Sleeve stomach

Dr. med. Fabian Sinowatz is a freelancer in the medical editorial team.

More about the experts All content is checked by medical journalists.

The sleeve stomach is a form of stomach reduction used to treat obesity. During the operation, a large part of the stomach is removed so that only a tube-like remnant remains and the patient feels full more quickly when eating. Read everything you need to know about the prerequisites for the operation, its benefits and risks!

What is a sleeve stomach?

The sleeve gastrectomy or sleeve gastrectomy is an operation to reduce the size of the stomach to treat obesity. The method is based on the principle of food restriction: the intervention reduces the stomach volume to about the size of a small banana. As a result, the stomach is already filled after small amounts of food. The stomach filling leads to a stretching of the stomach wall, which in turn triggers the feeling of satiety.

In addition, the gastric sleeve surgery also seems to set hormonal processes in motion that curb the appetite. There is evidence that, after a sleeve gastrectomy, the stomach produces lower amounts of the so-called hunger hormone "ghrelin" and that this also reduces appetite. At the same time, appetite suppressing messenger substances are released. These include, for example, “GLP-1” and “Peptide YY”.

The messenger substances also have a beneficial effect on various metabolic processes (metabolism). That is why stomach-shrinking operations are increasingly referred to as metabolic surgery. For example, in many patients an existing diabetes mellitus (type 2 diabetes mellitus) improves significantly after the operation.

The gastric sleeve surgery is performed worldwide with a strongly increasing tendency. In Germany, the sleeve gastrectomy is the most frequently performed procedure in obesity surgery.

Preparation for gastric sleeve surgery

Before the actual operation, certain preliminary examinations are necessary. This includes a reflection of the esophagus, stomach and duodenum (esophagogastroduodenoscopy) in order to rule out pathological changes such as inflammation, ulcers or tumors. An upper abdominal sonography can also be used to assess the liver, gallbladder and pancreas. To prepare for anesthesia, an EKG is also written and, if necessary, a lung function test ("Lufu") is carried out.

Particularly in the case of very pronounced obesity (BMI over 40 kg / m2) with fatty liver, a so-called protein-rich liquid phase is recommended to patients before gastric sleeve surgery. It starts around 10 to 14 days before the operation, depending on the hospital. During this time, patients should only consume liquid, protein-rich food. The aim of the liquid phase is a slight weight loss and reduction in fatty liver. Precise information on the course of this preoperative liquid phase can be obtained directly from the treating hospital.

Sequence of gastric sleeve surgery

With a sleeve stomach, most of the stomach is removed. What remains is a two to three centimeter narrow tube (sleeve stomach) with a capacity of around 80 to 120 milliliters.

The gastric sleeve surgery always takes place under general anesthesia. As a rule, however, no large abdominal incision is necessary, but the procedure is carried out as a so-called minimally invasive operation (keyhole technique) using a few small incisions in the abdominal wall. The actual operation takes a little more than an hour and is usually carried out in these steps:

1. After inserting the surgical instruments and the camera, the abdominal cavity is filled with a gas (usually carbon dioxide) in order to achieve better accessibility and a better view of the abdominal organs.
2. Now the surgeon drives a so-called stapler (stacker) along the curved lower edge of the stomach (large curvature). The stapler has two functions: On the one hand, it separates the lower part of the stomach. At the same time, clamps are inserted along the incision, which connect the wound edges and close the remaining stomach tube. A time-consuming seam by hand is therefore not necessary.
3. The separated part of the stomach is pulled out of the abdomen through one of the working channels with a so-called recovery bag made of plastic. Dye is then introduced into the stomach via a gastric tube. This is used to check the tightness of the staple seam along the cut edge. If the dye does not leak, the operation can be completed.

For whom a sleeve stomach is suitable

A sleeve stomach is a way of effectively reducing weight for very overweight people with a body mass index (BMI) of 40 kg / m² or more. In the case of additional illnesses such as diabetes, which could improve through weight loss, a sleeve stomach is also placed from a BMI of 35 kg / m².

The prerequisite is that the patient has already tried several unsuccessful weight loss attempts (with changes in diet and lifestyle) under medical supervision. Patients should be at least 18 and no more than 65 years old.

Sleeve stomach as an intermediate goal

In extremely overweight people, gastric sleeve surgery is sometimes performed as the first step in more complex obesity surgery. If the patient has then lost weight and thereby reduced his surgical risk, an even more effective operation is carried out in a second step, for example a biliopancreatic division or a gastric bypass. Such operations not only limit the supply of food (restriction), but also the utilization of food (malabsorption).

For whom a sleeve stomach is not suitable

A sleeve stomach is unsuitable for people whose obesity primarily results from the consumption of soft, high-calorie foods or liquids, which for example consume a lot of sweets, sweet drinks ("sweet-eater") or alcoholic beverages. Because such calorie carriers pass the sleeve stomach almost directly anyway (they run through it) without filling it and triggering a feeling of satiety

In these cases, a malabsorptive procedure such as gastric bypass is the more sensible option. The sleeve stomach is also unsuitable for people with reflux disease. Acid reflux and heartburn may become worse after the operation.

Effectiveness of gastric sleeve surgery

The chances of success with regard to weight loss are very high with sleeve stomach surgery: Initial studies show that on average patients manage to lose excess weight by between 33 and 83 percent. Since gastric sleeve surgery is a relatively new surgical technique, there are no long-term results on the success of the method.

Some people gain weight again after a few years of weight loss. A certain orientation with regard to long-term expectations is provided by a technique very similar to the sleeve stomach, the so-called "gastrointestinal mill operation". In this operation, which is no longer common today, a stomach tube was also formed, but the remaining parts of the stomach were left in the body. This technique, which is comparable to the sleeve stomach, showed in a study a five-year result of 60 percent loss of excess weight (Excessive Weight Loss = EWL).

Advantages of a gastric sleeve over other procedures

In contrast to other surgical procedures, with a sleeve stomach the function of the stomach basically remains intact. The closure of the stomach entrance and exit is also retained. Therefore, after a gradual postoperative diet, patients can eat almost normally again - only in smaller quantities.

The procedure is shorter and gentler than gastric bypass surgery, for example. On the other hand, sleeve gastrectomy is much more effective than gastric banding, for example.

Side effects

After the operation, patients have to artificially supply vitamin B12 via injections (intramuscularly or as a short infusion) for life. Because the vitamin can no longer be absorbed in sufficient quantities via the intestines. The reason: As a large part of the stomach is removed, it no longer forms enough “intrinsic factor” - a protein that is required for the absorption of vitamin B12 from the intestine.

A gastric sleeve operation cannot be reversed if, for example, the patient has successfully reduced his or her weight.

Risks and Complications

As with any operation, problems or complications can arise during or as a result of gastric sleeve surgery. In addition to the typical risks of general anesthesia, these include:

• Injuries to blood vessels with bleeding or secondary bleeding
• Injuries to other organs
• Disorders of wound healing or wound infections
• Leakage in the stomach seam (suture insufficiency) with leakage of stomach contents into the abdominal cavity and the risk of peritonitis (peritonitis)
• (Temporary) gastrointestinal disorders
• Adhesions of the abdominal organs

Compared to other bariatric surgical procedures, sleeve gastrectomy has a lower complication rate. The individual risk depends to a large extent on the patient's state of health.

Post-op nutrition

After gastric sleeve surgery, the diet usually consists of passed or liquid food for about one to two weeks. The hospital then recommends a nutritional plan to gradually build up your diet. In the long term, the daily food intake is divided into around five to seven smaller meals per day.

In principle, all foods are allowed again a few weeks after the gastric sleeve surgery, provided they are well tolerated.However, for effective weight loss, diet and lifestyle habits must be fundamentally and permanently changed. The sleeve stomach is only one - albeit more effective - component in obesity therapy.

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