During operation of sleeve gastrectomy, the large side of stomach is removed and a stomach tube having a volume of 100 to 150 ml is formed. In this procedure, there are two mechanisms providing weight loss;
1- Restrictive Effect: Weight loss due to a mechanical restriction with shrinkage of stomach volume and decrease of stomach movements.
2- Endocrine Effect: GHRELIN hormone, which is described as hunger hormone and secreted from the removed stomach, provides feeling of satiety by reducing hormone level. Ghrelin is a peptide protein produced by the cells on the upper part of stomach called fundus. It is a strong stimulant for the appetite enhancer region on brain. During sleeve gastrectomy operation, since the fundus part of stomach producing ghrelin is removed, the appetite decreases and contributes to weight loss. Because this procedure is a restrictive process of stomach volume, there will be no problem on the absorption of nutrients in the intestine. However, for the absorption of some vitamins they need an acid secreted from the stomach parietal cells. Therefore the patients have to take iron and B12 vitamin supplementation after surgery.
What are the risks of sleeve gastrectomy?
Very low rate of complications such as bleeding, organ injury, respiratory problems are available here as in all operations. The special complication for the sleeve gastrectomy is leakages from the part of stomach which was cut and sutured (stapler line) and sometimes a second intervention may be needed.
What are the results of weight loss due to sleeve gastrectomy?
It is possible that patients who underwent sleeve gastrectomy operation can lose 65-70 percent of their excess weight over a period of 1-2 years. There are studies showing that excess weight which is lost in 3 years is close to weight which is lost after gastric bypass surgery.
WhaIs the success guaranteed after sleeve gastrectomy? Is there a possibility to get weight again?
After sleeve gastrectomy, if stomach tube expands over time, gaining weight may be seen. The main effect of sleeve gastrectomy is restrictive effect; that means reduction of food intake. However, its effect may decrease in the case of feeding with liquid and high calorie foods. Normally it is possible to lose 65-70 percent of excess weight in the first 1-2 years. Still, if the eating habits can not be regulated after the third year, 5-25 percent of weight gain can be seen again. In this case, it is possible to change to another obesity operation such as gastric bypass surgery or BPD/DS. This second interference can also be done as laparoscopic.
In this operation, first stomach volume is reduced and thus the amount of food that patient can receive is decreased. Secondly, because the pathway in small intestine is shortened, absorption of food is decreased. Gastric bypass not only reduces stomach volume but also affects the absorption of food, this means foods are thrown away from the body before they are beneficial.
What are the types of gastric bypass (GB)?
There are two types of GB operation frequently applied in the world.
1- Roux en-Y Gastric Bypass (RYGB)
2- Mini Gastric Bypass
What is the Roux en-Y Gastric Bypass operation (RYGB)?
TRYGB operation shows effect in two ways:
1- The food intake is decreased by reducing stomach volume (stomach volume is approximately about 25-30 cc).
2- Absorption of the food eaten is restricted since large part of the stomach, duodenum and initial portion of small intestine are deactivated (bypass).
Normally, food comes directly stomach from esophagus and goes to duodenum by passing over there. After that, they travel through small intestine to large intestine and excretion occurs. In the RYGB application, the stomach is cut and stitched with special tools called stapler from the marked place to form a new small upper stomach pouch with approximately 25-30 cc.
Patients lose 65-80 percent of their excess weight an average within 18-24 months, postoperatively. Also, after the operation, the adaptation process is easier for the new feeding habit.
The most important limitation of this operation is that lack of some vitamins and minerals may occur in the following days because of impairment of absorption in food taken (such as vitamin B12, folic acid, iron deficiency, calcium and vitamin D deficiency). This new small stomach is about 5-10 percent of the old stomach, so the amount of food taken is greatly reduced. Following the food intake, foods come to small stomach from esophagus and then they directly pass to small intestine (they are not found in large stomach, duodenum and the initial part of small intestine). Thus all foods travel directly to small intestine without being absorbed because they do not stop by this area that is responsible for the absorption digestive system.
Besides, secretions (gastric fluid, liver bile, pancreatic liquid and duodenum enzymes) secreted from the deactivated regions switch to common pathway by mingling with nutrients from the site of connection to the small intestine.
What is Mini Gastric Bypass (MGB) operation?
The weight loss mechanism in MGB is just like in RYGB. However there are some technical differences in terms of the operation. The most important advantage of MGB is explained as technically easier to implement and its operation time is shorter.
Anti-diabetic Effects of Gastric Bypass
Mechanisms to explain weight loss and improved glucose tolerance after gastric bypass;
- ● Stomach volume decrease and leading to early satiety, small food portions and negative conditioning
- ● Due to mechanism which can not be defined exactly, ghrelin secretion disruption and upper intestinal bypass creating to mild bad absorption
- ● Increasing of PYY hormone release and accelerating access of food to the lower intestine
- ● Owing to taking concentrated carbohydrates, the formation of dumping syndrome contributes to weight loss in some individuals
Gastric balloon is an increasingly popular practice in recent years. The most important advantage of this application is that it can be performed endoscopically without requiring general anesthesia. Internal volume of gastric balloon is resistant to inflation with 400-700 cc liquid or air. Thus, since stomach volume decrease, intake of excess food is prevented.
GEstimated application time is 10-20 minute. The patient does not need to stay in the hospital, after the procedure the patient can be discharged with 3-4 hours of surveillance and intravenous serum application.
After application, especially in first 48 hours, nausea, vomiting and cramp-like pain can be observed. Medical treatment is applied to relieve such disturbances. These complaints are temporary and approximately after 1 week, the patient will be quite relieved.
The application of gastric balloon is a non-surgical treatment. It is an especially suitable for patients who do not consider surgical treatment but can not lose enough weight with diet and exercise. This application is limited in terms of time. The duration of the gastric balloon to stay at stomach is max. 180 days (6 months). After this time, gastric balloon has to be removed. The removal is done endoscopically and patient can return to normal activation after 2 hourseved.
During this time, patients may lose 30-45 percent of their excess weight. Success in losing weight is closely related to patient harmony. After the application, calorie restriction for the patients is recommended (1000-2000 kcal/day). This restriction can be applied easily, because much food intake can not be possible depending on application.
If it is desired that the gastric balloon is to remain longer than 180 days, it should be placed in the stomach by necessarily changing with a new one. Those who consider this application need to aim to changing their eating habits within 6 months.
Complication depending on gastric balloon application is very rare. In literature, balloon rejection and very rare balloon puncture have been reported in some patients. In such case, balloon must be removed endoscopically.
Gastric balloon is an easy to apply method that can be recommended for obese patients who do not consider surgical treatment and who hesitate for such surgical procedures. However, patients must strive to change their eating habits in order to ensure long-term weight loss with this method.
Who can be applied gastric balloon?
- ● 18-65 years (Under the age of 18 and over 65 applications can be done by experienced centers)
- ● Body Mass Index (BMI) bigger than 30 kg / m2 or BMI 27-30 kg / m2 with accompanying diseases (Hypertension, ischemic heart disease, type 2 diabetes, sleep apnea, joint disorders)
- ● Highly morbid obese patients at high risk for obesity surgery (BMI bigger than 50 kg / m2)
- ● Before the obesity surgery (tube stomach or gastric bypass) in order to prepare the operation
Who can not be applied gastric balloon?
- ● Stomach ulcer (active-hemorrhagic)
- ● Wound presence in esophagus (Grade III-IV)
- ● Large hiatal hernia (greater than 5 cm)
- ● Esophagus and stomach anomaly
- ● Pregnancy
- ● Aspirin and blood thinner usage (should be stopped at least 1 week before application)
The gastric balloon application procedure
All patients are required to stay hungry 6 hours before application and medication relief is provided intravenously for patients before the application. It is very important to apply gastric balloon in hospital condition and with the anesthesiologist. EKG, O2 saturation and blood pressure should be followed-up by monitoring all patients.
Before placement of gastric balloon, esophagus and stomach structure is evaluated by doing gastroscopy. If there is no obstacle for practice, by lubricating with a jelly gastric balloon is pushed from esophagus to stomach. By drawing the vacuum system on the inflated balloon, the balloon is released in the stomach and the process is completed. Approximately time for the gastric balloon application is 10-20 min. after the application the patient is taken to the room and monitored for 3-4 hours by applying serum and medicine intravenously then can be discharged.
Sedation Anesthesia of Gastric Balloon Application
The patient must be comfortable and fit in order to perform this procedure. This group of patients generally has high levels of anxiety, anxious about how to end the procedure and during the procedure they are in a nervous mood due to the thought that if they may feel venture or not. A type of sleep called sedation is ideal anesthesia for this intervention. The quality of the sedation-anesthesia application during this short intervention not only makes the procedure more convenient but also allows the procedure to finish without patient being aware of anything. Before the process, the patient should be hungry for 6 hours.
The entire process is performed in the hospital-equipped endoscopy unit under the most secure conditions. During the procedure, the patient is in a deep sleep and feels almost nothing. In our case experience of over 700, when the patients were asked if they remember anything after application and removal, they stated that they did not. The entire application period is 10-20 min on average.
Patients are discharged with suggestions after being observed for 3-4 hours at hospital. Removal of the gastric balloon is also performed by sedation-anesthesia in the same way. After the balloon is removed, the patients are discharged after being kept under surveillance for 1 hour.
In such applications sedation-anesthesia is a very ideal and safe method. However, be aware that such drowsiness procedures should not be performed without an anesthesiologist and a fully equipped endoscopy unit environment because the sudden distribution of medicines that provide anesthesia and drowsiness in obese people varies due to their fat mass ratios being high. In order to keep safety of patient at the highest level, rules should be followed carefully.
Revision surgery is the area of bariatric surgery that requires the most experience for it. Today, it constitutes about 5-10% of bariatric surgery applications around the world.
When referring to revision bariatric surgery, two basic concepts need to be known;
1- Revisional Bariatric Surgery
Post-surgery that does not result in adequate weight loss or results in weight gain;
- ● Weight loss is under 50% EWL (excess weight loss percentage)
- ● Gaining weight more than 15% of his last lost weight
- ● Recurrence of comorbid diseases
2- Re-Operative Bariatric Surgery
- ● Surgery for the complications of bariatric surgery
Evaluation of unsuccessful patient
Did the patient render the operation failed or did the operation render the patient failed? Or did the program render the patient failed? Revisional bariatric surgery decisions should be made after the answers for all these questions are meticulously assessed. These;
- ● Taking a detailed anamnesis from a patient by a doctor, psychiatrist and dietitian
- ● To review stress factors and medical treatments
- ● Close monitoring
- ● Supporting groups
- ● Upper gastrointestinal (GI) endoscopy
- ● Upper GI barium swallow tests
- ● To review operational notes
Which Patients Are Not Suited for Revisional Surgery?
Some patients applying for revision surgery should be rejected and appropriate conditions should be waited if they include;
- ● Drug users
- ● Those who have reflux and have not received medical treatment
- ● Those who have maladaptive feed
- ● SPatients who do not want to get vitamin and nutritional support
SurgeryRobotic Bariatric Surgery
Bariatric surgeries are commonly performed laparoscopically (closed surgery) all over the world. The Da Vinci Surgical robot considerably eases the difficulties experienced in laparoscopic surgery. The most important feature of the robot is that it provides three dimensional high resolution images and it is designed to allow hand movements of surgical instruments. The surgeon performs operations by sitting comfortably. Robotic surgery has great advantages in morbidly obese patients and those who have had surgery before. With this method, in which the hand-shake is removed electronically, a more stable and clear image is gotten. Especially developed in recent and selectively applied with a single hole robotic surgery will be able to make without a trace in also obese patients.
What are The Advantages of Robotic Surgery?
- ● Much less pain after surgery due to less traumatic approach to skin and muscles
- ● Significantly fewer risk of infection owing to minimal contact of the intraabdominal organs with air in the operating room compared to open surgery
- ● The three-dimensional and magnified image provides better visualization and preservation of veins and nerves. For example, blood loss is much less during robotic operations.
- ● 1-1.5 cm cuts with less scratches leave much less traces than 20-25 cm cuts in open surgery
- ● After the operation, get up earlier and oral feeding allow the patient to get better more quickly
- ● Most of the patients who underwent robotic obesity surgery are discharged on the 2nd or 3rd day
- ● Returning to work and daily life more quickly
What Obesity Surgies is Performed with Da Vinci Robot?
- ● Robotic Sleeve Gastrectomy
- ● Robotic Gastric Bypass (Roux en Y and Mini bypass)
- ● Robotic Duedonal Switch
- ● Robotic Revisional Surgery