Gastric Sleeve Considerations

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Introduction   

Gastric sleeve surgery is a type of bariatric surgery available for patients who have a body mass index (BMI) of 30 or greater, falling under the obesity or severe obesity categories. As the rates of obesity continue to increase, many patients who are obese are considering gastric sleeve surgery as a treatment to help lose weight and improve comorbid conditions. Therefore, nurses and healthcare providers must understand obesity and its common comorbidities and physical exam findings.  

Before surgery, nurses and healthcare providers should understand common diagnostic tests and eligibility for surgery. They should also understand the post-operative care considerations, including follow-up, management, and potential complications. This course aims to equip learners with knowledge related to obesity and gastric sleeve surgery by reviewing the definition, epidemiology, pathophysiology, and etiology. This course also describes the signs, physical assessment findings, comorbidities, diagnostic tests, and eligibility for bariatric surgical treatment.  

Lastly, it reviews postoperative care considerations and management, both short and long-term, along with patient discharge, education, follow-up, and emerging research.  

Definitions 

Bariatric surgery is a weight loss surgery performed on morbidly obese patients. There are three main types or concepts of bariatric surgery, which include: 

• Gastric restriction, like the gastric sleeve or gastric band 

• Gastric restriction with mild malabsorption, such as the Roux-en-Y gastric bypass 

• Gastric restriction and malabsorption, like the duodenal switch  

[12] 

Gastric sleeve surgery is also referred to as a sleeve gastrectomy, vertical sleeve gastrectomy (VSG), or laparoscopic sleeve gastrectomy (LSG). It’s a type of bariatric surgery where about a 15-20% portion of the stomach is removed following the greater curve of the stomach [12]. 

Obesity is defined as a body mass index (BMI) of 30 or more for adults. Severe or morbid obesity is classified as having a BMI of 40 or higher. For children and adolescents, a percentile range accounting for weight and growth is used. So, children and teens in the 95th percentile or greater are considered obese, and those within the 120% of the 95th percentile have severe obesity [10]. 

Epidemiology 

According to the World Health Organization’s 2022 statistics, every 1 in 8 people worldwide is obese, and this figure has more than doubled since 1990 for adults and quadrupled for adolescents. Furthermore, it’s estimated that 890 million adults and 160 million children and adolescents have obesity worldwide [14].  

In the United States, obesity rates are much higher when compared to worldwide figures. Data reported by the 2017-2018 National Health and Nutrition Examination Survey estimated more than 2 in 5 adults have obesity, and 1 in 11 adults have severe (also called morbid) obesity in the U.S. [10]. More recent U.S. obesity prevalence rates from 2017-March 2020 reported by the Centers for Disease Control and Prevention were 41.9% of adults 20 years and older are obese, and 73.6% are overweight.  

Obesity rates for children ages 2-5 years old, 6-11 years old, and adolescents ages 12-19 in the U.S. for the same period were 12.7%, 20.7%, and 22.2%, respectively [2]. Additionally, the percentage of U.S. adult males with obesity (including severe obesity) is slightly higher than females at 43% and 41.9%. However, when considering adults who are severely obese, females have a higher percentage at 11.5%, while males are 6.9% [10]. 

Etiology 

The etiology or causes of obesity are multifactorial, including genetic predisposition and socioeconomic, environmental, and psychosocial factors. Generally, obesity is caused by excessive intake of energy or calories and lack of energy expenditure through exercise [14]. Environmental factors, such as school, home, and workplace influences, are common contributors to developing obesity, as well as social and cultural norms.  

Stress, lack of physical inactivity, and poor-quality sleep also increase patient risk. Certain medications, like antidepressants, antipsychotics, birth control, and glucocorticoids, can also contribute to weight gain. Additionally, unhealthy eating habits increase risk, such as consuming excess calories and eating too many foods high in saturated fats and added sugars [9]. 

Pathophysiology  

As mentioned, obesity is the imbalance of caloric intake compared to energy expenditure. When a person consumes more calories than they expend through physical activity, this leads to energy being stored as fat and glycogen in the adipose tissue. This causes adipose hypertrophy and hyperplasia and ultimately leads to visceral fat formation, or fat tissue surrounding vital organs, including the heart and liver. As adipose tissue continues to increase, it secretes adipokines and inflammatory cytokines, signaling inflammatory pathways. This can ultimately lead to obesity-associated diseases or comorbidities, like liver disease, type II diabetes, cardiovascular disease, and malignant tumors [5]. 

Symptoms, Physical Exam, and Diagnosis 

While the screening and diagnosis of obesity may seem straightforward, it’s complex since many health conditions can develop or co-exist in patients with obesity. Typically, there are no specific signs or symptoms directly related to obesity, except for having an obese or severely obese BMI [9].  

As obesity affects many other organ systems, patients may develop symptoms or conditions affecting the following systems [12]: 

• Cardiovascular: pulmonary embolism, hypertension, atherosclerosis, or peripheral venous insufficiency 

• Respiratory: obstructive sleep apnea, obesity-hypoventilation syndrome, or asthma 

• Metabolic/endocrine: type II diabetes, dyslipidemia, or impaired glucose tolerance 

• Musculoskeletal: osteoarthritis or musculoskeletal strains 

• Gastrointestinal: gastroesophageal reflux disease, nonalcoholic fatty liver disease, or gallstones 

• Urologic: stress incontinence or increased risk of urinary tract infections 

• Reproductive: polycystic ovarian syndrome or male hypogonadism 

• Neurological: idiopathic intracranial hypertension or increased risk of developing dementia 

• Psychological: depression, substance abuse, or binge eating disorders 

• Dermatological: intertriginous dermatitis, lymphedema, or cellulitis [12] 

As mentioned, inflammatory pathways may lead to the development of malignant tumors, resulting in cancers of the prostate, breast, ovaries, pancreas, and endometrium [12]. Additionally, certain medical conditions may cause a person to become overweight or obese. Ruling out conditions like Cushing’s syndrome, hypothyroidism, and polycystic ovarian syndrome (PCOS) may help assess an initial probable cause [9]. 

Before undergoing bariatric surgery, patients must complete a full evaluation, including tests like a complete blood count, complete metabolic panel, thyroid function panel, lipid profile, coagulation studies, vitamin B12, serum iron, total iron binding capacity, folic acid, urinalysis, and blood typing. Most patients also complete an electrocardiogram, chest x-ray, and ultrasound of the gallbladder. An upper gastrointestinal endoscopy is also common to rule out upper GI diseases or conditions before surgery, which can pose complications or delay recovery [12]. 

Eligibility for Surgery 

The American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) sets eligibility guidelines for bariatric surgery, with the most recent update as of 2022.  

The criteria recommendations include individuals with: 

• BMI of 40 or higher 

• BMI of 35 or higher with or without comorbidities, like diabetes, obstructive sleep apnea, hypertension 

• BMI of 30 or higher with type II diabetes or metabolic syndrome 

• BMI of 30-34.9 who are unable to lose weight or have metabolic disease  

[3, 11] 

Furthermore, when considering the Asian population, BMI thresholds should be lowered, as a BMI of 25 or greater is considered obese in this population. The guidelines suggest that individuals of the Asian population with a BMI of 27.5 or higher are eligible for bariatric surgery. Additionally, an increasing number of older adults are undergoing bariatric surgery. The provider should weigh the risks and benefits with the patient before suggesting surgery options. However, the guidelines suggest there is no evidence against an age limit for bariatric surgery. Adolescents who are severely obese may also undergo bariatric surgery for weight loss and co-morbidity remission [3]. 

The guidelines also recommend patients who are eligible for surgery be evaluated by a multidisciplinary team, including medical, surgical, nutritional, and psychiatric evaluations. A nutritional evaluation helps determine unhealthy eating habits and behaviors, nutritional deficiencies, and weight history.  

A psychiatric evaluation helps assess mental health conditions, such as depression, substance abuse, or binge eating disorders, which may contribute to obesity since the prevalence of these conditions is higher in eligible surgery candidates [3]. 

There are a few contraindications to gastric sleeve surgery, such as severe uncontrolled psychiatric disorders (like malignant hyperphagia) and coagulopathies. Patients with Barrett’s esophagus or uncontrolled severe GERD are also contraindications to surgery. However, some surgeons may perform surgery on patients with Barrett’s esophagus. Furthermore, patients with high anesthesia risk may be excluded from undergoing gastric sleeve surgery [11]. 

Gastric Sleeve Surgery and Outcomes 

Gastric sleeve surgery is a type of bariatric surgery where about a 15-20% portion of the stomach is removed following the greater curve of the stomach [12]. So essentially, about 70-80% of the stomach remains, leaving the stomach able to hold less volume, resulting in weight loss due to gastric restriction of food intake.  

Additionally, ghrelin, a peptide that stimulates appetite, is also reduced since it’s secreted by the oxyntic glands of the stomach’s fundus. A reduction in ghrelin levels improves weight loss by making patients feel full or inducing satiety. Glucagon-like peptide 1 (GLP-1) is another peptide secreted in the small intestine when there is food present, and it increases insulin secretion and slows gastric emptying and gastrointestinal motility. After gastric sleeve surgery, GLP-1 levels are higher, thus promoting weight loss through improved glucose metabolism [11]. It’s often a preferred bariatric surgery since it does not involve placement of a foreign body, like a gastric band, or lead to malabsorptive deficiencies, like the Roux-en-Y gastric bypass [12]. 

Most patients who undergo gastric sleeve surgery have improved patient outcomes. A sleeve gastrectomy is more effective than the laparoscopic adjustable gastric banding surgery but less effective than the Roux-en-Y. Patients who undergo gastric sleeve surgery lose an average of 60.5% of their excess body weight five years after surgery, which equates to an average BMI of 30.2.  

The overall success rate after surgery is about 92% in one year, 89% after three years, and 75% after five years. The success rate is determined by a percentage excess weight loss of greater than 50% [11]. Conversely, one study found that 20% of patients who had gastric sleeve surgery were able to maintain their appropriate weight loss for five or more years after surgery [8]. 

Sleeve gastrectomy surgery also helps correct patient comorbidities. Surgery resolved type II diabetes for 66.2% of patients 13 months after surgery. Patient outcomes for individuals with nonalcoholic steatohepatitis (NASH) also improved at around 15 months post-surgery. The mortality rate for patients undergoing gastric sleeve surgery is 0-1.2%, and morbidity is 0-17.5% [11]. 

Post-Operative Management 

After surgery, most patients are admitted to the surgical post-op unit and then discharged the following day. Initially, patients arrive at the unit on supplemental oxygen via nasal cannula and are weaned thereafter. If patients are unable to be weaned from supplemental oxygen, they should start considering additional pathologies or complications, like pneumonia, respiratory distress, or atelectasis. Patients with obstructive sleep apnea may need to wear their continuous positive airway pressure (CPAP) device until they have recovered from the sedating effects of anesthesia. To promote lung expansion and reduce atelectasis, patients are encouraged to use an incentive spirometer [4]. 

Post-operative pain is initially managed with intravenous (IV) medications, such as scheduled IV acetaminophen and as-needed IV opioids for breakthrough pain. Once the patient can tolerate oral intake, they are converted to oral pain medications, like oxycodone and acetaminophen. Typically, patients should not take ibuprofen or other NSAIDs after surgery due to the increased risk of GI bleeding [4]. 

Nausea is another common postoperative concern. Therefore, patients are usually given scheduled doses of ondansetron and, if needed, prochlorperazine or a scopolamine patch to help with nausea and vomiting. Patients are allowed ice chips and little sips of water after surgery and then are advanced to a clear liquid diet and then a full liquid diet within 24 hours [4, 11]. The patient will initially be on IV fluids, which are typically discontinued the following day after surgery. Intake and urinary output are also closely monitored. For patients with diabetes, their blood glucose is closely monitored and maintained between 140-180 mg/dL [4]. 

Post-op gastric sleeve patients are considered at high risk for venous thromboembolism. Therefore, promoting early ambulation is key. Additionally, patients may receive mechanical sequential compression devices (SCDs), and/or low-molecular-weight heparin, or unfractionated heparin may be ordered depending on the patient’s risk stratification. Lastly, the nurse should anticipate that bloodwork will be ordered, including a complete blood count, basic metabolic panel, and others, depending on the healthcare facility or surgeon [4]. 

Early Post-Op Complications 

Nurses and healthcare providers must monitor post-op patients for potential complications. Post-operative bleeding is common and occurs in about 15% of patients. Signs may include pain, tachycardia, decreased hematocrit, decreased blood pressure, melena, and others [11]. A gastrointestinal leak is another complication, occurring in 1.5-7% of patients. Symptoms of a GI leak include oral intake intolerance, anxiety, abdominal pain, and unexplained tachycardia (usually above 120 beats per minute) [7]. 

Surgical site infections are also a potential complication. The nurse should monitor the patient’s surgical sites for erythema, swelling, or discharge, and the patient may also have a fever. Although rare, portal vein thrombosis may develop, where signs include nausea, fevers, abdominal pain, and leukocytosis.  

Other potential complications are small bowel obstruction, stomal obstruction, and marginal ulcers. Symptoms of a marginal ulcer may include abdominal pain, nausea, vomiting, difficulty swallowing, and vomiting blood.  

More serious complications include myocardial infarction, venous thromboembolism, and pulmonary complications like pneumonia and acute respiratory failure. Signs of venous thromboembolism may include leg swelling, pain, and erythema. However, some patients may develop signs of a pulmonary embolism, which may include chest pain, shortness of breath, tachycardia, or hemoptysis [7].  

If any signs of complications develop, the nurse should notify the healthcare provider immediately. The nurse should anticipate additional tests to be ordered, such as a barium swallow study, CT scan of the abdomen, bloodwork, chest x-ray, electrocardiogram, etc. However, this is dependent on the suspected underlying complication.  

Discharge and Follow-up Care 

Typically, patients are discharged from the hospital after 1 to 2 days. Patients must be able to tolerate a full liquid diet, have their pain controlled with oral medications, be able to ambulate, and have no signs of complications. Patient discharge education and follow-up are key.  

Patients are instructed to continue a full liquid diet for 2 weeks and take their vitamin supplements and may advance their diet once their bariatric surgeon approves. Vitamin supplementation is started, which usually entails vitamin B12, vitamin C, calcium, and vitamin D. However, this is up to the surgeon. Hydration is also important to discuss during discharge education. The patient should be encouraged to drink small amounts of water throughout the day to prevent dehydration [4]. 

Discharge instructions regarding medications should also be discussed. Timing and dosage should be reviewed for each medication, and instructions should be given on whether medications need to be crushed or in liquid form. Since most patients are prescribed supplements, frequent monitoring of these levels is needed, so this should be reviewed during discharge. Patients who are discharged on warfarin should be instructed on the importance of having their international normalized ratio (INR) checked and have a follow-up appointment already scheduled at the time of discharge. For those discharged on low-molecular-weight heparin, instructions on proper administration and site rotation should be discussed.  

The importance of frequent ambulation and activity restrictions, like not taking a bath or lifting anything greater than 10 pounds, should also be reviewed. Additionally, signs and symptoms of potential complications should be discussed, and instructions on what to do (i.e., call a surgeon or go to the emergency room).  

Lastly, the patient should be instructed on the importance of maintaining their follow-up appointments with the surgeon and other providers from their team. Follow-up appointments with the surgeon are often within 1-2 weeks after discharge. To help with appointment adherence, follow-up appointments should be scheduled before patient discharge [4]. 

Long-Term Management and Complications 

Patients may also develop long-term complications after gastric sleeve surgery. During follow-up appointments, the patient’s BMI, comorbidities, and medications are closely monitored. The patient’s blood pressure is measured, and adjustments are made to antihypertensive medications as needed.  

In addition, the patient’s blood glucose, hemoglobin A1C, and lipids are monitored at each follow-up visit and again, medications are adjusted accordingly. Patients’ bloodwork is also drawn to assess for nutritional deficiencies, like vitamin B12, folate, thiamine, etc., at least every six months. Also, vitamin D deficiency in gastric sleeve patients is common. Sleep apnea is also common, so patients are typically reassessed every 6-12 months with a sleep study [4]. 

Long-term complications, or those 30 or more days after surgery, may also develop after gastric sleeve surgery. In particular, patients are more susceptible to developing GERD, stomach ulcers, and Barrett’s esophagus and may be started on a proton-pump inhibitor (PPI) or sucralfate short or long-term. Some patients who are unresponsive to medications may require conversion to a Roux-en-Y surgery. As rapid weight loss promotes gallstone formation, cholelithiasis is also a common complication. Some patients may be started on ursodeoxycholic acid to prevent gallstone formation or may need their gallbladder removed. Kidney stones (nephrolithiasis) may develop, so patients may be instructed to avoid foods high in oxalate, such as leafy green vegetables, almonds, and potatoes.  

Depression is a common comorbidity before surgery, so close postoperative monitoring is also crucial. Stenosis and unexplained abdominal pain are other long-term complications that may develop where surgical intervention or exploration may be necessary [4]. 

Another important aspect of gastric sleeve patient care is understanding that they require ongoing care from a multidisciplinary team. Patients will benefit from nutritional or dietary support, physical or exercise therapy, and behavioral therapy.  

There are many support groups available for bariatric surgery patients, both pre- and post-operative. Lastly, as patients lose excess weight and their weight is stable for several months, they may undergo body contouring surgery to remove excess skin. Referrals to the appropriate specialties and teams are helpful for the patient and should be encouraged [4]. 

New Research 

There is much research surrounding bariatric surgery, its effects, and patient outcomes. One research study published in 2023 supported evidence that the use of probiotics after bariatric surgery may help with weight and food intake reduction [13]. Another research study published in 2024 found that patients who underwent bariatric surgery experienced a greater perceived health and overall mood at 15 years post-op than those who did not have surgery [6]. Although this study wasn’t specific to gastric sleeve surgery patients, it’s promising that patients who received a sleeve gastrectomy may experience similar perceptions.  

A study published in March 2024 reviewed the effects of bariatric surgery on electrocardiogram abnormalities. This study found that the QTc interval decreased after surgery, corrected poor R wave progression, and aided with the resolution of right ventricular hypertrophy in patients with morbid obesity [1].  

Conclusion

The prevalence of people with obesity is increasing in the U.S. and worldwide. Therefore, nurses and healthcare providers must be diligent with screening for comorbidities and understanding patient implications and available treatment options. Nurses must understand both short and long-term monitoring and management of patients who undergo gastric sleeve surgery or any other bariatric procedure. Patients should be educated on the importance of follow-up and adhering to their medications and postoperative treatment plans to improve outcomes.  

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