Sleeve Gastrectomy: what is it and what can go wrong?

A sleeve gastrectomy, also known as a gastric sleeve, is a procedure carried out to restrict the amount of food you can consume. The procedure works by removing 70-80% of your stomach, leaving you with a stomach shaped like a sleeve or a tube.

In most instances, to qualify for a sleeve gastrectomy you must have a BMI over 40. There are however some instances when you will qualify for a sleeve gastrectomy if your BMI is between 30 and 39.9.

What should you expect during the procedure and after?

Once you have made the decision to have a sleeve gastrectomy, what happens next?

Before your surgery you should meet with your surgeon to talk through the operation. During this meeting you should have an opportunity to ask your surgeon any questions that you have about the surgery. Your surgeon should also take you through the risks and benefits of the surgery, and provide you with advice about other options both surgical and non-surgical that are open to you.

As with any operation, there is a risk of serious complications (for instance; heart failure and blood clots) and this operation is no different.

There are, however, some risks specific to sleeve gastrectomy surgery that you should be advised about during your initial consultation, including, the risk of a gastric leak.

The surgery

Due to the nature of the surgery you will be given a general anaesthetic so that you are asleep whilst the surgery is carried out. Ordinarily, sleeve gastrectomy surgery generally takes between 2 and 4 hours.

Using a small camera to guide him, your surgeon will make a number of incisions into your stomach and he will then carefully remove 70-80% it. Once all of the excess stomach has been removed you will be left with a tube or sleeve-shaped stomach (see image below).

The remaining part of your stomach will then be closed using staples or stitches. During this part of the surgery there is a risk that a small hole or gap will be left in the staple/stitch line of your new stomach. If this happens your stomach juices can escape into your abdominal cavity causing you potentially serious, and in some cases, life-threatening harm.

It is not negligent for your surgeon to leave a small hole when stapling/stitching up your new stomach as it can be difficult for surgeons to ensure that they have not left any part of your stomach open. However, it is very important that you are closely monitored following your surgery to ensure that you do not have any signs of a gastric leak.

Common signs of a stomach/gastric leak include:

  • increased/rapid heart rate
  • dizziness, shortness of breath
  • a high temperature/fever
  • worsening abdominal pain
  • left chest or shoulder pain
  • abdominal distention.

If you experience any of these symptoms after your sleeve gastrectomy surgery it is very important that investigations are conducted quickly to work out whether you have developed a gastric leak.

If your doctor thinks you may have a leak they must arrange for you to be taken back to theatre for the leak to be closed. Timing is imperative in both identifying and treating a gastric leak. Surgery to repair a gastric leak must be carried out as early as possible to avoid serious and potentially life-threatening complications.

We spoke to a consultant surgeon who specialises in bariatric surgery, Mr. Abeezar Sarela, about what patients should expect and what can go wrong:

“The sleeve gastrectomy is generally very safe but, as with any operation, complications can occur. One feared complication is leakage, often simply called a ‘leak’, when the staples have not formed a water-tight seal and stomach juices have leaked out from within the sleeve gastrectomy.

Leakage causes inflammation of the inner lining of the abdomen, called peritonitis, the intensity of which can be variable. In some people, peritonitis is severe and it becomes apparent within a few days after the operation. Starting with intense abdominal pain, it may be accompanied by signs of sepsis: fever, fast heart rate, and a general feeling of being quite unwell.

Sometimes leakage can be ‘silent’ though, and may not come to light for weeks or even months after the operation. In such cases of ‘delayed’ leakage, it is believed that it must have started soon after the operation, but did not immediately produce symptoms because the leakage was only small and the body’s natural defence mechanisms were able to cope with it for some time.

Why does leakage occur? Very simply, body tissues are not guaranteed to heal. Whenever the stomach is stapled, in a sleeve gastrectomy or any other operation, there is always a risk that leakage can occur. As such, occurrence of leakage, in and of itself, does not necessarily mean that the surgeon did not perform the operation with appropriate care and skill.

Surgical skill is, of course, critical. The stapler is simply an instrument, and, as with any instrument, it will work only as well as the hand, and the mind, that uses it. There are various technical surgical manoeuvres that can be adopted to reduce the chance of leakage. These manoeuvres, however, are at most “nuances”, rather than distinct surgical steps that can be articulated and described in a written operation record.”

When may negligence occur with a sleeve gastrectomy?

We also asked Mr Sarela what information people might need to know if the operation did result in leakage and when these might show negligence has occurred:

“Much emphasis is placed only whether, or not, the surgeon did a ‘leak test’ during the operation, by insufflating air and a coloured solution into the sleeve and observing for leakage. There is, in fact, very little to support the value of a leak test. So if one was not done, and leakage did occur post-operatively, it would be hard to allege that performance of a leak test would have avoided leakage.

Some surgeons re-inforce or ‘buttress’ the staple line with synthetic material, or place sutures over the staple line. There is some evidence that reinforcement of the staple line reduces the incidence of leakage, but the evidence is weak and some surgeons do not use any reinforcement. So, if a surgeon does not use reinforcement, it will be difficult to claim not only that the surgeon should have done so but also that reinforcement is likely to have prevented leakage.

Instead, clinical negligence in cases of leakage after sleeve gastrectomy usually rests on failures to suspect, detect and treat leakage in an appropriate or timely manner. Most surgeons will not routinely do any x-rays or blood tests post-operatively as the occurrence of leakage is rare (about 1% of operations); it simply does not make sense to do them. Moreover, tests are exceedingly unlikely to show any abnormality unless the patient is somehow unwell, say, with severe pain or fever.

On the other hand, if a patient does have unexpectedly severe pain, fever, fast heart rate or some other issue of concern, then leakage should be suspected. In such a case, blood tests should be done promptly, and followed quickly by a CT scan. Most people will stay in hospital overnight after a sleeve gastrectomy operation. If they display any symptoms of concern, they should not be discharged.

Patients who are discharged should be warned about delayed leakage, and advised to get in touch with the hospital immediately in case of any signs of delayed leakage. If a patient reports symptoms of concern for leakage, then she or he should be advised to return to hospital immediately. In case of leakage, it is critical to act promptly, and serious problems are likely to be avoided to timely and appropriate action is taken.”

What you should expect to happen after Sleeve Gastrectomy

Providing your surgery goes well your new, smaller stomach will hold approximately 200ml; this means the amount of food that you will be able to eat will be much smaller which will induce weight loss. In addition, as your stomach is much smaller after the surgery it will not secrete as many hunger-causing hormones meaning that you will feel less hungry.

After the surgery some patients develop what is called ‘a stomach stricture’. A stomach stricture forms when the opening to or from your stomach becomes constricted preventing some or all of the food you have eaten from properly entering your stomach and/or intestines. Some of the symptoms of a stricture include; nausea/vomiting, difficulty swallowing and food intolerance.

If you develop a stricture the treatment that you receive will depend on how long the stricture is. If the stricture is picked up quickly after surgery it can often be treated with rest, intravenous fluids and you being placed nil-by-mouth. If it is diagnosed sometime later the treatment will depend on the length of the stricture. If your stricture is short it can often be treated by endoscopic dilation. For longer strictures, surgical intervention is sometimes necessary.

After surgery you will be returned to the ward for observation. You will usually remain in hospital for a couple of days so that you can be monitored.

If all of your observations are within the normal, expected range, you will be discharged home where you will spend around 3 weeks recovering from the surgery. You should be told before you go home what you should and should not eat and what medication (if any) you will need to take.

What will my diet be like after Sleeve Gastrectomy surgery?

Shortly after the surgery you will be able to start drinking small amounts of clear fluids. You will usually remain on a fluid only diet for a couple of weeks after the surgery. After a couple of weeks you will be able to begin slowly building up your food intake by eating pureed foods. Around four weeks after the surgery most people are able to progress to a normal diet.

You should be given information about how best to manage your food intake when you are in hospital.

Will I need to take vitamin and mineral supplements after the surgery?

Yes, you will need to take daily vitamin and mineral supplements for the rest of your life after the surgery. This is to ensure that your body is getting the nutrients it needs. You will be advised about this by your healthcare team before you leave the hospital after your surgery.

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