Which is right for you?
WHAT DOES SLEEVE GASTRECTOMY MEAN?
This keyhole operation is done to surgically remove a large portion of the stomach using a stapler gun, leaving behind a sleeve of stomach which restricts the amount of food that can be eaten before you feel full.The stomach sleeve is accurately sized by a tube which is passed down through the mouth. It is a restrictive procedure which does not require long term follow up or adjustment and weight loss starts soon after the procedure.
MECHANISM OF ACTION
Due to loss of the large stomach capacity and the formation of a long “sleeve” of stomach, an individual is restricted in the amount of food intake. This mechanism is similar to the band, however there is no band to adjust and it is a permanent operation. Weight loss is triggered by the surgery, slows down after several months and stabilizes at 18-24 months. As there is no reduction in absorption, multi-vitamins are advisable however not entirely essential.
ROLE OF SLEEVE GASTRECTOMY
Its role is considered to be half-way between a band and a bypass. Whilst the weight loss effect is considerable and sustained, it is also a permanent operation with limited risks and almost negligible nutritional maintenance. Frequent follow up for adjustment is not required and the operation takes approximately 1 hour to perform.
All being well, 2 nights stay in hospital is usually followed by discharge with anti-acids and blood thinners for 5 days. Most individuals return to work 2-3 weeks later. Follow up is essential, as with all these procedures, and is mainly limited to an assessment of weight loss and any possible nutritional deficiencies, although this is uncommon.
As with any surgery, risks such as bleeding, infection and clots forming in leg veins or travelling up to the lungs are possible. With this operation, the main risk, albeit small, is leakage from the staples used to create the long stomach “sleeve”. If this occurs, although uncommon, it is usually in the first 2 days following surgery and a return to surgery is essential to deal with the problem.
HOW DOES A GASTRIC BAND WORK?
A gastric band is formed of 3 components; a silicone ring, and tubing attaching the ring to a port.The ring is placed at the top of the stomach just below the gullet through keyhole surgery and locked into place. The tubing travels internally to the port which is placed just beneath the skin on top of the muscle of the tummy wall. This does not bulge, however can be felt through the skin to allow injection of solution into the port which tightens the ring creating an hour-glass effect on the stomach. The much smaller pouch above the ring quickly fills with food, restricting your ability to have any more and giving a sensation of fullness.
MECHANISM OF ACTION
As depicted in the video above, the band works by creating an hour-glass effect on the top part of the stomach, slowing food passing through to a trickle. This physical impediment allows an individual to feel fullness very soon after having a mouth-full or two of their meal. A slight sensation of nausea can develop if the pouch above the band is not allowed to empty before having any further mouth-fulls.
TYPES OF GASTRIC BAND
There are numerous commercial manufacturers of gastric bands. However, the market is dominated by one or two manufacturers who have developed their products to enhance patient safety, decrease the complication rate and make the procedure technically easier. WLSKent use Ethicon SAGB bands. The total fill volume of this band ranges from 8-11 mls of saline, however each individual is unique and so is their ideal fill volume. Bands have been licensed to be used at a lower BMI of 30 by the FDA.
Bands can be filled either in clinic or under X-ray guidance. The simplest method is a clinical fill, which is routinely performed in the outpatient department as part of the regular 8-12 weekly follow up. An injection into the port, which lies just underneath the skin, will travel in the band tubing to the ring surrounding the top of the stomach, tightening it. Sipping some water will then ensure that the band is not too tight.
As with all surgery, risks such as bleeding, infection and clots forming in the leg veins or travelling to the lungs are possible. There is a small chance of infection or leakage of the band tubing, or a slippage or erosion of the band ring. The port can sometimes flip to lie on one side or upside down, however this risk is minimized by the usage of new port stapling technologies. If any of these minor risks occur, then a further operation to change components or fix the defect may be required. These occurrences are normally covered within the surgery package for a period of time. For this and other reasons, it is not advisable to have a band fitted overseas.
WHAT DOES A GASTRIC BYPASS MEAN?
A keyhole bypass operation means that a small pouch of stomach is created by stapler guns leaving the remaining detached stomach internally. This pouch is then connected surgically to a length of diverted bowel to impair food absorption. So a combination of restriction and decreased absorption is achieved. This operation has become the most common weight loss procedure in some countries due to its effectiveness and long term success. Nutritional supplements are required following surgery.
MECHANISM OF ACTION
As depicted in the video above, a bypass procedure has several mechanisms of action. The first is restriction, achieved by creating a small pouch of stomach which limits the amount of food that can be eaten. This pouch is then connected to a diverted segment of bowel. This limits the absorption of food from two parts of the bowel (blue and yellow on video), whereby absorption is facilitated only when both colours mix together further down (green). Weight loss is triggered from the day of surgery, will slow down after several months and plateaus at 18-24 months after surgery.
Furthermore, this procedure has been shown to alter the chemical signals arising from the bowel to help reduce food craving and increase the sensation of early fullness.
Out of the 4 common interventions, bypass has the greatest and most sustained weight loss effect. It is a bigger operation, with limited risks and will require intake of a multi-vitamin tablet on a daily basis. Follow up is essential, as with all these procedures, and is mostly limited to checking levels of minerals and vitamins in the blood on a regular basis for top-ups if necessary.
The whole procedure is performed through keyhole surgery and usually takes 2 hours to perform. All being well, individuals are discharged with anti-acids and 5 days of blood thinner, following a 2 night stay in hospital. Most individuals are able to return to work 2-3 weeks later and will mostly remain on a soft, mashed diet for a few weeks prior to building up their diet.
As with all the procedures, the recommendation is to eat slowly and chew food well.
As with any surgery, the possible complications are bleeding, infection or clots forming in leg veins or moving to the lungs. With this surgery, albeit small, the main risk is leakage from the joins (see video) between bowels and stomach. If it does happen, it occurs in the first 2 days, and a return to surgery is required to deal with the problem. Other minor risks, such as hernia formation are much less common.
HOW DOES A GASTRIC BALLOON WORK?
Similar to a band it restricts the amount of food eaten by occupying the space inside the stomach. It is a rugby-ball sized balloon which is inserted by endoscopy into the stomach and filled with fluid. It can be left internally for 6 months and then removed endoscopically following this period of time.
As depicted in the video above, balloon insertion is an endoscopic procedure. Firstly an endoscope is passed through the gullet into the stomach to check that there are no medical contraindications such as severe inflammation or a large hiatus hernia. The deflated balloon is then passed through and inflated with liquid coloured with blue dye. A final check with an endoscope is done prior to detaching the balloon to lie free within the stomach.
This is a very simple, non-invasive procedure which carries the same minor risks of an endoscopy and can be performed under sedation without the need for an anaesthetic. There is a very rare theoretical risk of balloon rupture, which would lead to the blue dye escaping and colouring urine blue/green. If this occurs, the ruptured balloon is removed endoscopically.
The balloon most commonly used is the Allergan Orbera™ System which is designed to remain within the stomach for 6 months after which it has to be removed. It is a very good option for those motivated to return to their usual dietary and exercise patterns prior to their weight gain. It is also used as a staged approach for individuals with a high BMI to allow weight loss and a reduction of their risk prior to considering a more permanent weight loss operation.
Because of the space occupying effect within the stomach, it is very difficult to have any solids in the first 1-2 weeks following surgery. Liquid however is very important, and individuals are encouraged to drink copious amounts of fluid only for the first few days following insertion. It is not uncommon to feel slightly nauseous in the first few days post-insertion.