Prof. Dr. Toygar Toydemir
He received the title of Professor of General Surgery in 2020. Dr. Toydemir, who has extensive experience in reflux and obesity surgery, continues his work in these fields. You can read the rest of our article about Gastric Sleeve Surgery prices, treatment process, and post-treatment precautions.
Read More Make an AppointmentSleeve gastrectomy stands out as an effective surgical method in the treatment of obesity. In this procedure, performed using laparoscopic techniques, 75-85% of the stomach is removed, leaving a banana-shaped sleeve behind. Thanks to both the reduced stomach volume and the decreased production of the ghrelin hormone (which increases appetite), patients can feel full with less food. After the operation, it is possible for patients to lose up to 80% of their excess weight. However, this procedure also carries potential risks such as gastroesophageal reflux disease, nutritional deficiencies, and, rarely, leaks. Sleeve gastrectomy is an effective option for weight control and improving quality of life in suitable patients.
| Purpose | By reducing stomach volume, enable weight loss; reduce or eliminate health issues related to obesity. |
| Method of Application | Under general anesthesia, a large portion of the stomach is removed using the laparoscopic method. The remaining stomach is reshaped into a tube. |
| Eligibility Criteria | Body Mass Index (BMI) ≥ 40 or BMI ≥ 30–35 with severe obesity-related health problems (such as diabetes, hypertension, sleep apnea). |
| Duration of Surgery | Usually 1 hour |
| Length of Hospital Stay | 2-3 days. |
| Possible Complications | Bleeding, infection, leaks, thrombosis, gastric stricture, malabsorption. |
| Advantages | – Effective and long-term weight loss. |
| – Reduced appetite due to hormonal changes. | |
| – Possibility of improvement or remission of comorbidities such as diabetes and hypertension. – No anatomical alteration in the route of food through the digestive system. |
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| Disadvantages | – Irreversible procedure. |
| – Possible vitamin and mineral deficiencies; long-term follow-up and supplementation may be required. | |
| Postoperative Nutrition | An incremental diet starting with liquids, purées, and soft foods after surgery. In the long term, healthy and balanced eating habits should be developed. |
| Physical Activity | Light exercise is recommended for the first few weeks. Regular physical activity is required after full recovery. |
| Follow-Up | Regular doctor check-ups, blood tests, and dietitian support are necessary. |
Sleeve gastrectomy has become one of the cornerstones of modern bariatric surgery. It was first performed in the late 20th century as part of complex bariatric procedures such as duodenal switch and biliopancreatic diversion (BPD-DS). In these procedures, the stomach volume is significantly reduced to form a tube shape, thus achieving both restrictive and metabolic effects. While reducing the stomach volume limits food intake, preserving the pylorus (the valve at the stomach exit) aims to maintain normal gastric emptying and reduce the risk of dumping syndrome.
Sleeve gastrectomy evolved into an independent surgical method in the early 2000s. Initially, it was used as the first step of a two-stage approach for extremely obese patients with high surgical risks, preparing them for more complex procedures like Roux-en-Y gastric bypass. During this time, sleeve gastrectomy allowed patients to lose weight, thereby reducing surgical risks for the second stage. However, many patients experienced satisfactory weight loss and improvement in comorbidities with sleeve gastrectomy alone, eliminating the need for a second surgery.
The first laparoscopic sleeve gastrectomy (LSG) was performed by Dr. Michel Gagner in 1999. Laparoscopic surgery offered advantages such as faster recovery, reduced pain, and shorter hospital stays. The LSG cases Dr. Gagner presented at the 2002 International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) meeting contributed significantly to the acceptance of sleeve gastrectomy in the scientific community.
In 2012, the American Society for Metabolic and Bariatric Surgery (ASMBS) recognized sleeve gastrectomy as a primary bariatric procedure. This decision was supported by evidence demonstrating its safety, efficacy, and metabolic improvements. Over the years, refinements in surgical techniques have reduced complications and increased the long-term success of the procedure. However, issues such as gastroesophageal reflux disease and weight regain highlight the need for further research into patient selection and treatment strategies.
Sleeve gastrectomy is an effective surgical method in combating obesity, and its suitability depends on the patient’s individual health status and needs. Body Mass Index (BMI) is typically a key factor in determining surgical candidacy.
Individuals classified as having severe obesity (BMI ≥ 40 kg/m²) are considered suitable for surgery due to the significant health risks associated with obesity. For these patients, sleeve gastrectomy can improve quality of life and offer substantial benefits in managing obesity-related diseases.
Those with moderate obesity (BMI 35–39.9 kg/m²) who also have comorbidities such as type 2 diabetes, hypertension, or obstructive sleep apnea are also among the candidates for surgery. In this group, sleeve gastrectomy holds significant potential for the remission or improvement of these conditions. For example, weight loss may lead to improved glycemic control, decreased blood pressure, and resolution of sleep apnea.
Recent studies have explored the benefits of surgery for patients with mild obesity (BMI 30–34.9 kg/m²) who have metabolic syndrome or poorly controlled type 2 diabetes. However, the decision for surgery in this group must be made carefully. A personalized approach is adopted by considering the patient’s general health status, the severity of metabolic disorders, and possible surgical risks.
Sleeve gastrectomy is generally performed on patients who have not achieved successful weight loss through conservative methods such as diet, physical activity, and pharmacotherapy. Other factors such as age, psychological status, and eating habits should also be considered when evaluating candidates. Surgery may be an option for adolescents if they have severe obesity and related diseases, following a comprehensive evaluation.
While sleeve gastrectomy is an effective surgical method for treating obesity, it may not be suitable for some patients. Factors determining unsuitability arise from various medical and psychological conditions that may reduce the operation’s effectiveness or increase the risk of complications. Careful assessment of these conditions before surgery is vital to ensure patient safety and the success of surgical outcomes.
Severe Cardiovascular Diseases
Conditions such as advanced heart failure or severe coronary artery disease carry serious risks of complications during surgery. The stress of the operation may lead to heart attacks or arrhythmias in these patients. A thorough cardiological evaluation is essential, and non-surgical treatments may be more appropriate for such cases.
Uncontrolled Psychiatric Disorders
Untreated psychiatric conditions like major depression, schizophrenia, or severe anxiety can make it difficult to adopt necessary lifestyle changes after surgery. Stabilizing these psychiatric conditions before surgery is critically important.
Substance Abuse
Active substance abuse negatively affects postoperative recovery and adherence to dietary changes. Individuals with substance abuse issues should participate in rehabilitation programs before undergoing surgery.
Coagulopathy
Patients with bleeding disorders or those undergoing anticoagulant therapy have a high risk of bleeding during and after surgery. Detailed planning is required to manage these risks.
Nutritional Deficiencies and Non-Compliance
Severe nutritional deficiencies and an inability to comply with postoperative care can negatively affect the success rate of surgery. If the patient cannot maintain regular follow-up and dietary compliance, surgery is not recommended.
Sleeve gastrectomy is an obesity treatment method performed with laparoscopic surgical techniques and requires careful planning and execution by a specialized team. The procedure begins under general anesthesia, with the surgeon typically positioned between the patient’s legs and the surgical team working on the sides.
The first stage of surgery involves placing trocars (devices of 5–12 mm width allowing surgical instruments to enter the abdomen). Usually, five ports are created to accommodate the laparoscope and operative instruments. To clearly visualize the stomach and surrounding structures, the left lobe of the liver is elevated using a specialized retractor.
The initial surgical intervention starts near the greater curvature of the stomach, close to the pylorus (the distal end of the stomach). The gastroepiploic ligament is carefully dissected, and the short gastric vessels are ligated, mobilizing the stomach up to the left crus of the diaphragm. Any hiatal hernia discovered during the procedure is evaluated and repaired using a posterior cruroplasty technique. This can reduce the risk of gastroesophageal reflux disease (GERD) after surgery.
During the operation, a bougie calibrator is used to create the sleeve portion of the stomach. The calibrator is placed parallel to the stomach to ensure the correct diameter. Then, using linear staplers, the stomach is transected alongside the bougie. The resected portion of the stomach is removed from the abdominal cavity.
A leak test is performed along the stapler line. Using methylene blue dye or air, the surgeon checks for any leakage. After achieving hemostasis, the trocars are carefully removed, and large incision sites are closed to prevent hernia formation. The incisions are closed with cosmetic surgical sutures at the end of the procedure.
Although sleeve gastrectomy is an effective method for treating obesity, some early and late complications may occur. In the early period, staple line leaks, bleeding, venous thromboembolism (VTE), and infections are possible issues. Leaks from the staple line can lead to peritonitis and sepsis, which are life-threatening and may require urgent surgical intervention. Bleeding occurs in about 2-4% of patients and, in severe cases, may require blood transfusion or reoperation. Additionally, blood clots can form, leading to pulmonary embolism, a life-threatening emergency. Infections can cause abscesses at the surgical site and may require antibiotic treatment or surgical drainage.
In the long term, the most commonly encountered complications include gastroesophageal reflux disease (GERD), nutritional deficiencies, and gastric stenosis. GERD can cause heartburn and a burning sensation due to acid reflux. Nutritional deficiencies may involve vitamin B12, iron, vitamin D, and calcium. Gastric stenosis, a narrowing of the stomach, can cause food intolerance and vomiting, often necessitating endoscopic dilation or surgical revision. Other long-term issues may include weight regain, psychological challenges, and compromised bone health.
Sleeve gastrectomy is an effective surgical method in the treatment of obesity, and its success rates are evaluated in terms of weight loss and improvement in comorbidities. By removing a large part of the stomach, the procedure reduces stomach volume and also influences appetite hormones. As a result, patients consume less food and can maintain long-term weight control.
Weight Loss Success:
Sleeve gastrectomy provides effective weight loss for the majority of patients. Studies indicate that patients can lose up to 80% of their excess weight within the first few years after surgery. For example, if someone should ideally weigh 80 kg but weighs 180 kg, they have 100 kg of excess weight, and they could lose around 80 kg with sleeve gastrectomy. A systematic review reported an average percent total weight loss (%TWL) of 24.4% after sleeve gastrectomy. Although individual results vary, most patients maintain long-term weight loss according to supportive data. However, some weight regain may occur over time. Long-term follow-up studies show that up to 30% of patients may require additional surgical interventions.
Improvement in Comorbidities:
Sleeve gastrectomy significantly impacts obesity-related conditions such as type 2 diabetes (T2DM) and hypertension (HTN). Remission rates for T2DM range from 60-80%, and about 41% of patients with HTN achieve blood pressure control. Its effectiveness in these conditions is comparable to other bariatric surgeries like Roux-en-Y gastric bypass (RYGB). However, sleeve gastrectomy may have a higher incidence of gastroesophageal reflux disease (GERD), which can affect quality of life.
Quality of Life and Mortality Rate:
Weight loss and improved control of comorbidities enhance the quality of life for patients undergoing sleeve gastrectomy. Physical mobility, self-confidence, and general perception of health improve. Additionally, the risk of death from all causes can be reduced by up to 59%, indicating a positive effect on lifespan. The mortality rate associated with sleeve gastrectomy is about 0.4 per thousand.
A comprehensive preparation process before sleeve gastrectomy is critical for increasing the success rate of the operation and minimizing complications. This period involves several important steps, including medical evaluations, lifestyle changes, and patient education.
The patient’s overall health status should be thoroughly evaluated before the surgery. Reviewing medical history and comorbidities such as diabetes, hypertension, or sleep apnea helps in managing these conditions. Laboratory tests identify any vitamin or mineral deficiencies, allowing for corrective measures. Additionally, essential organ functions (like liver and kidney) should be assessed. Imaging studies help detect conditions such as gallstones or hiatal hernias that may require intervention during surgery.
Nutritional counseling is necessary to correct any preoperative nutritional deficiencies and help patients develop healthy habits. Moreover, psychological evaluation is essential since conditions like eating disorders or depression may affect recovery after surgery. This evaluation plays an important role in helping patients adapt to postoperative lifestyle changes.
Patients must adopt specific lifestyle changes before surgery. A low-calorie diet can help shrink the liver, making the operation safer. Quitting smoking and limiting alcohol intake support the healing process. Regular physical activity is also encouraged to improve cardiovascular health and facilitate weight loss.
Providing comprehensive information about the surgical process, potential risks, and requirements helps patients manage their expectations realistically. Education on dietary adjustments, portion control, and support systems ensures that patients are prepared both physically and emotionally.
Sleeve gastrectomy is not just a surgical intervention but also the beginning of a new lifestyle. The postoperative period is crucial for both increasing the success of the surgery and ensuring a healthy recovery. This process involves multiple elements, including dietary adjustments, physical activity, regular medical follow-up, management of potential complications, and psychological support.
After surgery, patients usually start with a clear liquid diet to promote healing of the stomach tissue. Subsequently, full liquids, puréed foods, and soft solid foods are introduced in stages. Finally, patients return to foods with normal consistency. This gradual transition is designed to allow the stomach to adapt to its new structure and to prevent complications. It is important to eat small, frequent meals, chew thoroughly, and avoid foods high in sugar or fat.
Because of the reduced stomach volume, patients may need to use supplements for a certain period to prevent vitamin and mineral deficiencies. Commonly recommended supplements include multivitamins, calcium with vitamin D, vitamin B12, and iron. Regular blood tests are crucial to monitor these levels and detect deficiencies early.
Light walking can begin early in the recovery process to improve blood circulation and support weight loss. Over time, patients can add aerobic exercises and muscle-strengthening activities to their routine. Exercise programs should be individualized to meet each patient’s needs.
Regular follow-up visits with the surgical team are essential to monitor weight loss progress, assess nutritional status, and detect complications early. Patients should be informed about potential warning signs of complications and seek prompt medical attention if necessary.
For which patients is sleeve gastrectomy appropriate?
Sleeve gastrectomy is generally recommended for individuals with a Body Mass Index (BMI) over 40 or those with a BMI over 35 who suffer from obesity-related health problems such as diabetes or hypertension. According to updated guidelines in 2022, patients with a BMI over 35 may be considered for surgery even in the absence of health issues. In individuals of Asian descent, surgical intervention may be considered when BMI is above 27.5. Candidates should have been unsuccessful in losing weight through diet and exercise and be willing to commit to lifestyle changes after the operation.
How does the weight loss process progress after surgery?
Patients typically experience significant weight loss following sleeve gastrectomy, with studies indicating an average of 70-80% after the first year. However, some patients may regain about 35% of the lost weight. Results depend on factors such as preoperative metabolic status, adherence to dietary guidelines, and physical activity. Early postoperative weight loss plays an important role in predicting long-term success; patients who experience marked weight loss in the first three months often maintain substantial weight loss at five years. Overall, sleeve gastrectomy is an effective intervention for obesity and leads to significant, sustainable weight loss in many individuals.
What are the risks of sleeve gastrectomy?
Sleeve gastrectomy can involve various risks. Early-stage complications include bleeding (around 2-4%) and gastric leaks (1%), which may lead to infections and require additional interventions. Over the long term, there is a risk of developing gastroesophageal reflux disease (GERD), observed in about 25% of patients. Nutritional deficiencies are common, and lifelong supplementation of vitamin B12, vitamin D, iron, and folic acid may be necessary. Other complications include gastric strictures (seen in about 3.5% of cases) and, rarely, damage to the vagus nerve, leading to difficulties in gastric emptying. Some patients may regain weight if they continue poor eating habits. The overall mortality rate of the procedure is low (0-0.1%), but it is important to discuss these risks in detail with a physician.
Which dietary plan should be followed after surgery?
The diet after sleeve gastrectomy is structured in stages to support recovery and adapt to the reduced stomach size. In the first stage, clear liquids (water, broth, sugar-free gelatin) are consumed. In the second week, protein-rich liquids (protein shakes, strained soups, sugar-free milk) are introduced. In the third week, puréed foods (eggs, cottage cheese, puréed fruit) can be consumed. From the fourth week onward, soft solid foods (steamed vegetables, well-cooked meat) are gradually added, and careful chewing is required. Around the fifth week, a normal diet can be resumed, focusing on lean proteins, vegetables, and whole grains. Sugary and fatty foods should be avoided, meals should be eaten slowly, and patients should stop eating when they feel full.
Can weight be regained after sleeve gastrectomy?
Yes, it is possible to regain weight after sleeve gastrectomy. Studies show that weight regain rates vary over the years, ranging from 5.7% at the end of the second year to up to 30% by the sixth year. Factors contributing to weight regain include age, poor eating habits, stomach dilation, and pregnancy. Additionally, weight regain in the second year post-surgery can be an important indicator for long-term outcomes. However, sleeve gastrectomy is generally effective, and patients can maintain an average of 53.6% excess BMI loss at 10 years, supporting continued weight management.
References
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