The sleeve gastrectomy is the most common procedure in obesity surgery. Non-reversible, it consists of removing part of the stomach. It allows to obtain a strong weight loss, thus reducing the risks associated with obesity and improving the patient’s quality of life. However, it requires lifelong medical and nutritional monitoring.

The sleeve gastrectomy (English sleeve for “sleeve”), also called longitudinal gastrectomy, sleeve gastrectomy or vertical calibrated gastroplasty with gastric resection, is one of the techniques of bariatric surgery, alongside the gastric band. , bypass and bilio-pancreatic bypass.

A restrictive and non-reversible technique, sleeve gastrectomy consists of removing approximately 2/3 of the stomach and, in particular, the part containing the cells secreting ghrelin, a hormone that stimulates the appetite. The great curvature of the stomach being resected, the stomach is reduced to a vertical tube.

Sleeve gastrectomy promotes weight loss via three mechanisms:

• it limits food intake by reducing the volume of the stomach. Because the stomach is smaller, the person can no longer swallow large amounts of food;
• it reduces the feeling of hunger because the secretion of ghrelin is limited;
• it modifies the bacterial flora of the stomach, which causes a change in the perception of tastes and appetite for certain foods.

On the other hand, this technique does not disturb the digestion of food, unlike the bypass which is a technique that is both restrictive and malabsorptive.

In some patients, sleeve gastrectomy is the first step in biliopancreatic bypass surgery.

Before the operation

The preoperative assessment includes in particular:

• assessment and management of comorbidities (cardiovascular, metabolic, respiratory, etc.);
• an assessment of eating behavior and the management of a possible eating disorder (ADD);
• a nutritional and vitamin assessment (dosages of albumin, hemoglobin, ferritin and iron saturation coefficient of transferrin, calcium level, vitamin D, vitamin B1, B9, B12) and a correction of any deficits, an assessment of chewing capacities;
• an esogastroduodenal endoscopy and the search forHelicobacter pylori.

The establishment of a therapeutic education program in dietetics and physical activity is recommended from the preoperative period.

The course of the operation

The operation takes place under general anesthesia. It lasts about 2 hours.

The intervention takes place by laparoscopic-laparoscopy, very rarely by laparotomy. Incisions (usually 3 to 5) are made in the abdomen and trocars are put in place. A tube, called a candle, is passed through the mouth into the stomach. It serves as a calibration for the new stomach. With an automatic clamp, the stomach is cut and sutured at the same time with a triple row of staples. The resected part of the stomach is then removed from the abdomen. 

The scars are sutured with absorbable suture, more rarely with nonabsorbable suture or staples.

Sleeve gastrectomy is intended for obese adult patients with a BMI ≥ 40 kg / m² or with a BMI ≥ 35 kg / m2 associated with at least one pathology likely to be improved after surgery (arterial hypertension, apnea syndrome obstructive sleep hypopnea and other severe respiratory disorders, type 2 diabetes, disabling osteo-articular diseases, non-alcoholic steatohepatitis).

The candidate for obesity surgery must, however, follow a specific course before being able to benefit from it. He must in fact have previously followed, without success, a well-conducted medical, nutritional, dietetic and psychotherapeutic treatment for 6-12 months, to be a candidate for the operation. Then, a preparation phase lasting several months precedes the agreement for the operation. This preparation includes different stages:

• have a first consultation with a practitioner experienced in the surgical management of obesity who will judge the indication or not of bariatric surgery;
• have multidisciplinary care to be informed about the different surgical techniques, their risks and benefits, and the importance of medical and nutritional follow-up after the intervention;
• do a medical check-up;
• take stock and benefit from psychological care.

It is only at the end of this course that the agreement for the surgery can be given – either postponed or refused. A prior agreement with social security is drawn up by the surgeon. It must be sent by registered mail to the health insurance fund, which has 15 days to respond and possibly summon you. After this period, the absence of response constitutes agreement.

Operative suites

In the days following the operation, any pipes put in place (bladder tube, gastric tube, drain, perfusion) are gradually withdrawn.

Painkillers are administered intravenously. Anticoagulant injections are given to prevent the risk of phlebitis.

Hospitalization lasts 3 to 8 days. A work stoppage of 2 to 3 weeks is prescribed depending on the general condition of the patient and his professional activity.

The resumption of food must be gradual. The food recovery program depends on the establishment, but the diet is generally completely liquid for the first 2-3 days, then consists of soup, mash, yogurt, then mixed and finally normal. However, it is essential to eat and drink in small quantities and to chew well.

The risks of complications

They are rare :

• ulcers, leaks or narrowing in the remaining stomach due to poor healing of the section of the stomach;
• early postoperative bleeding;
• nutritional deficiencies;
• gastroesophageal reflux disease (GERD) and inflammation of the esophagus;
• dilation of the stomach.

The mortality rate linked to the intervention is estimated at 0,2%.

The expected results

For a person of average height (1,70 m) with a BMI of 40 kg / m2, the expected weight loss is of the order of 45 to 65% of excess weight after 2 years, i.e. a loss of weight from 25 to 35 kg.

This weight loss improves the possible disorders associated with obesity, such as type 2 diabetes or high blood pressure, and of course the patient’s quality of life. 

Follow-up

Les is essential after obesity surgery. It is carried out by the multidisciplinary team, in conjunction with the attending physician, with a minimum of 4 consultations the first year with a member of the multidisciplinary team then at least 1 consultation per year. This monitoring has different goals: to assess weight loss, to monitor the general state of health and to take charge of any complications or nutritional deficiencies, to assess the psychological state of the person, to ensure that he is following his new habits. food and physical activity, etc. Personal commitment is indeed very important in the success of the intervention.

The sleeve is not reversible, but the tube will expand gradually and will no longer be effective after 5 to 7 years.