Sleeve gastrectomy

Most commonly performed bariatric procedure

Resulting stomach is small (restrictive) and has limited capacity to make ghrelin (since most ghrelin is made in fundus)
- 70-80% restriction
- Aim 50% excess weight loss

Indications

Barrett's with dysplasia
GORD unresponsive to maximal medical therapy - should have RYGB
- Incidence GORD goes up 19% post-op
- SG worsens GORD via decreased gastric compliance, proximal gastric pouch dilation, weakened distal oesophageal contractility, disruption of the gastric sling fibres, and compromise of the phreno-oesophageal membrane
- Can still give sleeve to patients with mild GORD, on the understanding that it is likely to get a bit worse afterwards

"The first modified Delphi consensus statement on sleeve gastrectomy" for further reading

Technique

Optical 10mm entry just to left of midline midway between umbilicus and xiphoid. 10mm Palmer's point, 12mm RUQ, 5mm LUQ, 5mm for Nathanson (just trochar to make this port)
Retract liver with Nathanson
Make window into lesser sac through gastrocolic ligament, right at inferior edge of stomach, about halfway along greater curvature
Carry this division along to the angle of His, staying right on the stomach, dividing short gastrics along the way
Now also free the greater curvature back about 5cm proximal to pylorus (go to the point where the stomach starts to widen, because this will be your initial stapling point, and you want to make a nice smooth tube with consistent width)
Start stapling the stomach. Green load for first one, then blue for subsequent loads.
- Initially just keep the stomach tube a consistent length until the incisura is passed, then use bougie
- Want to make a nice straight line towards the angle of His/inferior phrenic artery once the incisura is passed
- Avoid twisting or spiralling of the gastric tube
- Preserve left gastric vessels and lesser curve blood supply
- 34-40Fr bougie placed in stomach after the incisura is reached, directed along lesser curve (Craven uses 36Fr)
  - Smaller bougie gives higher chance of GORD, and larger is associated with weight regain
Suture omentum back onto staple line with interrupted, then can use some glubran on top
Remove resected stomach via RUQ port
Don't close fascia
Monocryl to skin

Sips water 4/24 to 50ml/hr, then bariatric free fluids for 2/52 aiming 100ml/hr, then pureed for 2/52, then soft diet for 2/52, then normal diet
No routine inpatient bloods
Bariatric bloods at 6/52 clinic F/U
SOOB for all meals day 1 post-op
Enoxaparin 6/24 post
PPI 1/12
3/7 celecoxib
Unusual to need PCA - strongly consider bleeding if pain is that bad

High-pressure system with sphincters at both ends - this is why leaks and GORD are more common than with RYGB
Expected weight loss at two years = approx. 60% excess weight, 30% total weight
Not reversible, but can be converted into a RYGB or duodenal switch.
Long-term (>10) outcomes are suspiciously poorly-studied. Meta-analysis 2023 found a relatively small number of total patients between 10 and 15 years follow-up but indicated:
- Mean TWL 24%
- Remission rate T2DM 45% and HTN 41% (two studies reported 0% T2DM remission)
- De novo GORD 32%, with incidence Barrett's 0.5% (almost certainly higher in reality)
- Revision surgery 19%

Outcomes for grade 1, 2, 3, 4 in successive columns:

Management
- Principles:
  - Broad-spectrum antibiotic coverage
  - Identification and repair of the defect (if possible)
  - Irrigation and control of contamination
  - Wide drainage (usually external)
  - Enteral access for feeding
- Medical management:
  - Antibiotics
  - Resuscitation
  - Consider TPN
- Early leaks: In general, prefer to leave early leaks alone if patient is stable and unless they have four-quadrant peritonism, to allow the collection to become organised. Risk of fistula.
- Indications for operation (laparoscopic washout and drainage if possible; generally avoid definitive management; consider placement of enteral feeding access):
  - Unstable patient
  - Diffuse peritonism
  - Free gas
  - Free contrast
- Abscesses can be treated percutaneously
  - Beware of possibility of converting it into an enterocutaneous fistula
- Novel therapies:
  - Fully covered stents
    - One study showed healing rate 90% in six weeks but migration occurs in almost half
    - Not used for this indication in modern times
  - Endoscopic vacuum therapy
    - Need frequent RTT to change it
  - Internal/external drain
  - Clips
  - Could even consider converting to RYGB