Gastric Sleeve and Nissen Sleeve

Mode of action: sleeve or vertical gastroplasty in Tunisia.

The sleeve consists of removing a large part of the stomach to form a tube. The food will first be slowed down during its passage through the tube, then be evacuated very quickly into the small intestine.

The Sleeve acts through several mechanisms that combine:

A restriction (such as gastroplasty).
A decrease in the level of grelin, which is the hunger hormone, which leads to a lack of interest in food.

The selection criteria are rigorous, it is not necessary to have a BMI greater than 40 to be operated on in Tunisia. We treat patients with a BMI of 30.

Result of a Sleeve in Tunisia

A Sleeve allows you to lose about forty kilos in one year. Namely a loss of 70% of excess weight. If it turns out to be insufficient to obtain greater weight loss, it can then be transformed into a bypass under good safety conditions.

Currently, some teams offer the Sleeve instead of gastroplasty (gastric banding) for the following reasons:

It causes a rapid feeling of satiety, like gastroplasty.
It does not require the placement of a foreign body (gastric band).
Vomiting is less common than with gastroplasty.
It decreases the level of ghrelin, and therefore the feeling of hunger, as in the bypass.
It is performed by laparoscopy

Detail of the intervention of the sleeve gastrectomy under celioscopy step by step "with Illustrations"

Below you will find photos showing the key steps of a typical sleeve gastrectomy surgery. These Gastric Sleeve illustrations can show candidate patients exactly how the Gastric Sleeve operation works and help them understand the basic steps and principles of this bariatric surgery .

1. Small incisions are made in the abdominal wall for the introduction of the trocars

The incisions can be up to 4 small.

2. Inspection of the stomach

The stomach is inspected. The blood vessels to the lateral side of the stomach are split. The stomach is therefore vascularized by two arterial circles:

The circle of lesser curvature
The circle of great curvature

3. Placement of the gastric tube to calibrate the part of the stomach that will remain

A candle tube or also called gastric tube is inserted into the stomach and serves as a size calibrator for the new stomach.

4. Beginning of stomach stapling: Gradually the stomach is stapled following the calibration (candle)

In this stage of the gastric sleeve procedure, the stapler is used to divide the stomach into two parts. From 4-6 cm of the pylorus (the valve between the stomach and the small intestine), At the beginning, the stapler is slightly further from the candle tube to avoid causing narrowing (stenosis).

5. The stapler will cut the stomach into two parts: The stomach is stapled over its entire length.

The remaining part will look like a slender tube, it has a sleeve shape, this is called sleeve gastrectomy which is carried out by following a gastric tube or candle tube.

6. Stomach resection: The stomach is completely divided into two parts.

The cut part (right) is about 75-80% of the original stomach volume. Once this part of the stomach is decompressed, it is removed through one of the incisions made (15 mm trocar).

Some scientists believe that the removed upper part of the stomach (fundus) has the function of secreting hunger hormones. Indeed, once this part of the stomach is removed, many patients do not feel hungry after surgery.

Note: The resected part is sent to the laboratory for analysis

7. Finally the result of intervention gastric sleeve: new stomach has about 20-25% of the volume of the original stomach.

The new shape of the stomach (Gastric tube) has about 20-25% of the volume of the original stomach. After this intervention, the patient eats much less, given the reduction in the stomach which leads to a rapid feeling of satiety, but also the patient is less hungry, this is due to the sleeve gastrectomy which reduces the level of ghrelin and therefore the feeling of hunger.

What are the risks of sleeve gastrectomy?

Malnutrition and vitamin deficiencies are rare.
No oral supplementation is necessary.
A biological assessment after a weight loss of 25 to 30 kg is carried out. It sometimes shows small vitamin deficits which are easily compensated orally.
The Sleeve is not reversible. However, in a certain number of cases, the tube risks dilating after 3 to 4 years, and is no longer effective.
Eating habits should be changed, 3 meals and possibly 2 snacks.
Vomiting is quite rare.
Regular monitoring by a multidisciplinary team is mandatory.
2 blood tests are necessary the first year, then 1 blood test per year, to look for a vitamin deficiency.

Hospitalization for a sleeve gastrectomy operation in Tunisia.

The duration of hospitalization is 4 to 5 nights for optimal monitoring.

For obvious security reasons, the duration of the stay will be imposed, namely 6 days / 5 nights on Tunisian territory. Essential time to ensure that you can return home safely.

Rate Sleeve gastrectomy in Tunisia: 3800€ stays of 6 days / 5 nights in the clinic.

What is the postoperative after bariatric surgery?

All about the Nissen sleeve!

Nissen's procedure was first performed in 1955, and it is used only in cases of great necessity. This is the combination of a sleeve gastrectomy and an anti-reflux assembly (Nissen operation).

This operation consists of making a valve with stomach, which will surround the esophagus on its terminal part (intra-abdominal) in order to prevent acid reflux. It is a kind of anti-reflux valve used to prevent the rise of food from the stomach to the esophagus. Once the valve has been made, a calibration tube is positioned in the stomach, and the latter is cut as for a sleeve gastrectomy. The Nissen Sleeve technique being a bit more complex, the hospitalization can be a bit longer.

What are the conditions to be able to benefit from a Nissen Sleeve and why do we have recourse to this operation?

The cardia ie the junction between the esophagus and the stomach is maintained just under the diaphragm. It will ensure a role of automatic closure of the entrance to the stomach, thus preventing the rise of acidic foods in the esophagus.

To be able to benefit from a Nissen Sleeve, it will be necessary, as for any bariatric intervention, to respect the criteria of the HAS: That is to say the weight, the regular postoperative follow-up and the preoperative assessment.

As explained by Dr Jabbes , The major problem caused by a Sleeve over the long term is the appearance of acid gastric reflux (treated with antacids for a long time) or food regurgitation (with a risk of pulmonary infections). This complication is the result of an alteration, during the operation, of the natural anatomical mechanisms preventing reflux.

This complication encroaches on the quality of life of patients and can even, in some cases, require a transformation of the Sleeve into a By-pass. This chronic reflux can in the long term lead to changes in the lining of the esophagus (i.e. transform the esophageal mucosa into a gastric or intestinal mucosa called endobrachy-esophagus) which in the long term can cause esophageal cancer (fortunately rare).

Patients who have undergone sleeve gastrectomy are now asked to have a fibroscopy check-up regularly to monitor the possible appearance of these lesions.

In patients suffering preoperatively from gastric reflux (which could be aggravated by the Sleeve), the alternative is to perform a By-pass. But, for various reasons such as the refusal of the patients or the taking of certain medications, the realization of a by-pass may not be desirable.

It is therefore to be able to perform a Sleeve and try to avoid this acid reflux and its risks of complication that this intervention was proposed.

The results of the Nissen Sleeve

In the short term, the results on weight loss are more or less identical, because of sleeve gastrectomy (about 70% weight loss), with good control of gastric reflux.

Eating comfort also seems comparable to that of a conventional sleeve gastrectomy.

Possible complications of the Nissen Sleeve

The risks of complications are those of sleeve gastrectomy, i.e.:

The risk of hemorrhage (estimated at approximately 2%), occurring in the form of a hematoma in the gastrectomy space (where the stomach was removed) or in the form of digestive hemorrhage (presence blood in the stool the days following the operation).
The risk of fistula (leakage) on the staple line, estimated between 1% and 2% in Sleeve gastrectomy, but which is rarer in the Nissen Sleeve: The anti-reflux valve would protect the suture line.
The risk of deep vein thrombosis (phlebitis or pulmonary embolism) rare but potentially serious. This risk can occur after any type of surgical intervention but more frequently in obese patients. This risk can be reduced by making the patient take an anticoagulant treatment, by having her wear anti-thrombosis stockings.

To these risks of complication is added that of necrosis or perforation of the gastric anti-reflux valve: This may require another operation to remove the necrosis and treat the infection.

In the long term, the risk is above all that of a resumption of weight favored by dietary errors, the absence of nutritional monitoring and physical and sporting activity and psychological monitoring.

The risk of deficiency in vitamins and mineral salts is the same as that of Sleeve gastrectomy and therefore requires compensation adapted to the blood tests prescribed by a nutritionist.

As with sleeve gastrectomy, gastric reflux may occur and require antacid treatment. Regular endoscopic monitoring is therefore desirable until more precise scientific data are available.

A long-term multidisciplinary follow-up is therefore essential to have a good result, prolonged in time and to avoid any complication.

Your food, following a Nissen Sleeve, will initially be liquid, to thicken over the weeks, until it is solid approximately one month after the procedure.

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