Sleeve Gastrectomy
What the Examiner Expects
A restrictive bariatric procedure involving resection of approximately 75–80% of the stomach along the greater curvature, creating a tubular gastric sleeve. The examiner expects you to know this is now the most commonly performed bariatric procedure, understand the indications (same BMI criteria as RYGB), and recognize the key technical points: stapling begins 4–6 cm from the pylorus along a 36–40 Fr bougie, preserving the antrum for gastric emptying. The fundus is resected, removing ghrelin-producing cells. The most common staple line leak occurs at the angle of His where the blood supply is most tenuous and the staple line intersects the esophagogastric junction.
Key Examiner Focus Points
- Restrictive procedure: 75–80% of stomach resected along greater curvature
- Staple line begins 4–6 cm from pylorus, calibrated with 36–40 Fr bougie
- Staple line leak at the GEJ angle of His is most common leak location
- Worsens or causes de novo GERD in some patients
- Now the most commonly performed bariatric procedure in the US
Common Curveballs
Staple line leak at the GEJ on POD 4 with contained collection
Initial management: NPO, IV antibiotics, CT-guided percutaneous drainage. Endoscopic stenting or endoscopic internal drainage can be effective. Most proximal sleeve leaks are chronic and require patience. Reoperation for drainage only if percutaneous drainage fails or there is free peritoneal contamination.
Patient develops severe GERD 1 year after sleeve gastrectomy
De novo GERD is a known complication. Maximize medical therapy (PPI). If refractory, conversion to Roux-en-Y gastric bypass is the definitive treatment — the Roux limb eliminates bile reflux and the small pouch reduces acid production.
Intraop leak test with methylene blue shows a leak at the staple line
Reinforce with interrupted sutures or an omental patch. Retest after reinforcement. Place a drain near the repair. Do not leave a known leak — this must be addressed before leaving the OR.
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