Laparoscopic Sleeve Gastrectomy (LSG)

In this procedure around 75% of the stomach is removed and the stomach is converted into a narrow tube. This is done by multiple applications of a surgical stapler which staples and cuts at the same time.

How does LSG work?

The LSG works through restriction of the amount of food that can be consumed, as the stomach is now a narrow tube and cannot accommodate food. The tube fills up rapidly and the patient then feels full and cannot eat any more.

However, research has also revealed that there are more complex and interesting ways in which the operation leads to weight loss. These include rapid entry to food into the bowel which changes the hormones produced by different parts of the bowel. The hormones play a role in influencing appetite and metabolism of sugars and fats.

How is the LSG performed?

The operation is done by keyhole surgery. This procedure is always performed under general anaesthesia. The procedure takes between 45 mins to an hour.

What are the advantages of LSG over other procedures?

• Quicker to perform and less complex as compared to gastric bypass.
• No foreign body (unlike a gastric band) in the body and no need for multiple visits to the clinic or hospital for adjustments.
• As effective in terms of weight loss as a gastric bypass in the short term.
• Can be followed by a gastric bypass or a duodenal switch if weight loss is not satisfactory.

What are the side effects of LSG?

The risk of any serious complications is less than 1%.

There are some complications which occur as side effects of any procedure under general anaesthesia. These are thrombosis of the legs and the lungs, pneumonia, heart attacks etc. Fortunately with safe anaesthesia these are quite rare nowadays. They occur more commonly in people who already have existing heart or lung diseases.

Other complications specific to the operation

• Leakage: there could be leakage from the long staple line. Various methods are used to detect a leak as soon as possible. Post-operative observations such as heart rate, temperature and blood tests can indicate a leak. Once discharged patients are advised to look out for increasing pain, temperature and general feeling of being unwell. Leaks generally close by themselves. However, in some cases repeat surgery maybe required to close the leakage.
• Bleeding: bleeding from the staple line can occur especially in patients who have high blood pressure after surgery. Most bleeding will thus stop with control of blood pressure with medications. However, in some cases repeat surgery maybe required to apply clips over the staple line.
• Narrowing of the tube: with time the tube could narrow due to scarring. This usually causes difficulty in swallowing with a sensation that the food is stuck. This can be resolved with endoscopy and a balloon to open up the narrowing but surgery may be required.
• Acid reflux: The operation can have two effects on acid reflux. In those with pre-existing reflux, the surgery and resulting weight loss may improve this or the operation can make existing acid reflux worse and may cause this in patients who did not suffer from reflux before the surgery. This is treated by taking anti- acid medication. Rarely, if it is severe, surgery may be required to convert to a gastric bypass.

Other side effects of LSG

• You will lose your appetite and may not feel very hungry.
• You will be unable to eat large meals after the surgery.
• You may experience some diarrhoea which can be controlled with medications.
• Eating and drinking food substances rich in sugar may result in a condition called 'dumping'. This is an uncommon side effect which is due to the sudden rush of sugars (carbohydrates) in the food into the bowel. This produces a surge in the blood insulin which then reduces the sugars in your blood. You can experience light-headedness, sweating and nausea. This is controlled by reducing the sugars in your food, eating slowly, chewing really well and drinking water after meals and not with meals.

Pre-operative advice

• You will be seen by a dietician and asked to undertake a 2-4 week low caloric diet. This is to shrink the size of the liver which needs to be kept away from the area of surgery. If the liver is too large it will be difficult to perform the surgery. Therefore, it is essential that you follow the diet strictly.
• You should go for short walks everyday to make your heart and lungs stronger. You will be taught deep breathing exercises which you must do every three times every hour to help clear your lungs. You will need to do these after the surgery so it is better to get used to these exercises before you come for the surgery.

Post-operative care

Day of surgery

• After the operation you will remain in the recovery area of the operating theatre for 1-2 hours. Following that you will be transferred to the ward.
• You should try to get up and go for a walk (visiting a toilet is a good reason for this short walk) aided by a nurse.
• You can drink small sips of water on the night of the surgery.
• Please ask the nurses for painkillers and anti-sickness medication. You may feel nauseous and in some discomfort but we don't want you to be in pain and retch.

1st day after surgery

• You can start on clear fluids and progress to soup etc for supper. Some of the medications will be changed to tablets. Intravenous fluids maybe stopped and the needle is your arm maybe removed if you are drinking adequate amount is fluid.
• Blood tests will be performed.
• You should sit out in a chair and walk around as much as possible
• Deep breathing exercises are good to keep the lungs open.

2nd day after surgery

• You should be able to go home.
• You should get someone to pick you up from hospital and not drive a car yourself. It is also best to avoid public transport at busy times.

Other post-operative advice

• You must walk as soon as you can after your surgery. Once you have recovered from the anaesthesia, you will be requested to go for short walks. This also reduced the risk of clots but also helps in breathing and moving more oxygen into your lungs.
• You must do deep breathing exercises regularly (3 times an hour) to prevent any lung problems
• You must avoid smoking after surgery.

Drinking and eating after a band

• You will be on fluids for the first week
• Then on pureed diet for 10-14 days
• Soft diet (fork mashable food) for weeks 3-8 weeks
• 2 months after surgery you can start having a regular diet.

It is very important to appreciate that a sleeve is successful if you follow this advice.

• Eat slowly: Every meal must take at least half an hour.
• Chew your food well: You must chew every mouthful at least 20 times.
• Eat small amounts often.
• Must avoid sugary and high caloric foods.
• Try to separate the solid component of your meal from the liquid component. That is drink water around half an hour after a meal and not with the meal.

Follow-up after surgery

• You will be seen by the surgeon 2 weeks and 6 weeks after surgery.
• After that you will be seen at 3 months, 6 months and a year after surgery.

Laparoscopic Roux-en-Y Gastric Bypass (LRYGB)

The procedure consists of the creation of small stomach pouch which is disconnected from the rest of the stomach with multiple applications of a surgical stapler which staples and cuts at the same time. 50-75 cm of small intestine is measured and the bowel is divided at this point with a stapler. One end is called the alimentary end and the other one is called the bilio-pancreatic (BP) end. The alimentary end is brought up and a join is created between the alimentary end and the stomach pouch. A further 75-120 cm of small intestine is measured from the join and another join is created between this point and the BP end.

How does LRYGB work?

There are two ways in which the operation works- restriction and malabsorption

(a) Restriction: The small pouch leads to restriction in eating as the patient feels full as soon as the pouch fills up.

(b) Malabsorption: The 50-75 cm of small bowel (called the BP limb) and the 75-120 cm of small bowel called the alimentary limb would normally have been involved in the digestion and absorption of fats and carbohydrates. However, as a result of the operation, the BP limb only consists of the digestive juices and the alimentary limb only serves as a food channel. The two meet at the lower join and the digestion and absorption occurs in the part of the small bowel called the common channel. Thus around 125-175 cm of small bowel that would have been involved in absorption, does not perform this function, leading to weight loss

However, research has also revealed that there are more complex and interesting ways in which the operation leads to weight loss as well as the dramatic effect of the operation on diabetes. These include changes to the hormones produced by different parts of the bowel which influence appetite and metabolism of sugars and fats.

How is the LRYGB performed?

The operation is done by key hole (laparoscopic) surgery. This procedure is always performed under general anaesthesia. The procedure takes between one to two hours.

What are the advantages of LRYGB over other procedures?

• More effective in terms of weight loss as compared to band and sleeve gastrectomy
• Helps in the treatment of diabetes within weeks of surgery, regardless of weight loss
• Rapid weight loss (most weight lost by 18 months) as compared to band (2-3 years) and sleeve (2-3 years)

What are the side effects of LRYGB?

Even though LRYGB is a complex procedure, which should be performed only by trained and experienced surgeons, the complication rate is still quite low. The risk of complications is less than 5% and the risk of dying is 2-3 in a 1000.

There are some complications which occur as side effects of any procedure under general anaesthesia. These are thrombosis of the legs and the lungs, pneumonia, heart attacks etc. Fortunately with safe anaesthesia these are quite rare nowadays. They occur more commonly in people who already have existing heart or lung diseases.

Other complications specific to the operation

• Leakage: there could be leakage from one of the two joins. The join between the bowel and the stomach pouch is more likely to leak than the other one. Various methods are used to detect a leak as soon as possible. A test is performed during the operation itself to ensure that the join is secure. In addition, a drain is left in the abdomen near the join. The patient is asked to drink some blue dye on the day after surgery. Presence of the dye in the drain would indicate a leak. If there is no blue dye in the drain and there is still a suspicion of a leak, an x-ray or CT scan with dye can be done to check for leaks. Leaks generally close by themselves. However, in some cases repeat surgery maybe required to close the leakage.
• Bleeding: bleeding from the staple line can occur especially in patients who have high blood pressure after surgery. Most bleeding will thus stop with control of blood pressure with medications. However, in some cases repeat surgery maybe required to apply clips over the staple line.
• Internal hernias: When the bowel is moved around inside the abdomen, there is a potential to create pockets inside the abdomen into which bowel can get stuck. This can occur from days to years after the surgery. The patient experiences abdominal pain with associated vomiting. X-rays and CT scans maybe required but repeat laparoscopy is usually needed to detect and fix the internal hernia.
• Bowel blockage: This could be due to internal hernias or due to scar tissue (adhesions) from the operation. The patient experiences abdominal pain, bloating, vomiting and constipation. X-rays and CT scans maybe required but usually surgery maybe required to divide the scar tissue or repair the hernia depending on the cause.
• Ulcers: these occur at the join between the stomach pouch and the bowel and are called stomal or marginal ulcers. They occur more commonly in smokers, in patients who take painkillers such as ibuprofen and in patient with other risk factors. These are prevented and easily treated with acid reducing medication. Rarely these ulcers can rupture and cause infection inside the abdomen for which emergency surgery is required.

Other side effects of LRYGB

• You will lose your appetite and may not feel very hungry.
• You will be unable to eat large meals after the surgery.
• You may experience some diarrhoea which can be controlled with medications.
• Eating and drinking food substances rich in sugar may result in a condition called 'dumping'. This is an uncommon side effect which is due to the sudden rush of sugars (carbohydrates) in the food into the bowel. This produces a surge in the blood insulin which then reduces the sugars in your blood. You can experience light-headedness, sweating and nausea. This is controlled by reducing the sugars in your food, eating slowly, chewing really well and drinking water after meals and not with meals.
• Rarely some patients experience chronic abdominal pain which is difficult to explain.
• Rarely, some patients may experience hair loss. This is usually temporary and maybe related to nutritional deficiencies.

Pre-operative advice

• You will be seen by a dietician and asked to undertake a 2-4 week low caloric diet. This is to shrink the size of the liver which needs to be kept away from the area of surgery. If the liver is too large it will be difficult to perform the surgery. Therefore, it is essential that you follow the diet strictly.
• You should go for short walks everyday to make your heart and lungs stronger. You will be taught deep breathing exercises which you must do every three times every hour to help clear your lungs. You will need to do these after the surgery so it is better to get used to these exercises before you come for the surgery.

Post-operative care

Day of surgery

• After the operation you will remain in the recovery area of the operating theatre for 1-2 hours. Following that you will be transferred to the ward.
• You should try to get up and go for a walk (visiting a toilet is a good reason for this short walk) aided by a nurse.
• You should not drink any water or fluids on the night of the surgery, though you will be given special sponge 'lollipops' to keep your mouth wet.
• Please ask the nurses for painkillers and anti-sickness medication. You may feel nauseous and in some discomfort but we don't want you to be in pain and retch.

1st day after surgery

• You will be asked to drink blue dye on the morning of surgery. If this does not come out in the drain, then a leak is unlikely and you can start drinking fluids. Start with water, and gradually progress to some beverages and fruit juices. If these cause no problems you can have some soup/ ice cream/ jelly etc for supper. Some of the medications will be changed to tablets. Intravenous fluids maybe stopped and the needle is your arm maybe removed if you are drinking adequate amount is fluid.
• The drain maybe removed if there is not much fluid draining out.
• Blood tests will be performed.

2nd day after surgery

• You should be able to go home.
• You should get someone to pick you up from hospital and not drive a car yourself. It is also best to avoid public transport at busy times.

Other post-operative advice

• You must walk as soon as you can after your surgery. Once you have recovered from the anaesthesia, you will be requested to go for short walks. This also reduced the risk of clots but also helps in breathing and moving more oxygen into your lungs.
• You must do deep breathing exercises regularly (3 times an hour) to prevent any lung problems
• You must avoid smoking after surgery. This increases the risk of developing an ulcer between the stomach and the bowel.
• You must avoid taking painkillers such as brufen. They increase acid secretion and can cause ulcers at the join between the stomach pouch and bowel.

Drinking and eating after a bypass

• You will be on fluids for the first week.
• Then on pureed diet for 3 weeks.
• Soft diet (fork mashable food) for weeks 5-12 weeks.
• 3 months after surgery you can start having a regular diet.

It is very important to appreciate that a bypass is successful if you follow the advice given to you by your surgeon.

• Eat slowly: Every meal must take at least half an hour.
• Chew your food well: You must chew every mouthful at least 20 times.
• Eat small amounts often.
• Must avoid sugary and high caloric foods.
• Try to separate the solid component of your meal from the liquid component. That is drink water around half an hour after a meal and not with the meal.

Follow-up after surgery

• You will be seen by the surgeon 2 weeks and 6 weeks after surgery.
• After that you will be seen at 6 months and a year after surgery.