Tube gastrectomy (synonyms: sleeve gastrectomy; SG) is a surgical procedure in bariatric surgery. Sleeve gastrectomy may be offered for obesity with a BMI ≥ 35 kg/m2 or greater with one or more obesity-associated comorbidities when conservative therapy has been exhausted. In contrast to other bariatric procedures (bariatric surgery) such as gastric banding, greater weight reduction can be achieved with tubular stomach surgery. Unlike gastric banding surgery, tubular stomach surgery represents an irreversible change. If necessary, the effect of the operation is not sufficient, so that a complementary bypass procedure may become necessary. The extent to which tubular stomach surgery can successfully maintain weight loss in the long term must be awaited.
Indications (areas of application) for bariatric surgery [according to S3 guideline: Surgery for obesity and metabolic diseases, see below]
- In patients with a BMI ≥ 40 kg/m2 without concomitant diseases and without contraindications, bariatric surgery is indicated after exhaustion of conservative therapy after comprehensive education.
- Patients with a BMI ≥ 35 kg/m2 with one or more obesity-associated comorbidities such as type 2 diabetes mellitus, heart failure, hyperlipidemia, arterial hypertension, coronary artery disease (CAD), Nephropathy, obstructive sleep apnea syndrome (OSAS), obesity hypoventilation syndrome, Pickwick syndrome, nonalcoholic fatty liver (NAFLD), or nonalcoholic fatty liver hepatitis (NASH), Pseudotumor cerebri, gastroesophageal reflux disease (GERD), bronchial asthma, chronic venous insufficiency (CVI), urinary incontinence, immobilizing joint disease, fertility limitations, or polycystic ovary syndrome (PCO syndrome) should be offered bariatric surgery when conservative therapy is exhausted.
- In certain circumstances, a primary indication for bariatric surgery may be made without a prior attempt at conservative therapy. The primary indication may be given when any of the following conditions exist: in patients.
- With a BMI ≥ 50 kg/m2.
- In whom a conservative therapy attempt was classified by the multidisciplinary team as not promising or hopeless.
- With particular severity of concomitant and secondary diseases that do not allow postponement of a surgical intervention.
Contraindications
- Unstable psychopathological conditions
- Untreated bulimia nervosa
- Active substance dependence
- Poor general health
- Lack of indication – should obesity be caused by a disease (e.g., hypothyroidism, Conn syndrome (primary hyperaldosteronism, PH), Cushing’s disease, pheochromocytoma)
Before surgery
- Detection of existing concomitant diseases – before surgery, in addition to a medical history, detailed diagnostics are necessary to assess, among other things, the risk of surgery and the subsequent success of the operation. Diagnostic measures to assess diabetes mellitus should include fasting blood glucose and HbA1c measurement. In addition, due to the high risk of concomitant diseases, detection of sleep apnea syndrome, hypoventilation (inadequate breathing), pulmonary arterial hypertension (increased blood pressure of the pulmonary vessels), coronary heart disease (CHD) and cor pulmonale (heart disease secondary to lung disease) must be performed.
- Medication preadjustment – to reduce the risk of complications as much as possible, existing diseases usually need to be optimally adjusted with medication before the procedure. Furthermore, it is indispensable that the gastrointestinal tract (gastrointestinal tract) is also subjected to a detailed examination. Among other things, this serves to diagnose gastroesophageal reflux disease (heartburn) or a gastric ulcer. In such cases, preoperative therapy is necessary, for example, with proton pump inhibitors (PPI; acid blockers).
The surgical procedure
Tubular stomach is a restrictive procedure that additionally reduces gastric acid production.Furthermore, the tubular stomach surgery leads to a decrease in the level of ghrelin (appetite stimulating hormone from the gastric mucosa), so that the feeling of hunger can be significantly reduced. During the operation, the fundus and corpus (the largest part of the stomach) are removed, leaving only the antrum area as the remaining stomach. The procedure reduces the volume of the stomach by approximately 90%. Despite the large resection volume, the procedure is usually performed minimally invasively, which both improves the cosmetic result and reduces the risk of wound healing problems. Because tube stomach surgery is a relatively new bariatric procedure, long-term results cannot yet be adequately assessed, which is why the procedure should currently be viewed critically, especially in young people.
After surgery
Following the operation, checks must be made to exclude complications and to check the function of the gastrointestinal tract. Following surgery, patients undergoing surgery are transferred to an “intermediate care” unit so that optimal care can be provided. Cautious mobilization of the patient should take place at an early stage, if necessary on the first postoperative day. On the second postoperative day, a gastrography swallow should be performed to detect possible insufficiencies or stenoses. A slow and gentle diet buildup over several weeks should be aimed for.
Possible complications or sequelae
- Stenosis – there is a significantly increased risk of gastric stenosis (0.7-4.0%) with tubular stomach surgery compared with other bariatric procedures.
- Lumen dilation – analogous to possible stenosis, the risk of significantly dilated lumen (opening of the hollow organ) is also higher compared to other bariatric surgery procedures.
- Staple suture insufficiency – especially if the procedure had taken longer than average (OR 1.04 for each ten-minute increase in operative time).
- Pulmonary embolism – the risk of pulmonary embolism did not differ significantly between bariatric surgery procedures.
- Gastric ulcers – the development of an ulcer (ulcer) in the stomach is significantly lower with tubular gastric surgery than, for example, with Roux-en-Y gastric bypass.
- Thrombosis and wound healing disorders – as with any abdominal surgery, there is a risk of primary postoperative complications such as thrombosis and wound healing disorders.
- Gastroesophageal reflux disease (synonyms: GÖRK; gastro-oesophageal reflux disease (GORD)) – frequent reflux (lat. refluere = to flow back) of acidic gastric juice and other gastric contents into the esophagus (esophagus) (> 40% of cases).