Parsa Hospital Bariatric Surgery Department

What Does “Sleeve” Mean?

The word “sleeve” in English refers to the part of a garment that covers the arm. In sleeve gastrectomy surgery, after the surgeon removes the majority of the stomach, the remaining portion of the stomach takes on the shape of a narrow tube, a clothing sleeve, or a banana. This is why this name was chosen to describe this type of surgery. This visual analogy helps patients better understand the anatomical changes made to their stomach. Beyond its literal meaning, undergoing sleeve surgery signifies embracing a new lifestyle and committing to different eating habits due to the permanent change in stomach structure.

Cost of Sleeve Gastrectomy

The cost of sleeve gastrectomy in Iran varies and depends on several factors. These include the type of hospital (public or private), the surgeon’s experience and fees, basic and supplementary insurance coverage, and the city where the surgery is performed. Approximately, this cost can be around 100 million Tomans or more. This total amount comprises various expenses, including operating room fees, surgical consumables (especially staplers, which constitute a significant portion of the cost), surgical and anesthesia team fees, hospitalization costs, and necessary medications. Basic and supplementary insurance may cover a portion of these costs under specific conditions (such as having a body mass index (BMI) above 40).

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What is Sleeve Gastrectomy?

Sleeve gastrectomy is a specialized weight-loss surgery during which the surgeon permanently removes about 75% to 80% of the stomach’s volume. The remaining stomach becomes a narrow, vertical tube (resembling a sleeve). This significant reduction in stomach volume severely limits the amount of food an individual can consume in one sitting. Furthermore, by removing the part of the stomach responsible for producing the hormone ghrelin (the hunger hormone), appetite is also significantly reduced. This procedure is recognized as one of the most common and effective obesity surgeries worldwide and plays a crucial role in improving or resolving obesity-related conditions such as type 2 diabetes, high blood pressure, and sleep apnea.

Gastric Sleeve Surgery

Gastric sleeve surgery, medically known as laparoscopic sleeve gastrectomy, is a type of bariatric surgery (weight-loss surgery). In this procedure, the surgeon uses a laparoscopic technique—meaning they make a few small incisions on the abdomen and insert special instruments and a camera—to remove about 70% to 80% of the stomach, primarily its lateral part and the fundus (the top, rounded part of the stomach). The remaining stomach takes on the shape of a narrow tube resembling a banana or a sleeve. This surgery typically lasts between 45 minutes and 2 hours, and the patient is discharged after 1 to 2 days of hospital stay. Recovery after this procedure is faster than traditional open surgeries due to the minimally invasive nature of laparoscopy.

Difference Between Sleeve and Bypass

The main difference between sleeve gastrectomy and gastric bypass surgery lies in how the digestive system is altered and the mechanism of weight loss:

• Sleeve Gastrectomy: In this method, a large portion of the stomach (about 70-80%) is removed to drastically reduce its volume. The food pathway from the esophagus to the intestines remains unchanged, and food still passes through the duodenum. Weight loss primarily results from restricting food intake and reducing the hunger hormone (ghrelin).

• Gastric Bypass: In this method, the surgeon creates a small pouch in the upper part of the stomach and then connects this pouch directly to a section of the small intestine (usually the jejunum). This causes food to “bypass” a large part of the stomach and the initial section of the small intestine (duodenum and early jejunum). As a result, in addition to restricting food intake, the absorption of calories and nutrients is also reduced.

In terms of complexity, sleeve surgery is generally considered simpler and less invasive than bypass surgery and has a shorter operating time. Gastric bypass, especially the classic type, may lead to more nutrient malabsorption and requires more diligent lifelong vitamin and mineral supplementation.

What is “Money Sleeve”?

The term “money sleeve” in the context of weight-loss surgeries like sleeve gastrectomy or gastric bypass is not a recognized or relevant medical term. Based on available information, a similar term, “master-slave,” refers to a specific type of relationship or dynamic in the realm of sexual issues and deviations and has no connection whatsoever with obesity treatment, bariatric surgeries, or medical concepts related to weight loss. Therefore, it is important to consider these two concepts completely separate and avoid seeking incorrect information in the medical field based on this phrase.

Cost of Sleeve Surgery

The cost of sleeve surgery (referring to sleeve gastrectomy) encompasses a range of expenses. These include the surgeon’s and surgical team’s fees, hospital-related costs (such as operating room, hospitalization fees, equipment, and medications used during hospitalization), the cost of specialized disposable surgical instruments (especially laparoscopic staplers, which are used to cut and seal the stomach and constitute a significant portion of the cost), pre-operative tests and consultations, and post-operative care and follow-up visits. This cost will vary across different healthcare centers (public or private) and depend on factors such as the city of surgery, the surgeon’s experience, and the patient’s insurance coverage. For precise cost information, direct consultation with a surgeon and review of insurance conditions are essential.

Diet After Sleeve Gastrectomy

The diet after sleeve gastrectomy is a precise, phased eating plan designed to aid stomach recovery, gradually adapt it to the new volume, and ensure adequate nutrient intake. This diet typically includes the following stages:

• Stage 1 (First few days after surgery): Clear liquids. Includes water, strained broth (chicken or beef), very weak and decaffeinated tea, and very diluted fruit juices without added sugar.

• Stage 2 (Approximately 1 to 2 weeks after surgery): Full liquids. Includes low-fat milk, diluted and unsweetened yogurt, thoroughly blended and thin soups, and specialized protein drinks.

• Stage 3 (Approximately 2 to 4 weeks after surgery): Pureed foods. Includes thoroughly mashed and blended foods with a baby-food-like texture, such as pureed meat or fish, cooked and pureed vegetables, and pureed soft fruits.

• Stage 4 (Approximately 4 to 6 weeks after surgery and beyond): Soft foods, then modified regular diet. Soft foods are gradually added to the diet, followed by solid foods with a natural texture. Emphasis is placed on consuming small, frequent meals, thorough chewing of food, prioritizing protein, and avoiding high-fat, high-sugar, and processed foods.

Strict adherence to this diet is crucial for preventing complications and achieving successful weight loss.

Post-Sleeve Gastrectomy Care

Post-sleeve gastrectomy care involves a set of essential measures to ensure proper recovery, prevent complications, and achieve desired weight loss outcomes. This care includes:

• Wound Care: The small laparoscopic incisions should be kept clean and dry. Daily showering and washing the wound sites with mild soap and water, followed by thorough drying, are recommended.

• Pain Management: The doctor will prescribe appropriate pain medications. Self-medication, especially with non-steroidal anti-inflammatory drugs (NSAIDs), should be avoided.

• Diet: Strict adherence to the phased diet prescribed by the medical team is very important.

• Fluid Intake: Drinking enough water and fluids (about 1.5 to 2 liters per day) is essential to prevent dehydration.

• Physical Activity: Light and regular walking from the first days after surgery is recommended to prevent blood clots and aid recovery. Heavy activities and lifting heavy objects should be avoided for several weeks.

• Medications: Regular use of prescribed medications such as proton pump inhibitors (to reduce stomach acid) and vitamin and mineral supplements as directed by the doctor is essential.

• Medical Follow-up: Regular follow-up visits with the surgeon and nutritionist are mandatory to assess the recovery process and adjust the treatment plan.

Nutrition After Sleeve Gastrectomy

• Nutrition after sleeve gastrectomy plays a vital role in the short-term and long-term success of the surgery. The key principles of this nutrition include:
• Prioritize Protein: Consumption of high-quality protein (such as lean meat, chicken, fish, eggs, low-fat dairy, and legumes) is essential for maintaining muscle mass, tissue repair, and prolonged feelings of fullness.
  Small, Frequent Meals: Due to the drastic reduction in stomach volume, meals should be consumed slowly and in small portions (e.g., 4 to 6 meals per day).

• Thorough Chewing: Every bite should be thoroughly chewed to facilitate digestion.

• Adequate Fluid Intake: Drinking water and calorie-free fluids between meals (not with food) is important to prevent dehydration.

• Vitamin and Mineral Supplements: Due to reduced food intake and potential changes in absorption, lifelong use of multivitamin, calcium, vitamin D, vitamin B12, and iron supplements, as prescribed by the doctor, is often necessary.

• Avoid Specific Foods: High-fat, high-sugar foods, carbonated beverages, and processed, nutritionally poor foods should be avoided.

How to Sleep After Sleeve Surgery

Regarding how to sleep after sleeve surgery, general recommendations exist for comfort and to aid recovery.

In the first few weeks after surgery:

• Sleep on your back or on the side opposite to the painful area: Avoid sleeping on your stomach to prevent pressure on the incisions and the newly operated stomach.

• Elevate your upper body: Using several pillows to elevate your head and upper body (so that your head is elevated for about two weeks) can help reduce abdominal pressure, ease breathing, and decrease the likelihood of reflux.

• Personal comfort: Ultimately, choose a position in which you feel most comfortable and that does not put pressure on your stitches. If you have concerns about a specific sleeping position, consult your doctor or surgical team.

Prohibitions After Sleeve Surgery

After sleeve gastrectomy, adhering to certain prohibitions and restrictions is essential for maintaining health, preventing complications, and achieving successful weight loss. These include:

Dietary Prohibitions:

• Hard, dry, and slow-digesting foods: These foods should be strictly avoided in the early stages of recovery.

• High-fat and fried foods: These foods can cause digestive discomfort and hinder the weight loss process.

• Very sweet foods and sugary drinks: High sugar intake can lead to dumping syndrome (though less common in sleeve than in bypass) and weight gain.

• Carbonated and alcoholic beverages: These drinks can cause stomach distension, gas, and discomfort, and have no nutritional value.

• Certain raw and fibrous vegetables initially: These may be difficult to digest at first.

Medication Prohibitions:

• Non-steroidal anti-inflammatory drugs (NSAIDs): Such as ibuprofen, naproxen, diclofenac, and mefenamic acid, as they increase the risk of stomach damage and ulcers.

• Self-medication: Any medication, even herbal remedies, must be taken only with the knowledge and prescription of a doctor.

Other Prohibitions:

• Smoking: Smoking hinders the recovery process and increases the risk of complications.

• Chewing gum: Can cause air to enter the stomach and lead to bloating.

• Overeating and eating quickly: These habits must be completely abandoned.

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Sleeve Gastrectomy or Gastric Bypass

Choosing between sleeve gastrectomy and gastric bypass is a significant and personal decision that should be made in close consultation with your surgeon and based on each patient’s specific circumstances. Neither of these procedures is inherently “better” than the other, and each has its own advantages and disadvantages.

Sleeve gastrectomy may be more suitable for individuals who:

• Are concerned about complications from nutrient malabsorption and the need for lifelong supplementation.

• Prefer a simpler procedure with shorter operating time and potentially fewer short-term complications.

• Have a history of multiple abdominal surgeries that would make bypass more difficult.

Gastric bypass may be more suitable for individuals who:

• Have a very high body mass index (BMI).

• Suffer from severe, uncontrolled type 2 diabetes (bypass has a stronger effect on improving diabetes).

• Have severe acid reflux problems (sleeve can sometimes worsen reflux, while bypass usually improves it).

The final decision is made after a thorough evaluation by the medical team, considering the patient’s goals and preferences.

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Differences Between Bypass and Sleeve

The key differences between gastric bypass surgery and sleeve gastrectomy are as follows:

Anatomical Changes:

• Sleeve: A large part of the stomach (about 70-80%) is removed, and the stomach becomes tube-shaped. The digestive pathway and intestines are not manipulated.

• Bypass: A small pouch is created from the stomach and directly connected to a more distant part of the small intestine. In this method, a large part of the main stomach and the initial part of the small intestine are bypassed from the food pathway.

Mechanism of Weight Loss:

• Sleeve: Primarily through restriction of food intake and reduction of the hunger hormone (ghrelin).

• Bypass: A combination of restriction in food intake and reduced absorption of calories and nutrients (malabsorption).

Complexity and Operating Time:

• Sleeve: A simpler procedure with shorter operating time.

• Bypass: A more complex procedure with longer operating time.

Malabsorption and Supplement Needs:

• Sleeve: Nutrient malabsorption is less significant, but some supplements are still needed.

• Bypass: Nutrient malabsorption is considerable, and the need for lifelong and precise vitamin and mineral supplementation is crucial.

Impact on Co-existing Conditions:

Both methods are effective in improving obesity-related conditions, but bypass often has a stronger and faster effect on improving type 2 diabetes.

Potential Complications:

Short-term and long-term complications may differ for each method. Bypass carries risks such as internal hernia or marginal ulcers that are not present in sleeve. Sleeve may worsen reflux in some individuals.

Post-Sleeve Gastrectomy Care

Post-sleeve gastrectomy care is crucial for a successful recovery and achieving sustainable weight loss results. This care is a comprehensive program including:

• Adherence to Doctor’s Instructions: This includes precise medication intake (such as pain relievers, stomach protective medications, and supplements), following the phased diet, and performing recommended physical activities.

• Wound Care: Keeping the small laparoscopic incision sites clean and dry to prevent infection.

• Proper Nutrition: Adequate fluid intake, focus on protein, and avoidance of prohibited foods.

• Physical Activity: Starting with light walking and gradually increasing activity according to the plan to prevent complications and aid weight loss.

• Follow-up Visits: Regular attendance at scheduled appointments with the surgeon and nutrition team to monitor recovery progress, adjust diet and supplements, and manage any potential issues. Long-term success after sleeve gastrectomy significantly depends on the patient’s commitment to this care and making sustainable lifestyle changes.

BMI Calculation for Sleeve Surgery

Body Mass Index (BMI) calculation is an essential step in assessing an individual’s eligibility for sleeve gastrectomy. BMI is calculated using the following formula:

BMI = Weight (in kilograms) / (Height (in meters))2

Common criteria for considering sleeve surgery based on BMI include:

• BMI of 40 or higher: Individuals in this category (morbidly obese or Class III obesity) are typically considered suitable candidates for sleeve surgery.

• BMI between 35 and 39.9 with obesity-related conditions: Individuals whose BMI falls within this range (Class II obesity) and who also suffer from one or more serious obesity-related conditions such as type 2 diabetes, high blood pressure, severe sleep apnea, or severe joint diseases, may also be candidates for surgery.

The specialist doctor will make the final decision regarding the suitability of the surgery by calculating BMI and considering other health conditions, medical history, and previous weight loss attempts.

Best Sleeve Gastrectomy Surgeon

Choosing the best sleeve gastrectomy surgeon is a crucial decision that directly impacts the outcome of the surgery and the patient’s health. Key criteria for identifying a good surgeon include:

• Specialization and Academic Qualifications: The surgeon should be board-certified in general surgery and preferably have a sub-specialty in bariatric and metabolic surgery or an advanced laparoscopy fellowship.

• Experience and Skill: The number of successful surgeries performed, a history of working in reputable centers, and high proficiency in laparoscopic techniques are of great importance. The surgeon should also be able to manage potential complications.

• Commitment to Patient and Follow-up: The best surgeon prioritizes the patient’s health and satisfaction, provides thorough and honest consultation before the operation, prepares the patient mentally, and follows up on the patient’s condition and recovery process after surgery.

• Effective Communication: The ability to communicate well with the patient, answer their questions and concerns, and provide clear and understandable explanations are important characteristics.

• Surgical Team and Hospital: Collaboration with an experienced team (anesthesiologist, nurses) and performing surgery in a hospital with appropriate and standard facilities and equipment are also important. Researching previous patients of the surgeon (while respecting privacy), reviewing online reviews and records (with caution), and seeking opinions from other doctors can also help in this choice.

The use of an abdominal binder after sleeve gastrectomy is a topic with differing opinions:

• Proponents of abdominal binders: Some surgeons and patients believe that using an abdominal binder can help support abdominal muscles, reduce swelling and bruising at the incision sites, and create a greater sense of security and comfort during the recovery period. This group may recommend using a binder for a few weeks after surgery, according to specific instructions.

• Opponents or cautious users of abdominal binders: Another group of surgeons believes that abdominal binders do not significantly prevent skin sagging or accelerate the weight loss process. They are also concerned that improper or overly tight binder use might increase intra-abdominal pressure, put pressure on the stomach staple line, and even increase the risk of leaks or other complications.

Given these different viewpoints, the most important step is to consult your own surgeon. They will provide the best recommendation regarding the use or non-use of an abdominal binder and its proper method, considering your specific condition, the type of surgery performed, and your recovery process.

Period After Sleeve Surgery

Changes in the menstrual cycle (period) after sleeve gastrectomy are a relatively common phenomenon with various reasons:

• Impact of rapid weight loss: Significant and rapid weight loss after surgery can cause physiological stress on the body, leading to temporary changes in hormone levels and consequently irregular periods.

• Hormonal changes: Obesity itself is associated with hormonal imbalances, especially increased estrogen levels (due to the conversion of androgens to estrogen in fat tissue) and insulin resistance, which can lead to menstrual irregularities or even their cessation (amenorrhea). Sleeve surgery and the resulting weight loss help reset these hormones. In the initial months after surgery, this re-regulation may manifest as delayed periods, changes in bleeding amount, or duration.

• Long-term improvement: For many women who experienced menstrual irregularities due to obesity before surgery (especially those with polycystic ovary syndrome or PCOS), menstrual regularity improves after weight loss from sleeve surgery, and even fertility increases.

• Medications: Some medications used during or after surgery to prevent bleeding may temporarily affect the menstrual cycle.

Usually, these changes are temporary, and after a few months, with relatively stable weight, the menstrual cycle returns to a more normal or regular pattern. If irregularities persist or concerns arise, consultation with a gynecologist is recommended.

Conditions for Sleeve Gastrectomy

To undergo sleeve gastrectomy, an individual must meet specific conditions that are evaluated by the medical team. The most important of these conditions include:

What is Gastric Bypass Surgery?

Gastric bypass surgery is a type of bariatric surgery (weight-loss surgery) performed with the aim of significant weight loss in individuals with morbid obesity. In this surgical procedure, fundamental changes are made to the structure of the stomach and the food pathway in the digestive system.

Generally, this procedure involves two main stages:

• Creation of a small stomach pouch: The surgeon separates the upper part of the stomach and creates a small pouch (usually about the size of an egg or a walnut). This pouch will be the patient’s new, functional stomach, and its capacity to hold food is very limited.

• Rerouting the small intestine (Bypass): This small stomach pouch is then connected to a section of the small intestine (usually the middle part called the jejunum). By doing this, after food enters the small stomach pouch, it “bypasses” a significant portion of the main stomach and also the initial part of the small intestine (duodenum and early jejunum).

These changes cause the individual to consume less food (due to the limited volume of the stomach pouch) and also reduce the absorption of calories and nutrients from the food consumed (due to bypassing the absorptive part of the intestine). Gastric bypass surgery is recognized as one of the most effective methods for weight loss and improving obesity-related conditions, especially type 2 diabetes.

Classic Bypass

Classic bypass, also known as Roux-en-Y Gastric Bypass (RNYGB), is recognized as the standard and primary method of gastric bypass surgery and has been used for decades. The main features of this method include:

• Creation of a small stomach pouch: A small pouch, approximately 15 to 30 cubic centimeters in volume, is separated from the upper part of the stomach. This pouch severely limits the amount of food a patient can eat in one sitting.

• Creation of two anastomoses (connections):

  • Gastrojejunostomy: The small stomach pouch is connected to a section of the small intestine (jejunum) that has been measured and cut (this part of the intestine is called the Roux limb).

  • Jejunojejunostomy: The other part of the small intestine that comes from the main stomach and duodenum (and contains digestive juices, called the biliopancreatic limb) is connected to the Roux limb at a lower point, so that digestive juices mix with food and digestion continues. This Y-shaped structure gives the operation its name, Roux-en-Y.

Classic bypass, due to its dual mechanism (restriction and malabsorption), leads to significant and sustainable weight loss and remarkable improvement in metabolic diseases, especially type 2 diabetes. However, this method is technically more complex than sleeve or mini bypass and requires precise nutritional care and lifelong supplementation.

Mini Bypass Surgery

Mini bypass surgery, also known as Single Anastomosis Gastric Bypass or Omega Loop Bypass, is a type of bariatric surgery that has been developed as a simpler version with variations compared to the classic Roux-en-Y bypass. The main features of this procedure include:

• Creation of a tubular stomach pouch (sleeve-like): The surgeon creates a longer and narrower stomach pouch (similar to what is created in sleeve surgery, but usually slightly larger) from the upper part of the stomach.

• Creation of one anastomosis (connection): This stomach pouch is directly connected to a loop of the small intestine (usually at a distance of 150 to 200 centimeters from the beginning of the duodenum). This connection is in the shape of the Greek letter Omega (Ω), which is why it is also called the Omega Loop Bypass. Unlike classic bypass, which has two connections, mini bypass has only one connection.

Like classic bypass, this method also helps with weight loss by both restricting the amount of food consumed and creating a degree of malabsorption (by bypassing a portion of the intestine). Mini bypass has gained popularity due to its greater technical simplicity, shorter operating time, and some studies showing fewer short-term complications.

However, one concern associated with this method is the higher likelihood of bile reflux into the stomach and esophagus in some patients. Like other bypass surgeries, this procedure also requires lifestyle changes and supplementation.