Gastric Sleeve Surgery – pros, cons, guidelines

Obesity and overweight have become the most pressing health issues facing the planet. The health complications and conditions relating to obesity impact on people socially, psychologically, physically and financially. The costs related to obesity are in the billions of dollars per annum.

Unfortunately obesity has proved an extremely difficult condition to treat and surgical interventions have become more common. Many people are asking questions about weight loss surgeries. One of the newest procedures is gastric sleeve surgery.

This blog overviews gastric sleeve surgery. Information has been taken from medical websites, YouTube and people who have had bariatric surgery procedures. There is a case study blog that is regularly updated that gives you a step-by-step personal insight into the gastric sleeve procedure.

So, what is bariatric surgery?

Baros is a Greek word for weight so not surprisingly bariatric surgery is weight loss surgery. Bariatris surgery is generally performed on severely obese individuals who have been unsuccessful in their weight loss and attempts.

To be eligible for bariatric surgery you need to fulfill one of two weight criteria. The first is you must have severe or morbid obesity. The accepted guideline for severe obesity is having a Body Mass Index or BMI of more than 40. To determine your BMI you divide your weight in kilograms by the square of your height in metres.

The second criteria for bariatric surgery is having a BMI greater than 35 and an associated medical condition related to obesity. Example of obesity related medical conditions are diabetes, high blood pressure or high blood fat levels like cholesterol.

There are two types of bariatric surgery:

The first uses devices to reduce the size of the stomach. An example would be lap band surgery.

The second type of bariatric procedure are gastric bypasses or surgeries which remove a portion of the stomach like gastric sleeve surgery.

Gastric Sleeve involves removing the lateral two-thirds (>~60%) of the stomach with a stapling device. The procedure can be done using keyhole surgery.

The remaining stomach is more like a tube or ‘sleeve’ than a sac. It is estimated that the remaining stomach has about a 200ml capacity. This represents a significantly reduced stomach capacity and would only allow an entrée sizes meal.

The gastric sleeve procedure is ‘restrictive’ as opposed to ‘malabsorptive’. This means that it restricts the amount of food you can consume. There is reduced surface area of stomach lining as a result of the surgery so not only do you need to eat less, you need to chew well.  Chewing your food well maximizes the absorption of what you do eat. Poorly chewed food will cause discomfort and just pass through and be eliminated by the bowel. Being able to eat much smaller portions means that what you do eat must be of a high nutrient value.

The gastric sleeve procedure originated as the first part of a duodenal switch surgery in people with severe obesity. The gastric sleeve allowed enough weight loss in these high risk clients to permit the second surgery.

Let’s look at who gastric sleeve surgery is suitable for.

As we have already said, having severe obesity or a BMI of more than 40 is the first criteria.

Another criteria is having an increased risk of health problems such as sleep apnoea, hypertension, diabetes, cardiovascular disease and fatty liver, or a combination of these problems. These conditions have the potential to shorten your life span.

A third criteria for gastric sleeve surgery could be that you are experiencing chronic physical symptoms. Physical symptoms could include fatigue, back pain, reflux, impaired mobility and difficulty performing tasks such as tying your shoe laces or even washing yourself.

A fourth criteria is that your weight has impacted on you psychologically. You may be experiencing levels of depression, anxiety and stress that impact negatively and significantly on your life. You may also have very low self-esteem and limited self-confidence.

Another criteria is that your obesity has impacted on you socially. For example it may have impacted on your current relationships, your ability to have an intimate relationship, or your confidence in being able to attend social events. You may not be able to travel or go to the movies because you cannot fit in a normal sized seat.

A necessary criteria for weight loss surgery is that you have genuinely attempted to lose weight by a variety of means but been unsuccessful.

Weight loss surgery is not a panacaea for weight loss. There are many people who have had the surgery and gained weight because they eat or drink the wrong foods, and do not make the necessary lifestyle changes such as regular exercise.

Weight loss surgery will work for you only if it is accompanied by lifestyle changes and changes in your thinking. It is imperative that you practice  mental self-discipline in relation to food choice and do regular exercise

Gastric sleeve surgery is an option for people for whom a gastric bypass is contraindicated. This includes people who have conditions such as inflammatory bowel disease. It also includes people with higher risk of complications such as smokers or those on anticoagulation therapy like warfarin.

Gastric sleeve surgery may not be an option for people who have significant issues with a hiatus hernia or a history of severe gastroesophageal reflux disease. This is because once the gastric sleeve procedure is performed further gastric reflux surgery generally cannot be done.

Now let’s look at the pros and cons of the gastric sleeve

The first pro is that the procedure reduces hunger. The surgery cuts out more than 60% of your stomach. This reduces the concentration of biochemicals in your stomach that cause the sensation of hunger.

The second pro is that there is no band or other permanently restrictive device or foreign body left in your body after the surgery. The problem  with the gastric band is a number of objects are left in your body. The band can slip, erode or cause infections.

The third pro is the large amount of weight you lose after having the procedure. Different websites report different ranges of weight loss. One site reported 30-50% weight loss in the first 6-12 months. Another site estimated that people who undergo this procedure achieve 40-60% weight reduction over the first 1-2 years.

A fourth pro is that the significant weight loss resulting from the bariatric surgery will generally lead to improvements in blood pressure, diabetes, sleep apnoea, joint pain, reflux and fatty liver etc.

A fifth advantage of the gastric sleeve is there is no malabsorption of nutrients. As noted above the gastric sleeve surgery is a restrictive procedure as opposed to one that is malabsorptive. You will be able to eat what you previously did but will need to eat in much smaller amounts and may find some foods physically uncomfortable to consume. And, because you are eating less you will need to ensure that you eat nutrient dense foods, not junk foods!

A sixth pro of surgical treatments is that the risk of surgery is often less than the risks caused by severe obesity.

A final pro is that another surgery called a gastric bypass or duodenal switch can be performed after this procedure.

And, now for the cons or downside of gastric sleeve surgery.

The foremost downside of gastric sleeve surgery is that it is irreversible. It is a permanent procedure.

The second downside is that the procedure is expensive and not usually covered by medical insurance companies or medicare

As the gastric sleeve is a surgical procedure there could be post-operative complications such as infections, pneumonia and bleeding. As the procedure involves stapling part of the stomach, leakage is always possible. If leakage occurs it may cause infection and other health problems. The more obese you are prior to surgery the higher the risk of complications. However, the literature indicates a mortality risk of less than 0.3%.

The fourth issue with gastric sleeve surgery is that it only restricts your capacity to consume solid foods not liquids. There are high energy liquid foods that if consumed after a gastric sleeve will prevent weight loss. Drinking high calorie liquids frequently enough could even cause weight gain. Be warned, having a gastric sleeve does not mean you can get away with eating and drinking what you like!

A fifth issue is that after a gastric sleeve the remaining stomach will gradually stretch and permit larger meals. If you make unhealthy food choices you may gain weight.

A sixth issue is that because 60% of your stomach has been removed your stomach space is much smaller and you will feel full more quickly. If you overeat or swallow poorly chewed food you may feel uncomfortable and vomit.

A seventh issue is that you will need to reframe your relationship and attitude towards food because you will not be able to eat what and how you did previously. There will be a mourning involved. You will need to get used to watching other people eat in a way you no longer can.

An eighth issue is acknowledging that most people eat psychologically, not in response to hunger. So, despite some people saying the gastric sleeve operation reduces the production of the hunger hormone, most of my clients don’t eat because they are hungry. Most people eat because they are bored, upset, or out of habit. If people on the planet only ate when they were hungry then none of us would be fat! So, even after having the gastric sleeve you will need to exercise ongoing commitment to healthy eating and exercise.

Once you have made the decision to proceed with a gastric sleeve surgery, the surgeon will give you pre-operative guidelines.

Pre-operatively you will likely be recommended a meal replacement or liquid diet program to follow for between one and four weeks.

On the day of your surgery you will only be allowed ice to suck.

From day one post-op to day three you will only be allowed clear fluids. As rule of thumb you will be required to drink 30-50mls of water every 15 minutes to ensure adequate hydration.

From day four  to day 10 to 14 you will be transitioned to mixed fluids. Mixed fluids include clear broth, soups, custards, milk drinks, juices etc. It is essential that you maintain an adequate water intake to prevent dehydration. If you become dehydrated you are more likely to experience nausea and to be readmitted to hospital for intravenous rehydration.

By week three post-op you will be transitioned to soft, watery/liquidy foods as tolerated, as well as the mixed fluids. Foods you may include at this stage could be oatmeal consistency foods, thicker soups, pureed fruit perhaps mixed with yoghurt or custard, mashed potato/pumpkin with gravy etc

In the longer term you will be recommended to consume foods as tolerated and at least 2 litres of water daily.

When you have progressed to eating normal food, choose food that you are able to chew into a consistency that you can swallow easily. If food is difficult to swallow it may cause discomfort or reactions such as vomiting. Mashed, pureed or naturally soft semi-liquid foods will be initially easier to eat.  You will learn through experience that it is essential that foods be chewed to a soft or mashed consistency to make swallowing easy. Meals you previously took five minutes to eat, may take up to an hour to consume!

There are a number of things you can do to help you manage the changes to eating post-gastric sleeve surgery.

The first thing to do is to ensure you cut food into very small pieces. Many people reduce their bite sizes to a quarter the size they would normally have eaten pre-surgery. It may even help to try eating with a teaspoon or small fork to ensure you only take small bites.

The second recommendation is that  you chew all food extremely well. As stated above chewing food well ensures it is a soft consistency when you swallow, reducing discomfort. While chewing practice mindfulness. Focus on the taste and texture of the food and how it feels in your mouth. Mindfulness practice will help you slow down your eating. Avoid foods you cannot chew well.

Thirdly, avoid consuming liquids with meals.

Fourthly, stay hydrated. Drink 2-3 litres between meals.

Fifthly, to avoid reflux avoid known gastric stimulants such as tea, coffee, fatty foods, spices, and avoid lying down immediately after a meal. Also avoid gasey drinks like mineral and soda waters with gas.

Sixth, eat five to six small meals a day. Your meal sizes will be much smaller because the gastric sleeve surgery only leaves a small sleeve for your stomach. Lunch may be a piece small piece of fruit and half a sandwich. As mentioned numerous times in this blog, because you can only eat small amounts of food, what you eat must be of high nutritional value.

Seventh, beware of high calorie fluids and foods with a soft fluidy consistency that are easy to consume such as milkshakes, cordial and soft drink, fruit juice, sports drinks with sugar, ice cream, custards, puddings, crème caramels, blancmanges etc It is easier to drink on weight than it is to eat it on!

Following is a food intake that was tolerated by a patient at day 4 post-gastric sleeve surgery.

• Breakfast: One Up and Go
• Mid-morning: One cup of reduced fat iced coffee
• Lunch: One cup of soup
• Mid-afternoon: 1 cup of milk
• Dinner: Half a cup of Low-fat custard

The total energy of this food intake is 2496kilojourles or 594 kcalories. It is 35grams of protein. A dietitian would view the intake as nutritionally inadequate. A recommendation to supplement this intake is extra juice for more energy, vitamins and hydration as well as extra sources of liquid protein.

Below are some gastric sleeve post-op comments summarised from U-Tube

Comments from Day 1 Post- gastric sleeve surgery included the following:

• after surgery you are only given ice.
• swallowing is difficult.
• you may experience significant pain and be given pain killers.

Comments from Day 2 Post- gastric sleeve surgery included:

• you are usually an inpatient for two days and two nights.
• you are discharged two days after the surgery.
• you are asked to walk around the second day.
• by day two you are feeling better than day one, but still experience discomfort particularly in certain positions.
• juice is provided on day 2.
• patients say they eat what is given but admit that there stomach is still swollen. They made comments like,  ‘the liquids don’t feel great in the stomach even though it is nice to have something in the mouth’.
• Two u-tube videos said that it was in the immediate post-surgery period that they questioned what they had done. To deal with their doubts they said they focused on successful outcomes of people who were further down the track post surgery.

Comments from Day 4 Post-gastric sleeve surgery included the following points:

• Patients reported feeling weak at this stage and attributed the weakness to having no protein.
• On discharge one person commented that they brought a bag they had to carry to the hospital, but had to purchase a bag with wheels that they could pull because they could not carry anything. She said she had no energy to lift anything and was still in pain and on pain killers.
• A patient in Australia said she was advised to do NO lifting for two weeks after the surgery.
• At day 4 one person on u-tube reported not being hungry but liking the smell of food. They said they were dreaming about food.
• By day 4 swallowing was reported as easier.

Comments from Day 6 Post-gastric sleeve surgery were as follows.

• Some patients reported feeling dehydrated and were making a conscious effort to stay hydrated.
• At day 6 most people were saying they were still on clear liquids but said they would be starting full liquids in the near future. Full liquids included fat free cream soups and meal replacements.
• Patients reported sleeping less. For example, one reported only sleeping 5 hours.
• Some said their energy levels were fluctuating from some days with reasonable energy levels to other days with no energy.

Comments from the second Week Post- gastric sleeve surgery were as follows. 

• One person had lost 20 pounds or 10 kilograms post surgery.
• Someone said the second week post-surgery can still be difficult as the body is still healing.
• Another person commented that drinking water was difficult.
• By week two most people were drinking protein shakes and milk. By week three they had progressed to soft foods.
• One person said that during week two they were only consuming 200 kilocalories a day. Considering that you cannot nutritionally balance a dietary intake on 200 kilocalories per day it is hardly surprising that this person reported feeling weak.
• By week two the bruising caused by the surgery was resolving.
• By week two, for some, the pain had abated and they were no longer taking pain medication.
• Some people said they had started multi-vitamins.
• Some people said they were worried about muscle loss because of the significant levels of weight they had lost. They were told they needed 70-80 grams of protein per day and were unable to eat that much.
• One person reported the difference between feeling full on liquids and feeling full on solids.
• Most people emphasised staying hydrated.

Comments during the fourth week post- gastric sleeve surgery were as follows:

• Difficulty meeting protein needs remained an issue.
• One person said that if they ate bread they had to spit it out.
• It was suggested that the easiest foods to eat were foods with a high water content like strawberries and fruit, yoghurt and soups.
• By week four activity levels can be increased.

Comments at ten weeks post-astric sleeve surgery were as follows. 

• At this stage people can be exercising.
• Weight loss will be significant enough to have caused you to throw out your old “big” clothes and replace them with smaller sizes.
• Confidence levels will have increased, as will energy levels.
• If drinking alcohol it will impact on you more, so monitor it carefully.
• As you are on a reduced food intake it is important to eat nutrient dense foods when you do eat, to eat small bites, eat slowly and over a period of 30-60 minutes.
• Bread and thick chunky foods do not feel good when they are swallowed so avoid them.
• People will be eating better.
• Some people complained of a “sour stomach” and were taking  “acid reducers” and enzyme support supplements.
• A 300ml or 10oz protein shake was taking an hour to drink.
• They had all learned to eat very small bites and recognised that it takes a long time to eat.
• Fried foods were not tasting good and were hard to swallow.
• People were saying that they judged food by how it felt.
• Warning, warning, warning: ice cream was described as feeling good and tasting good, so keep it out of the house.

General comments were made on u-tube and included the following.

• The pain of the surgery can last up to 1 ½ weeks.
• It is during the high pain period that people experience the most self-doubt about having had the surgery.
• It took about 2-3 weeks to feel better.
• After recovery people described their meal sizes as children’s sizes and then probably with something left over.
• One person admitted that he believed that the change to his eating habits, and how he now had to eat, would require an adjustment of 1 – 1.5 years.
• Another person said they mourned not being able to eat properly.
• One person said that it was a procedure one should not do if they were lazy and hadn’t tried to lose weight. He advised that it should be everyone’s last resort. He also warned to “be prepared for a life changing experience”. He said, “My life is nothing like it was before. I miss eating big meals, but I can now do a lot of stuff I couldn’t do for years.”
• A few people suggested recouping your surgery costs by selling your clothes on ebay.
• Another suggestion was to buy clothes that look good when they get loose because it was very likely you would be losing several clothes sizes.

DietPsyche’s Recommendation is to ensure you have your dietary intake monitored by a registered dietitian to ensure nutritional adequacy. Another recommendation was to discuss the significant changes the surgery creates in your life with a psychologist to assist adjustment.

In summary, while the gastric sleeve procedure markedly reduces your capacity for food, it is still important to exercise discipline in food choice and to make lifestyle changes including regular exercise. It is crucial that you avoid fluids and fluid consistency foods high in calories  and low in nutrients such as soft drinks, milk based drinks and soft desserts like icecream. As you will only be able to eat small amounts what you do eat matters more. To ensure nutritional adequacy and good health you MUST make healthy food choices.

Remember, “If it is to Be; it is up to Me!”. Your health is in YOUR hands.