The main signs of dehydration are dizziness, headache, lethargy, nausea, coated tongue and darker urine.
  • Low appetite and change in food preferences: it’s common after surgery not to be hungry and to have a different taste in food. You need to eat to ensure a balanced nutrition and to prevent complications.
  • Gas: also commo after surgery, especially during the first few weeks. It may be a sign of lactose intolerance.
  • Excessive skin: If you lose weight, excess skin occurs, depending on many factors: how much you weight you lost, body size, age, genetic factors and even gender. There are ways to reduce the excess skin, but only plastic surgery helps you get rid of it. These methods include massage and exercise. Plastic surgery is closely linked with weight loss, so it’s advised to get your surgeon's opinion before making the decision to have one.
  • Pregnancy: most surgeons recommend to avoid pregnancy within the first 12 months after the gastric sleeve surgery. This can cause you or your baby complications and deficiencies. It’s recommended you take measures to prevent possible pregnancy (rapid weight loss increases your fertility)
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