We normally reduce the stomach to contain around 100 – 150 ml when full. It is very important to choose the right stomach size, so that weight loss is achieved without causing food intolerance and lower quality of life. We found that this size fits most patients, but we take into account all hints towards a bigger or smaller size.

Your stomach will never regrow, but it will stretch after surgery. How much a stomach could stretch is unknown, but we expect it to remain at a maximum of around 250ml.

Shape plays an important role in determining your progress after surgery. We find that the ideal shape is a gradual increase in diameter from the cardia to the antrum. We also are very focused on axial rotation, angulation, and narrowing at the mid-stomach (the incisura), to make sure that the shape fits your physiology.

Ghrelin is a hormone that produces the sensation of hunger. It is produced by microscopic glands inside the flesh of the stomach, which reside mainly in its upper part. Surgery will not stop all ghrelin production, but the majority of the glands will be taken out.

Some patients might lose hunger signals and schedule their eating around the time of day only. The majority of patients will still feel hunger, but in a much lower intensity. We have also observed other rare changes in patient habits, like losing interest in your favorite food or being unable to tolerate smoking.

The vagus nerve informs our brain about how the food we are ingesting is moving through the esophagus to the stomach. With a sleeved stomach, the bolus will be traveling more slowly, causing the vagus nerve to communicate the feeling of a full stomach more quickly, prompting you to stop eating.

In the pre-operative preparation, we will assess your suitability of weight loss surgery as well as your anesthetic tolerance:

• We need to know details of your general health, medications, previous surgeries, etc.
• We need to have blood tests and ECG (other tests might be needed)
• We review your medication and adjust the dosage. Blood thinning medications and diabetes medications are particularly in need to be reassessed. You should not take diabetes medication on the day of the surgery
• We discuss your psychological status and mange dosage of any mental health medications you might be taking
• Cardiac and blood pressure medications should be continued. Make sure to inform us about them
• Cardiac stents and management of both aspirins and plavix is addressed if necessary
• Please inform us of any significant previous anesthetic reactions or any significant allergies

At this stage, we also help you prepare in the best way for weight loss surgery:

• We inform you on how to plan your work, family, and social commitments
• We agree with you on the pre-surgery diet
• Brisk walking for few hours every day before surgery will improve recovery post-surgery
• Smokers should stop smoking a few weeks before surgery. Smoking will cause breathing difficulties and frequent coughing which can be painful after surgery
• Try not drinking alcohol, as it puts more burden on the liver and increases the severity of fatty changes
• Patients are required to fast from midnight of the night before surgery. Patients undergoing surgery in the afternoon might still consume liquids up to 4 hours before surgery, unless they have any issue with previous lap bands and esophageal dilatation

Pre-operative logistics:

• The hospital will inform you on the time of surgery
• The nurse will check you and go over the paperwork with you
• We will perform a few formal check-ups and anesthetic review in the operating theatre
• Once on the operating table, we will insert an intravenous canula, provide oxygen to you via a mask, and prepare everything for surgery
• We will then give you anesthesia, which takes 30-40 seconds to take full effect

The operation is performed laparoscopically (also known as keyhole surgery). We sometimes make exceptions and perform open surgery on patients with previous complex open surgeries and other conditions that might make laparoscopic procedures impossible.

We will start by cleaning the operation site with antiseptic and the proper drapes. The first incision will be right under the left ribcage. This will be used for the insertion of the camera. We then insert the other working ports through other small incisions. The greater Omentum is a fatty tissue that covers your intestines. It will be dissected from the stomach. This will allow for the restriction of the lateral border of the stomach following the insertion of the calibration tube (Bogie). The Bogie is then inserted by the anesthetist. We proceed by resecting the left lateral border of the stomach. In this stage, we use a stapling device and leave the stomach big enough to contain 100-150 ml. In this stage, surgeon experience is fundamental, as there is no clear measurement to take to make sure the stomach is the right size.

We then look at the shape of the stomach. It is important that the stomach is narrow at the top and slowly curving and increasing in size as we go towards the lower end. Dr Khaleal also folds and stitches the lower end of the stomach to prevent future stretching or dilatation. In the next step, we reinforce the stapling line by attaching the new stomach wall to the fat layer (Omentum). This process keeps the stomach in place and avoids twisting and bleeding from the staple line. The last quarter of the staple line will be folded to re-shape the lower part of the stomach where stapling is difficult and could lead to complications.

The surgery is now over, and we inject a local anesthetic and conduct a final inspection to make sure everything has been done by the book. We clean the wound and close it with dissolvable stitches under the skin. Steristrips and waterproof dressing are then applied.

The anesthetist will then slowly reverse the anesthetic and will remove the breathing tube when you are wake enough. You will not feel or remember anything from the surgery, as you will be on a sedated sleep the whole time.

You will be admitted at the recovery ward as soon as you are awake enough.

The day of surgery
You will be nil by mouth, which means you will not be able to get any food, drink, or medication via your mouth. It is also common to feel some pain and discomfort. Laparoscopic surgeries are much less painful than open procedures, but the extent of the pain you feel will depend on personal factors (e.g. age, comorbidities, psychology).

You will receive nutrients through your intravenous canula, and oxygen though your mask or nasal tube.

The first day after surgery
In the morning, you will be assessed to check your suitability to start drinking water and the liquid diet. You should also be able to come off the bed and move around.

Oral intake and diet overview
The first day after surgery, you will be asked to start drinking water to see if you start tolerating the oral intake of nutrients. Around midday, you will be instructed to drink 20ml of water every hour for a few hours. If there is no vomiting episodes or excess nausea, you will be able to progress to the full liquid diet and continue that diet for around 5 days.

The color of your urine is fundamental to determine if you are drinking enough. If dark, try and increase your oral intake.

No food that needs chewing should be consumed in the first four weeks after surgery. Your diet will progress slowly as summarized here. Please consult Surgery follow-up guide for detailed information on your post-surgery diet.

Days 1 to 5: Clear fluid diet
Week 2: Pureed diet
Week 3: Pureed diet with the addition of chicken or meat to the blend
Week 4: Thicker puree, with a consistency closer to mashed foods
Week 5: Soft food diet
Week 6: Full diet

Vitamins and protein supplements

Daily multivitamins are very important to cater for the needs of your body. Even people with a full stomach might need vitamin supplements, as the food we consume normally is very poor in vitamins.

Here is a breakdown of the fundamental vitamins you need and their effects:

• Vitamin B12
  Usually, an injectable preparation is needed. The absorption of this vitamin needs a special protein produced by the stomach, and since the stomach is smaller, less protein is produced. This leads to less vitamin B12 absorption.
• Vitamin D
  The majority of us have low levels of vitamin D. This vitamin is very important for bone mineralization, the immune system and overall wellbeing. Adequate level is needed to prevent hair loss.
• Calcium
  It is important to have an adequate calcium intake to avoid early osteoporosis, especially in pre- and post-menopausal ladies.
• Iron
  It is usually difficult to absorb, and it needs adequate stomach acid to facilitate absorption. Having a smaller stomach leads to a lower acid production and thus less iron absorption. Supplements could be oral or through infusion if a severe deficiency is encountered.
• Silica and other hair and nail preparations
  Supplements help to stabilize and prevent excess hair loss.
• Protein
  An average of 60 – 70 gram of protein is needed daily, to keep a lean body weight, a sense of well-being, and to help preventing hair loss.
• Fiber
  Many patients suffer from constipation due to insufficient fiber intake, as they do not consume enough fruits and vegetables. We usually recommend Benefiber to help with bowel movement.

You will need to take it easy in the first 5 to 7 days. Some patients can go back to their office job one week post-surgery, but others might feel weak, depending on how much initial calories restriction they had.
If calories are too restricted the body will switch into severe starvation mode to decrease its energy expenditure. This will make you feel like you have no energy – not even to move around. The body will eventually start burning its stored fat to supply itself with the energy needed to resume a normal level of activity.

You should be able to drive around 5 to 7 days after the surgery. You should also be able to return to office duties from 1 to 3 weeks after surgery depending on your overall recovery.

Around 3 to 6 weeks after surgery, you should be able go back to work on light duties, meaning activities that do not involve hard pulling or pushing, nor lifting over 5 kg.

Regarding physical exercise, do not push beyond normal walking for the first 2 weeks. On the 3rd week, you may start brisk walking and gentle jogging. Full sport activities can be started 6 weeks after surgery.

You can restart your physical intimacy roughly at 3 weeks.
If you have children at the age where you need to lift them and change nappies, you may need help for a few weeks.

Heavy lifting or physical activities of any sort could lead to the development of abdominal wall hernia but should have no effect on the actual sleeved stomach, unless you get involved in extreme activities or direct accidents.

You will have waterproof dressing covering the wound. It could stay up to 7 – 10 days. Some bruising in and around the wound is expected in some patients. Minor blood oozing might happen too, only excessive bleeding leaking through the dressing needs attention.

Infection is not very common and not very troublesome as we don’t have a foreign body inside to worry about.

You may shower from the first day, but you do need to pat the wound dry.

Pain is normally not a big issue, and the majority of our patients are pleasantly surprised of the lack of pain after surgery.

You will receive instructions on how to inject at home any pain relief medication you might have received at the hospital. The majority of patients won’t need more than dissolvable Panadol. Endone and Targin are stronger pain relief medication options.

Lower chest wall pain could be related to fast eating and drinking very quickly. Any pain around the wound is usually due to muscle stretching and bruising from the surgery.
Shoulder tip pain might be significant in patients who had hiatus hernia repair.

Excessive pain with other symptoms should prompt you to contact us for advice.

Unusual pain in the chest or legs should be investigated, as it might indicate a deep venous clotting and pulmonary embolism.

Diabetic medication
During the pre-operative diet, you will usually cut half the dosage of the diabetes medication you are taking. No diabetic medication should be taken the day of surgery. Your blood sugar will be monitored after surgery, and you will begiven quick-acting insulin in small doses if needed.
The majority of patients will not need any insulin, as the amount of calories ingested is quite small.
If you are taking long-lasting insulin, the dose will be decreased with the aim of stopping it once suitable.

Blood thinners/anticoagulant
Most patients will get an injection of Clexane to prevent blood clots. If there is a history of venous thrombosis, we will most likely keep you on Clexane for a few weeks to avoid complications. Each patient will be assessed individually.

Blood pressure medication
This depends on your blood pressure measurements.

Antidepressants and other psychiatric medication
We try and delay the use of such medications, but they can be taken even on the first day after surgery.

Arthritis medication
It’s very important to stop this medication until the full diet is allowed. Using alternatives and suppositives might be needed.

Cholesterol medication
There usually is no need for these medications after surgery. If still needed, you will be able to restart a few weeks after surgery.

Herbal medications should be stopped, as we don’t completely understand their effect, nor if they have any.

Other medication should be discussed as needed.

Acid medication
Acid medication is administered through the drip (IV canula) whilst you are in hospital. On discharge, you will be given a prescription for Pariet tablets 20mg for 2 weeks. This should help your stomach wound healing, and your acid reflux episodes.

Acid reflux might persist. We have observed that the majority of episodes sets down in about 3 months. If reflux persists for a long period and you are not responding to medication, formal assessment and investigation is needed. Some patients might need surgical intervention.

During initial surgery we try to make sure a few boxes are ticked to prevent or lessen the impact of possible post-operative acid reflux. A common difficulty is given by a very large fatty liver which obscures the hiatus. This makes it difficult to assess or repair any hernia during the initial surgery. Although it is not ideal, some do come back for a second surgery, which is normally much safer once some weight is lost.

Although there is a great variation between different patients’ experiences it is difficult to say when it is necessary to call the practice. A few events should raise concerns.

Staple line leakage
Leakage happens for lower than 1% of the patients. It usually causes fever and severe sudden pain after eating, especially if you were not following your dietary instructions.
If you start eating solid foods early, it will be like poking your finger through the staple line trying to break it. You might get away with it, but you should remember that leakage is potentially life-threatening, and it can be quite painful.

We have perfected the procedure to minimize leakage, but we also need you to follow the diet instructions. Even with everything being handled perfectly, leakage might happen.
If it happens, let us know and we will make sure to tend to your complications. We recommend nobody operate on you without consulting us, as we have performed your procedure and know your case very well.

If you are worried that you have a leakage, don’t hesitate to call us. We do not mind “false alarms” and would rather you call us every time you suspect anything. In this way we can make sure there is nothing to worry about or catch the issue as early as possible.
Other more common causes of pain include localized bleeding, normal post-operative pain, psychological issues, lung clots, infections, splenic infarction (sharp decrease in blood supply to the spleen), lung collapse, back-related pain (if you already suffer from chronic back pain), severe acid reflux and inflammation of the lower esophagus, and multiple other related and non-related causes.

Severe acid reflux
Most of the acid reflux is manageable at home with acid medication. Only in the extreme cases, when the sleeved stomach is pulled up into the chest, a semi-urgent surgical intervention is needed. With proper stitching and plication this shouldn’t happen.

Recurrent vomiting and dehydration
Vomiting is not uncommon following sleeve gastrectomy, and it has many causes. Most patients will stop vomiting soon, but some goes on even for a few days and may need readmission for hydration.
The most common cause of prolonged vomiting is usually severe inflammation and oedema of the newly sleeved stomach. If there is some unavoidable angulation in the gastric tube, it might lead to complete blockage.
To counteract and decrease the oedema and the inflammation we usually use Dexamethasone, a strong steroid.

Bleeding
Some blood loss is unavoidable. Bleeding could range from negligible to a level where blood transfusion might be needed. Thankfully, the probability of significant bleeding is low. Bleeding is usually from the newly formed staple line, and stitching usually is the best way to control it, which we routinely do.
Bleeding could also occur from other organs, including liver, spleen, greater Omentum, and the port sites. After surgery, we will monitor your blood levels routinely to check for significant drops.

Deep venous thrombosis
Obesity is one of factors which encourages clotting of the blood in the deep veins. We do take due precautions, like routinely injections of Clexane and putting on stocking and pneumatic calf compressors during surgery. If you are a higher risk patient you might need about 2 weeks of Clexane injections, which you can inject independently at home. The risk of clotting is the highest in the first 3 weeks after surgery, and fades away gradually. Long distance travelling is obviously not advisable in the first 4 weeks.

Hypoglycemia
Literature has registered occasional severe attacks of hypoglycemia, which could lead to fainting. This is usually due to a much higher level of insulin production in an insulin-resistant individual.
Once weight lost occurs, the insulin sensitivity improves but the level of insulin secretion remains the same. This will lead to severe hypoglycemia if the oral intake is inadequate. It can take a few weeks for the sugar level to stabilize.

One of the best ways to prevent these attacks is pre-operative dieting and weight-loss, which trains your body and gets it ready for the post-operative period.

Diet, vitamin and mineral sufficiency or deficiency

A balanced diet including enough proteins, essential elements, and vitamins is important to maintain a healthy body in the long term. There are good recipe books that have been put together specifically for weight loss surgery patients and are available for purchase.

For summarized information, you can also read our post-surgery diet guide.

It is essential to consult an experienced dietician, as it will help preventing long-term nutritional deficiencies. Self-education about food, calories, additives and chemicals can be helpful. After surgery, your stomach is not only smaller, but its functioning will be affected. It will produce less acid, affecting calcium and iron absorption. Stomach emptying will also be quicker, leading for a few patients to develop dumping syndrome.

Vitamin B12 deficiency is also common, mainly due to a decrease in protein produced by the stomach to facilitate the uptake of the vitamin in the small bowel.

Eating and chewing techniques

Although not as severely as with lap band surgery, sleeve gastrectomies cause resistance to food passage. We recommend chewing your food thoroughly. Pushing down your food without proper mastication will lead to severe stretching and dilatation of the esophagus. A stretched esophagus could serve as another stomach, and it could accommodate even more food than a sleeved stomach.

The importance of physical activities cannot be overstated. Exercise helps you maintaining your weight loss and significantly improves your health. Losing weight alone doesn’t make you healthy. Our body is dynamic, and our weight will change with our level of activity. If we don’t exercise, our muscles will get weaker and our bones will become brittle, which will lead to several health issues, ranging from back pain, disc prolapse, osteoporosis and associated fractures, and issues to both muscles and tendons. Our heart and lungs will become less efficient, and our immune responses will drop significantly.

It is important to keep moving and expose our body to gradually higher and higher levels of physical challenges. Consulting a personal trainer and/or exercise physiologist might optimize your quest for very healthy body.

It is very important to re-evaluate your need for pre-existing conditions’ medications regularly, especially in the early stages after surgery. Weight loss has a mostly positive effect on pre-existing medical conditions. Our bariatric physician will be able to guide you through all the changes in your conditions and related medications you might experience after surgery.

If you lose enough weight, the skin might fold and its sagging could become a significant issue. In the severe cases (or for aesthetic reasons) surgical intervention might be needed. Through our clinic we offer abdominoplasty (tummy tuck) at an affordable price for our patients.

We advise to avoid pregnancies in the first 12 months after surgery.

Weight loss surgery is a strong tool to help you lose weight. The surgery can’t, however, stop all the tricks that our body has to regain weight. Your effort will be fundamental in being able to achieve and maintain the weight loss that you will see after surgery.