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Gastric bypass
surgery
Surgery is a serious step forward and should only be contemplated
after you have undertaken considerable research into the various
options. You should have discussed other options with your GP.
The decision for surgery is probably the most important decision of
your life and should be considered as the last resort - only after all
other reasonable alternatives have failed.
You must take an active part in the surgical weight loss process in
order to maintain nutrition and optimise weight control.
What is the laparoscopic gastric bypass operation?
The operation is performed with keyhole surgery. While you are
asleep, instruments are passed through about 5 - 6 small holes in
the skin.
The surgeon then performs the
operation by viewing the abdominal
cavity on a monitor (TV screen).
The basic principal behind the
operation is to separate the top part
of the stomach from the lower part
using a stapling device or stitches.
A part of the small bowel is then
brought up to join with the newly
formed stomach pouch. Digestive
juices are redirected to join the food
further “downstream”.
How does the gastric bypass operation work?
This operation has 2 parts (restrictive and malabsorptive) to help
you lose weight and become healthier.
The restrictive part of the operation decreases the capacity of your
stomach from its current capacity of 2 - 3 litres to 20 - 30 ml.
This limits the amount of food that you can eat to about
5 - 6 tablespoons. Your calorie intake decreases and at the same
time you experience an earlier feeling of satisfaction.
The malabsorptive part comprises of separating your food from
digestive juices that come from the liver, pancreas, stomach and
small intestine. Normally the food is mixed with these juices before
it can be digested properly and absorbed into body. The small
intestine is surgically re-arranged so that food does not mix with
digestive juices until much further “downstream”.
Restrictive and malabsorptive elements result in both a
decreased amount of food that you can eat and the reduced
absorption of what has been eaten.
Gastric bypass ensures that long-term weight reduction and
maintenance is achieved not by building a dislike of food, but by
changing your relationship with food. Many patients simply “do not
feel hungry”. They stop eating because they are satisfied not
because they are full.
What are the benefits of having laparoscopic gastric
bypass?
Apart from obvious effective long-term weight reduction and
improvement in mobility, surgery can result in improvements in:
• Cholesterol levels
• Coronary heart disease
• Diabetes
• High blood pressure (Hypertension)
• Obstructive sleep apnoea
• Osteoarthritis
What are the risks associated with this operation?
Obesity is a serious health problem and surgery is serious therapy
designed to combat this disease. Most operations are
straightforward, however as with any operation there are risks
associated with having a general anaesthetic.
Specific to this procedure, there is a small risk of:
•
Deep vein thrombosis (DVT or blood clot in the leg veins)
•
Pulmonary Embolus (PE or blood clot on the lungs)
•
Chest infection
•
Wound infection
•
Leakage from staple or stitch line
•
Intestinal blockage from narrowing of the new joins, or a
twisting of the bowel (internal herniation or adhesions)
•
Bleeding requiring transfusion or another operation
The risks increase if you already have other medical conditions
such as heart disease or high blood pressure. However, any
problems that do arise can be rapidly assessed and appropriate
action taken by our team of experts.
There is a 1 in 200 risk of death and around 5% risk of side-effects
or complications such as those mentioned above.
Long-term complications can arise several years after the
operation. Therefore it is vital that you commit to long-term clinical
appointments with our team.
Long-term complications can include the formation of gallstones,
thinning of hair, twisted bowel causing pain or blockage, stomach
ulcers leading to perforation or bleeding, nutritional and vitamin
deficiencies that can lead to anaemia, osteoporosis or conditions
affecting the nervous system.
Due to an excessive amount of loose skin, patients may also
develop problems that include infection or irritation. Some patients
may require plastic surgery to remove excess skin. It is important to
note that access to this on the NHS is severely restricted and is
unlikely to be available to you.
What are the alternatives to laparoscopic gastric
bypass surgery?
The alternatives are non-surgical and surgical:
Non-surgical alternatives are lifestyle changes, drug treatments
and low calorie diet programmes. Most of the patients referred to
us have already undergone these treatments. Once your BMI is
above 40 these measures do not usually result in a sustained
weight loss.
Surgical alternatives are a laparoscopic gastric banding operation
or laparoscopic sleeve gastrectomy. Your consultant will explain
these alternatives in detail along with reasons as to why a gastric
bypass operation may be a more suitable procedure for you. We
aim to provide you with all the necessary information, enabling you
to make the correct choice of procedure specific to your needs.
Remember an option that you can take includes not receiving any
treatment at all. The consequences of not receiving any treatment
can be further weight gain, shortened life span and an increase in
obesity related diseases. If you would like more information please
speak to your consultant or the nurse caring for you.
If you would like information on counselling with regards to any
matters addressed in this booklet please speak to your GP. Access
to a clinical psychologist is available in Derby for anyone who feels
they would benefit from this service.
Getting ready for your operation
It is very important that you are as healthy as possible before the
operation and that you continue to do your best to lose weight.
You will not be accepted for surgery if you smoke.
Following referral by your GP you will be invited to attend a clinic
where you will be seen by a consultant surgeon and a dietitian.
The surgeon will evaluate your history and discuss different
treatment options with you. The dietitian will take a diet history and
give you dietary advice for before and after the operation.
Sometimes there are significant changes that you need to make to
your lifestyle and to your diet. You may be asked to attend the
clinic a few months after this to see if you have been successful in
making these changes before a recommendation for a surgical
procedure can be made.
Food provides not only nourishment, but also comfort and support
that help us deal with the daily stresses of life. Food sometimes is
our best friend. It is difficult to anticipate the emotional effect this
type of surgery will have on you.
Just being aware of the role food plays in your emotional well-being
is not enough. Before we can make a recommendation for surgery,
we must be assured that you have a realistic understanding and
expectations of what will happen after surgery.
For these reasons, you may be required to have a formal
psychological evaluation before surgery. This is by professionals
who thoroughly understand how this process applies to you. For
those who are not ready for surgery, specific recommendations will
be made. Only once we are satisfied with your evaluation will
surgery be agreed as an appropriate treatment for you.
You will be asked to attend the pre-operative assessment clinic.
You will need to have some blood tests including tests to check the
level of nutrients in your body. You will also undergo some routine
tests including a heart trace (ECG) and maybe an x-ray. You will be
required to follow a strict diet for 1 - 2 weeks before the operation.
If you have diabetes you will also be given a patient information
leaflet detailing what to do with your diabetes medications whilst on
this diet.
On admission
You will generally come into hospital on the morning of the
operation.
For a time before certain types of anaesthetic you will need to stop
eating, drinking and chewing gum. This will be explained to you
and you may also be given a booklet about this. If you have any
questions please contact the hospital - telephone number on your
admission letter.
You will be asked some routine questions about your general
health, the medicines you take at the moment and any allergies
you have.
You will be asked to sign a consent form to say that you
understand what you have come into hospital for and what the
operation involves.
You will be given a theatre gown to wear. A nurse or porter will
walk you to theatre. If this is not possible you will be taken on a
wheelchair or trolley.
What type of anaesthetic will I have?
The operation is performed under general anaesthetic, which
means you will be asleep throughout.
You will meet your anaesthetist before the operation. If the
anaesthetist has any concerns about you having a general
anaesthetic you will undergo a specific anaesthetic assessment
well in advance of your surgery.
What should I expect after the operation?
The operation usually takes 2 - 3 hours.
After the operation you will be transferred to the bariatric bay on the
general surgical ward. This is a designated area where the nursing
staff are trained to look after patients who have had weight loss
surgery.
You will be encouraged to get out of bed on the day of your
operation. You are also expected to perform breathing exercises.
You will have your pulse, blood pressure, breathing and wounds
checked regularly by a nurse. This is called the enhanced recovery
programme.
Anaesthetics can sometimes make people feel sick. It is important
that you inform the nurse immediately if you feel sick. They may
offer you an injection that will help.
It is usual to feel drowsy for several hours. You will be given
oxygen through a face mask until you are more awake.
You will have a drip running into a vein in your arm/hand to give
you fluids. This will continue until you are able to drink a sufficient
amount of liquids to keep you hydrated.
You will be allowed to start drinking small amounts of clear fluid
soon after your operation and progress on to tea, coffee and similar
fluids the next day.
You will have daily injections and wear compression stockings to
further reduce the risk of blood clots.
You may have a tube in your nose to empty your stomach, and a
urinary catheter. In most cases these will be removed the day after
your surgery.
If you currently use a CPAP mask for sleep apnoea, bring this with
you; you should be able to use it at night, as you would at home.
Wounds and dressings (stitches)
You will have 5 - 6 small wounds. Wounds are usually glued but
may have staples (metal clips) or stitches to keep them together
while they heal.
Staples will be removed after 10 days and stitches will be removed
after 7 days. No treatment is required for glued wounds, not even
plasters. If there is oozing from your wounds a dressing will be
applied.
In most cases you are allowed to take a shower 24 hours after the
operation - do not have a bath until the wounds have healed.
Pain relief
If you experience pain it is important to inform the nurse who can
give you painkillers. These can be in the form of injections, tablets
or a combination of the two. Pain due to trapped wind can usually
be relieved by moving about (mobilising). Shoulder tip pain is
usually the result of gas under the diaphragm and improves once
you start moving.
Mobilising
As soon as possible after your operation you will be encouraged to
get up and move around. This is important as it also helps to
reduce the risk of blood clots forming. At home we expect you to
continue to take regular, short walks for exercise.
Going home
You will be expected to stay in hospital for 2 - 3 days, depending
on your recovery.
Sometimes it is not possible to perform this operation using a
laparoscopic (keyhole) technique and a larger incision has to be
made. This may be the case if you have had previous surgery on
your abdomen. If this happens you will generally have more
discomfort after the operation. You will need to stay in hospital
longer and it will take longer before you are able to return to normal
activities.
DISCHARGE INFORMATION AND
AT HOME ADVICE
During your stay in hospital one of the bariatric team members will
see you and explain your expected recovery following discharge
from the hospital. You will be supplied with detailed information and
instructions, both verbal and in writing. You will also receive contact
phone numbers in case you have any questions or unexpected
problems at home.
If you need to be admitted to another hospital following your
surgery at Derby, we would like to know about it as soon as
possible. We provide a bariatric on call system, which means that
there is always an expert surgeon available to deal with
unexpected problems or complications.
You are likely to feel tired and need to rest during the day when
you get home but this will improve with time.
Wound care
Check the wounds for signs of infection - redness, pain and heat.
If any of these occur, see your GP as you may need a course of
antibiotics.
Do not worry if glued wounds open slightly, this can happen and
just require a simple dressing.
Pain relief
It is usual to feel some pain after this operation and you may feel
bloated. Take the painkillers you were given from the hospital,
follow the instructions and do not exceed the stated dose. People
rarely have problems taking tablets, however soluble forms can be
taken if necessary in the early period following the operation.
Diabetes
If you have diabetes it is generally expected that it will improve
after your operation. It is important for you to closely monitor your
blood sugars.
Your diabetes medication will need adjusting and this will be done
initially before you are discharged from hospital in accordance with
the protocol.
If you have type 1 diabetes you should never stop taking
insulin.
On discharge from hospital you should contact your own diabetes
team within the first week and arrange an appointment.
In the case of a diabetic emergency you should contact your own
diabetes team urgently or attend your local Emergency
Department.
The following details will be completed as you leave the hospital,
and it is therefore important that you bring this booklet into hospital
with you.
Stitches (ward staff to complete as appropriate)
Your wound has been glued.
Your stitches will dissolve - you do not need to have them
taken out.
Your staples/stitches will need removing in ___________ by
the practice/district nurse.
Time off work
Most patients are able to return to work within 2 - 3 weeks after
surgery if their occupation does not require strenuous activities.
Your particular occupation and recovery will dictate when you will
be able to return to work.
Returning to normal activities
We would normally expect you to take about 3 - 4 weeks to get
back to normal. You should avoid heavy lifting for 4 weeks.
Driving
Do not drive until you can wear a seatbelt comfortably and feel able
to perform an emergency stop. Your insurance company may
refuse to meet a claim if they feel you have driven too soon. It is
advisable to contact your insurance company with regards to cover
following a general anaesthetic.
Diet
How you eat after this operation will determine how successful you
will be at losing weight. Following the dietary guidelines will also
reduce your risk of complications. Your dietitian will provide you
with detailed information before you leave hospital. The following
information gives an overview.
Liquids will pass through your new stomach quite quickly, but solids
will stay for a longer period. The key is to be patient. Your stomach
is still going through a healing process and will empty faster with
time. This will make it possible for you to eat larger portions of food
at a later stage.
WEEK 1
Liquids - anything that can be sucked up through a
straw. No lumps or bits. Avoid fizzy drinks at this stage.
WEEK 2
You may progress to pureed foods. Continue to avoid
fizzy drinks. You will need to separate solid foods from
liquids. Avoid drinking within 30 minutes of a meal.
WEEK 3
Start including soft foods now.
WEEK 4
Most patients progress to a fairly normal diet at this
stage, although in small amounts and very well
chewed. You may find rice, white bread and tougher
cuts of meat a problem at this stage. Limit fatty and
sugary foods and drinks.
WEEK 5
AND
BEYOND
The key to good nutrition is variety. We want you to
experiment with food. Try to add one new food type at
a time. It is still early days and foods you cannot
tolerate now may be quite enjoyable 6 months later.
It is really important at this early stage to develop a
habit of eating 3 meals a day and limiting any in
between snacking.
The most dangerous habit after gastric bypass surgery
is snacking all day long.
Dumping Syndrome
Diarrhoea, cramping, dizziness and nausea are symptoms of
Dumping Syndrome and are caused by eating sugary foods or
drinks.
To avoid these symptoms, you will need to follow a low sugar and
low fat diet.
Exercise
It is important to introduce gentle exercises such as walking as
soon as you feel better. This will help you lose weight and tone
muscles.
If you don’t exercise and move your muscles, your body will think
they are unnecessary and will burn your muscles for its fuel long
before it touches your fat.
Further appointments
You will have an appointment with the consultant surgeon and
dietitian 6 weeks after leaving hospital.
We expect you to contact us if you have any problems or
questions.
After undergoing surgery the following points must
be taken into account at all times.
• The capacity of the stomach is greatly reduced to
approximately 15 - 20 ml (size of an egg cup).
• You will need to take regular sips of fluids throughout the day.
• You must chew all food more thoroughly.
• You should wait approximately 30 minutes after eating before
having a drink.
• You will need to eat regular small meals.
Use a tea plate instead of a dinner plate.
• Drinking too fast or eating too much food too quickly may
cause vomiting.
• Choosing the wrong texture could cause vomiting so it is
important to follow the advice given to you by the dietitian.
• As these dietary changes will have an effect on your social
and family life you must consider the impact on events such
as dining out, holidays etc.
• Success with gastric bypass is dependent upon attending all
follow up appointments as well as modifying diet and
behaviour.
If you do not attend for follow up, you can develop nutritional
deficiencies, which can have very serious consequences for
your health.
Frequently asked questions
Will I have to follow a special diet before my surgery?
Yes. You will need to follow a special diet for 2 weeks before your
surgery. The purpose of this diet is to shrink your liver.
Over a number of years, as you have eaten more calories than
your body has used, you have converted this energy into a
substance called glycogen and stored it. One of the places it is
stored is in your liver causing it to become enlarged.
The liver is positioned across your stomach and so obscures the
surgeon’s view. Therefore he will gently lift it out of the way. This is
much more difficult with an enlarged liver.
This diet reduces your calorie and carbohydrate intake which
encourages your body to use the stores in your liver, causing it to
shrink. This makes it easier and safer for the surgeon to move your
liver out of the way.
A diet information sheet will be sent to you when you are given a
date for surgery.
Will I need to follow a special diet after my surgery?
Yes. As a result of your surgery you will have stitches and staples
around your gastric pouch and small intestine. It is essential that
you protect these and allow them to heal. In order to do this you will
need to follow a liquid diet followed by a soft diet for several weeks.
See Diet section for more details.
What about medication?
You should be able to manage your normal prescribed medication.
Large tablets may need breaking in half (i.e. Metformin).
Your diabetes medication will need adjusting and this will be done
initially before you are discharged from hospital in accordance with
the protocol.
If you have type 1 diabetes you should never stop taking
insulin.
On discharge from hospital you should contact your own diabetes
team within the first week and arrange an appointment.
In addition as you lose weight, the dosage of certain medication will
need to be adjusted.
At the time of your discharge you will be prescribed antacid tablets
for 6 weeks, blood thinning injections for 2 weeks and painkillers.
Do I need to take any supplements?
Yes. Because the volume of food you can eat is small, we suggest
that you take a complete multivitamin and mineral supplement.
Some people will also need an extra iron supplement.
A calcium supplement is also recommended (1000mg/day).
It is common for gastric bypass patients to have low vitamin B12
levels. Most people need this by injection every 3 months.
Does a gastric bypass limit the exercise I can do?
No. You are encouraged to walk as soon as possible. Once your
wounds are dry you can swim.
After 6 weeks you will be able to continue with any activity or
exercise you wish to do. A gastric bypass will not restrict any
aerobic, stretching or strenuous exercises.
Remember the more active you are the better weight loss you will
see.
Will it hurt?
You may suffer with wind pain for up to 2 weeks. This pain may
move up into your shoulder (this is perfectly normal after
laparoscopic surgery). Getting up and moving about as soon as
possible is the best way to relieve this.
What about pregnancy?
You should inform us if you think there is any chance you could be
pregnant at any stage whilst you are considering or once you have
had the gastric bypass.
It is possible to have a healthy pregnancy following a gastric
bypass. You may need to adjust your supplements during
pregnancy and may require more frequent blood tests for estimates
of nutrients.
It is recommended that you should not try to become pregnant
for the first 18 months following surgery.
How much weight can I expect to lose after my surgery?
The average weight loss after a laparoscopic gastric bypass
operation is 65 - 70% of your excess body weight.
For example if you weigh 22 stone and your ideal body weight is
12 stone, your excess body weight is 10 stone. You can expect the
bypass operation to help you to lose up to 7 stone of this.
If you follow all the guidelines and advice we offer you may be able
to lose more.
You will always need to work hard to lose your weight even with
gastric bypass surgery.
Will I be sick a lot after the surgery?
Gastric bypass limits the quantity of solid food you can eat. If you
are feeling sick or vomiting regularly it may mean that you are
either eating too much or you are not chewing your food properly.
What are the differences between the laparoscopic and open
procedures?
Laparoscopic patients have less pain, better cosmetic results and
less chance of wound or hernia problems following surgery. The
risk of breathing complications is lower following laparoscopic
surgery.
How does the operation really work? If I have the same
appetite as I do now but with a smaller stomach, won’t I be
frustrated most of the time?
Through mechanisms we do not fully understand, gastric bypass
has effects on one’s hunger and food selection. The majority of
patients do not have the desire to overeat. Many patients find
healthy foods more satisfying and high fat and junk foods repulsive.
The operation is successful because your individual relationship
with food changes. The success of our patients is because of their
choices in food selection and quantity rather than simply “feeling
full faster”.
Life after surgery
After the initial settling period you will develop certain routines. You
will not be able to eat nearly as much food as you were used to
eating. Although most patients are no longer hungry, it is difficult to
predict how much this volume restriction will affect your life.
Especially as many social and family events centre on food.
Weight loss reaches a peak 1 - 3 years following surgery. After this,
patients can continue to “re-model” themselves, losing inches as
opposed to weight; changing body fat composition, muscle mass,
etc.
Remember some basic principals about gastric
bypass surgery
• Gastric bypass surgery is not a cure for obesity, but can be
used to control obesity and related diseases.
• You should aim to achieve optimum health and avoid longterm complications rather than focus primarily on weight loss.
• Eat slowly. The slower you eat the more time your brain has
to realise there’s food in your stomach. Stop eating when you
are satisfied not when you are full.
• Drink plenty of liquids (mainly water).
• Always start your food with a protein. It fills you up and helps
curb cravings.
• Do not drink while you are having your meal.
• Remember to take your supplements daily.
• Attend your follow up appointments including blood tests.
• Exercise plays an important part in helping you achieve
successful weight loss following surgery.
• Attend a support group regularly.
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