Download Bariatric Service Weight loss surgery

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Contents
Page
Introduction
3
Surgical team
3
Surgical pathway
3
Flow chart of process from referral to surgery
5
List of main types of bariatric surgery
6
Gastric balloon information
6
Gastric band information
7
Gastric bypass information
8
Sleeve gastrectomy information
9
Dietary information:-
Bariatric Service
Weight loss surgery
Patient Information Booklet
Pre-op liver shrinking diet
Gastric Band post-op diet
Gastric Bypass post-op diet
Intragastric Balloon post-op diet
Sleeve Gastrectomy post-op diet
10
12
14
17
17
General information about bariatric surgery:Before your operation
Your hospital stay
Discharge from hospital
Possible problems
Other things to take into consideration
18
19
20
21
23
Team contact details
26
Further reading
26
Summary sheet of risk and benefits of each operation
27
Appendix 1 – patient progress chart
Appendix 2 – Gastric band record of fill volume
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Introduction
website (www.somersetobesityservice.org.uk). An “ideal” body weight would be a BMI of
19-25.
Welcome to the Bariatric Service at Musgrove Park Hospital, Taunton. We have been
carrying out operations to help reduce people’s weight since 2004, and have been
awarded Centre of Excellence for Bariatric Surgery status by the Surgical Review
Corporation in the United States, as well as being the Lead Centre for Bariatric Surgery
within the South West.
This booklet is designed to give you some background information about the main types
of surgery we perform here in Taunton and to guide you through the pathway from initial
referral to your post-operative care so that you can make an informed choice on your
preferred operation.
Surgical team
Our surgical team at Musgrove Park Hospital include:Mr David Mahon
Mr Richard Welbourn
Dr Nicholas Kennedy
Dr Steve Harris
Dr Jane Bellamy
Dr Helene Lindsay
Dr Matt Ward
Dr Mohammed Lone
Miss Karen Coulman
Mrs Ilana Alder
Ms Anne Wheeler
Miss Yasmin Ferguson
Mrs Amanda Knight
Dr Vanessa Snowdon-Carr
Consultant Surgeon
Consultant Surgeon
Consultant Anaesthetist
Consultant Anaesthetist
Consultant Anaesthetist
Consultant Anaesthetist
Consultant Anaesthetist
Staff Grade Anaesthetist
Bariatric Dietitian
Bariatric Dietitian
Bariatric Dietitian
Bariatric Clinical Nurse Specialist
Bariatric Service Administrator
Clinical Psychologist for Bariatrics
Surgical pathway
Bariatric surgery is carried out for health reasons and you will need to meet national
guidelines for an operation, which have been drawn up by NICE (National Institute for
Clinical Excellence):•
•
Body mass index (BMI) 35kg/m2 with a weight-related medical condition
such as Type 2 diabetes, high blood pressure, high cholesterol, sleep
apnoea, or
BMI 40kg/m2 without weight-related illness.
If you want to, you can work out your own BMI by dividing your weight in kilograms by
your height in metres squared eg (weight) 95kg ÷ (height) 1.5m x 1.5m = BMI 42.
Alternatively there is a quick and easy BMI checker on the Somerset Obesity Service
It is important to understand that although bariatric surgery can be successful in reducing
your weight and body mass index, it is unlikely that you will reach the “ideal” BMI.
However, the intention is to help you to lose 50-70% of the extra weight you are carrying
and therefore improve your health and quality of life.
Before being referred for surgery you will need to have been seen in a weight
management clinic in your local hospital by the Consultant Endocrinologist and Dietitian
who will look at your eating behaviour and any existing medical conditions. They will
recommend a personalised programme to help prepare you for surgery. This will need to
be followed for at least 6 months and is likely to include dietary advice, medication, blood
tests, tests on your heart or lungs and, where appropriate, psychological support.
If surgery is a possible option you will be invited to attend a group meeting in Taunton to
be given information about the operations and aftercare by the Nurse Specialist and the
Dietitian. It is essential that you attend this session if you want to be considered for
surgery, even if you are a BOSPA member (British Obesity Surgery Patients Association
– http://www.Bospa.org).
If you then wish to proceed with surgery you will be referred to the Bariatric Surgical
Team at Musgrove Park Hospital, who will send you an appointment to attend a one stop
clinic in the Outpatients Department to assess your suitability for an operation. You will
be seen by the Bariatric Clinical Nurse Specialist, the Bariatric Dietitian, the POAC team
including a Consultant Anaesthetist, and one of the Consultant Surgeons. You will have
some pre-operative blood tests taken, a heart tracing (ECG), blood pressure, pulse,
breathing test (peak flow) and a urine test and should set aside at least 3 hours for this
appointment.
Your case will then be discussed at our bariatric team meeting. Following approval, you
will be put on the waiting list for an operation.
On condition that there are no last-minute problems with your test readings or
anaesthetic assessment, you will then be sent details regarding a date for your operation.
Patients are usually admitted on the day of surgery. For all operations except gastric
balloon insertion, you will need to follow a special liver shrinking diet for 2 weeks before
your surgery, or as directed by your surgeon
(see page 10).
Please see the flow chart on the next page.
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Flow chart of process from referral to surgery
Referral from Local Medical
Weight Management Clinic /
Consultant Endocrinologist
Main types of bariatric operations carried out at Musgrove Park
Hospital
At Musgrove Park Hospital, the main types of bariatric surgery we perform are:Laparoscopic gastric band
Laparoscopic Roux-en-Y gastric bypass
Sleeve gastrectomy
Intragastric balloon
Patient attends Preoperative Education Group
Brief explanations follow. Please bear in mind that at the group meeting mentioned
above, these options, risks and benefits will be explained more fully
Gastric balloon
Patient attends One Stop Clinic and sees Surgeon,
Clinical Nurse Specialist, Dietitian and Anaesthetist.
Pre-Assessment is also completed at this
appointment.
Discussed at Multi-Disciplinary
Team meeting following Surgical
Assessment Clinic, or at separate
meeting in Taunton or Peninsula
Team agrees – patient
placed on waiting list
Team disagrees - patient
and GP are notified by letter
re reasons and any action
needed, ie further tests
Once test results are
received and are
satisfactory, patient is then
placed on the waiting list
Admission Date for surgery
is confirmed
Unsafe or unsuitable –
patient discharged
The surgeon may suggest you have a gastric balloon inserted. This is a silicone balloon
which is fitted in the stomach via the mouth as a day case under light general
anaesthetic. It is sometimes used to help a patient lose weight to make one of the other
operations such as gastric bypass safer. It stays in place for 6 months. On average,
patients lose 10-20% of their excess weight with the balloon.
•
Risks
o Balloon rupture within stomach (it is filled with blue dye so you would know
if this had happened because your urine would turn blue/green).
•
Benefits
o Helps make further surgery safer by reducing your weight beforehand.
o Assists in changing eating habits.
o Minimally invasive – inserted via your mouth rather than via surgical
wounds.
o Done under light general anaesthetic as a day case.
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Gastric band
Gastric bypass
The gastric band is a silicone band which is fitted around the upper part of the stomach
to make it into an hourglass shape so that it restricts the amount that can be eaten. The
band can be adjusted to make it tighter by filling it with fluid through an access port which
sits under the skin below your breastbone. The band is not filled when it is inserted but
there is often some post-operative swelling to the stomach which can cause restriction.
When this swelling subsides, you will probably feel hungry again and be ready for your
first fill at 6-8 weeks post-operatively. You are advised to have 2 weeks off work.
•
•
Risks
o Risks associated with a general anaesthetic and operation (eg blood clot,
chest infection)
o Risk of death – 1 in 1000
o Weight loss may not start immediately (first band fill is 6-8 weeks post-op)
o Wound or access port infection
o Tubing leakage
o Band slippage
o Band erosion (the band works its way from the outside to the inside of the
stomach)
o Stretching of the stomach pouch or oesophagus (food pipe) if you overeat
o Risk of inadequate weight loss, or weight regain (patients need to
continue to manage their diet carefully post-operatively).
o Difficulty getting the correct level of restriction which suits the patient
o Risk of vitamin/mineral deficiencies – need to take a multivitamin and
mineral tablet, and additional calcium with vitamin D for life.
Benefits
o Band results in average of 50-60% excess weight loss over two years
o Keyhole surgery
o Overnight stay in hospital
o Adjustable and reversible
o No alteration in digestion
The Roux-en-Y gastric bypass is usually done as a keyhole operation and works by
restricting the amount you can eat and also limiting the amount of nutrients and calories
which can be absorbed during normal digestion.
Patients can lose a significant amount of their excess weight with this operation and
many patients with type 2 diabetes find that their diabetes goes into remission or they
don’t need to take as much diabetic medication.
•
Risks
o Risks associated with general anaesthetic and any operation (eg DVT,
pulmonary embolus, chest infection, bleeding)
o Risk of death – 1 in 200
o Leak from staple lines at operation sites internally
o Internal hernia/bowel obstruction
o Possible difficulty eating some solid food such as bread and meat
o Risk of vitamin/mineral deficiencies – you will need to take a multivitamin
and mineral tablet, as well as a calcium with vitamin D supplement daily
for life. Vitamin B12 injections will be needed from approximately 6
months after surgery
o Risk of inadequate weight loss, or weight regain (patients need to
continue to be careful of their diet post-operatively)
o Hair loss (in acute weight loss phase)
o Possibility of forming gallstones in future
o Feeling cold
•
Benefits
o Average of 70% excess weight loss over 2 years
o Improvements in type 2 diabetes in patients with that condition.
o Weight loss starts immediately
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Sleeve gastrectomy
Pre-operative Liver Shrinking Diet
Dietary Preparation – Just because you have been offered a surgical treatment for
your morbid obesity, this is not an excuse to sit back and eat as much food as you can!
Any weight you can lose through dieting before your surgery is an advantage – it will
make the surgery easier and will reduce the risks associated with it. It will also help
prepare you for the dietary changes you will be making after surgery.
For 2 weeks before your surgery (or advised by the surgeon), it is vitally important that
you follow a very restricted diet – one that is low in fat, sugar and carbohydrates. The
reason is to shrink your liver down to ensure that the operation can be done by the
keyhole (laparoscopic) method.
If your liver is too big, the surgeon may abandon the operation, or you will have to have
an open operation, the risks of surgery will increase and your recovery will be delayed.
The surgeon may suggest you have a sleeve gastrectomy. The sleeve gastrectomy is a
“halfway house” to a gastric bypass. The stomach is divided into one long column and
the part which is no longer needed just stays closed off within your abdomen rather than
being removed. Restriction of food intake leads to weight loss but the digestive process
is not altered as it would be with the bypass. Sleeve gastrectomy is carried out on
patients whose body mass index or illnesses mean that the risks outweigh the benefits of
the gastric bypass. However, at a later stage the surgeon may agree to convert the
sleeve gastrectomy to a full gastric bypass once the patient has lost a significant amount
of weight.
•
Risks
o
o
•
Risks associated with a general anaesthetic and operation (eg DVT, chest
infection, pulmonary embolus, wound infection, bleeding).
Risk of vitamin/mineral deficiencies – you will need to take a multivitamin
and mineral tablet, with additional calcium with vitamin D supplement for
life.
Benefits
o
o
o
Reduction in the amount that can be eaten.
Weight loss similar to gastric bypass up to one year after operation
May be able to convert to a full gastric bypass at a later stage
By following a strict diet, your body reduces its glycogen stores (glycogen is a form of
sugar stored in the liver and muscles for energy). With each ounce of glycogen, the body
stores 3-4 ounces of water, so when you follow a very strict diet, especially one that is
low in starch and sugar, your body loses its glycogen stores and some water. The liver
shrinks as it has less glycogen and water in it. This diet is only recommended for two
weeks before surgery (or as advised by your surgeon) and is not to be followed
afterwards. You may find that you lose a lot of weight during the pre-operative diet, but it
will be mainly be water loss. Please ensure you continue to drink throughout the day.
Menu suggestions for the pre-operative liver shrinking diet
If you are in doubt about a food then it is best to avoid it. It is very important to avoid
cakes, biscuits, chocolate, crisps and sugary drinks. You are aiming for approximately
800kcal per day in total.
Breakfast
Small bowl of plain cereal (25g or the size of a small multi pack box)
Or
1 medium slice toast with scraping of margarine
Lunch
1 slice bread or 2 crisp breads
Salad (no dressings, unless just vinegar based without oil)
Small portion of meat or fish (size of pack of playing cards) or cheese (size of a
small matchbox), 2 eggs or 2 tablespoons of baked beans
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Dinner
Post-op Gastric
operation
1 small potato or 2 tablespoons of pasta or rice
Vegetables- any vegetables but try to have mostly the green varieties.
Small portion of meat or fish or cheese or eggs or quorn or tofu dish (portions as
above)
Band Diet – the first six weeks after the
Eating and drinking- by the time you leave hospital you will be eating a pureed diet.
You will need to continue this for the first four weeks, while your stomach is settling down
again after the operation.
Daily One third of pint of semi-skimmed or skimmed milk over the day for drinks and
cereals
Two portions of fruit (a portion is one apple, one pear, one small banana, an
orange, or a handful of berries).
Water, tea, coffee, low calorie squash, low calorie fizzy drinks allowed freely.
(Limit fruit juice to one small glass per day.)
One low fat, low sugar yoghurt or fromage frais per day.
If you think you will have difficulty following this diet, an alternative would
be to have a very low calorie liquid diet, eg 4 x Optifast or Slimfast sachets
per day, plus 1 – 2 litres calorie free fluids. You would need to do this for 1
week. If you prefer this option please contact the Bariatric Dietitians to
discuss this further.
Eating guidelines for the first six weeks:
• Eat 4-5 small meals per day (about 1-2 tablespoons at each)
• Eat pureed food for the first 4 weeks and then mashed for the next 2 weeks.
• A pureed diet means your food should for the first 2 weeks be the consistency of
baby food or apple sauce – many people find a hand held blender most suited to
pureeing small quantities of food.
• For weeks 3-4 your puree can be thicker but still without lumps
• Weeks 5-6 your food should be soft enough to be easily mashed with a fork
• From week 6 start having solid foods again.
• Drink water between meals – you need extra fluids after the operation and may
find you cannot drink a whole glassful at once so have several small drinks
between each meal. Try to take a pint more water than you usually would in a
day. Avoid fizzy drinks because they may cause wind to be trapped in your
stomach which can be painful.
• Eat slowly and stop as soon as you feel full.
Here are some sample menus to help you plan your eating in the first 6 weeks:
Breakfast (choose one from the list below)
•
•
•
•
2-3 tablespoons porridge or Ready Brek (blended)
1 Weetabix with skimmed milk
Yoghurt or fromage frais
1 scrambled egg blended or finely mashed with a fork
Lunch/snack meal (choose one from the list below):
•
•
•
•
•
Soup blended to a smooth consistency (100 – 150mls)
Milky pudding such as rice, sago or semolina
Fruit custard – eg stewed apple, mashed banana blended with custard or tinned
fruit blended with custard
Yoghurt or fromage frais
1-2 tablespoons pureed tinned fruit in juice
Dinner (choose one from the list below):
•
•
•
•
5-6 tablespoons (100g) cottage pie, blended
5-6 tablespoons (100g) bolognaise and mashed potato, blended
5-6 tablespoons (100g) fisherman’s pie, blended
5-6 tablespoons (100g) mashed potato with grated cheese
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•
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5-6 tablespoons (100g) baked beans with mashed potato, blended
Some people find it easier to buy low calorie ready-made meals and blend them to a
smooth consistency. If you are making your own meals, you may need to make a sauce
in order to obtain the right texture when blended. Dried packet sauces can be made with
skimmed milk, tomato-based ‘Cook-In’ sauces are useful and gravy granules can be
made up with hot water. Pureed food can be very bland so add herbs and spices if you
yearn for some extra seasoning. After the first four weeks you will progress to more solid
food (i.e. mashed, not pureed) for two weeks. The portion sizes will be the same as
those described above but you do not need to blend/liquidize the food.
Post-op Gastric
Bypass Diet – first six weeks after surgery
Eating and drinking – while your stomach is settling down and healing itself after
the operation you need to introduce solids very slowly. Don’t be tempted to rush this
stage; the timings mentioned are a guide only. If a food causes problems, go back to
tolerated foods and then retry the food again after a week or two. Often a difficult food
stops being a problem over time.
Week 1 (7 days from day of operation) – Fluids only
From six weeks you should start introducing solid food again. Do not be tempted to
remain on mashed food even though it may be easier to eat.
Vitamin and mineral supplements – There is a risk of developing certain vitamin
and/or mineral deficiencies with this type of operation, so the following should be taken
for the rest of your life:1
A daily multivitamin with minerals. Examples are: Sanatogen Gold A-Z,
Centrum Complete A-Z, or any equivalent A-Z multivitamin with minerals.
These are available to purchase over the counter at supermarkets,
chemists and health food stores. Forceval is another good option, but is
available on prescription only. It comes as a large capsule which some
people
may find difficult to manage.
For the first 6 weeks after the operation, it is recommended that your medication
is crushable, and that if this is not possible you should have a liquid or chewable
preparation. During this time, you may want to take a chewable multivitamin such
as Bassett’s Active Health multivitamin with minerals for adults, or a liquid
multivitamin such as Abidec. However, these are not complete so you should
switch to one of the multivitamin tablets listed above after the first 6 weeks. If you
find that you have trouble swallowing tablets, breaking the tablet into 2 or 3
pieces might help. Some people instead choose to crush their multivitamins and
take them with drinks or food.
2
3
Extra calcium + vitamin D, for example Calcichew D3 Forte (available on
prescription) – 1 three times per day with meals. Calcium + vitamin D can
also be purchased over the counter. However, ensure that you take 12002000mg per day of calcium + 10-20ug per day of vitamin D.
There may be other supplements that your GP would prescribe, depending
on the results of your blood tests.
Examples are water, tea, coffee (use sweeteners rather than sugar), herb/fruit teas,
skimmed milk, low calorie fruit squashes, fruit juice, consommé, bouillon, thin soup,
sugar-free jelly.
Week 2 (7-14 days) – Sloppy pureed food
Continue the fluids as above but add runny puree foods (that will tip off a spoon) such as
low fat yogurt (e.g. Muller Light), low sugar custard, soup, mashed potato with gravy or a
small amount of cheese (grated so that it melts into the potato without lumping), parsley
or other sauce for flavour, pureed stewed apple, pureed tinned fruit (e.g. peaches, pears,
apricots), Weetabix or ReadyBrek with lots of milk.
Weeks 3 – 4 (14-28 days) – Pureed food.
By this stage you should be starting to add more protein foods such as meat, fish,
chicken, beans, lentils and eggs. All food should be pureed and low in fats and sugars.
Here are some example meals to choose from:
Breakfast:
• 2-3 tablespoons porridge or Ready Brek (blended), or
• 1 Weetabix with skimmed milk, or
• Low fat yoghurt or fromage frais, or
• 1 scrambled egg blended
Lunch/snack meal:
• Soup blended to a smooth consistency (100 – 150mls), or
• Milky pudding such as rice, sago or semolina, or
• Fruit custard – e.g. stewed apple, mashed banana or tinned fruit blended with
custard, or
• Low fat yoghurt or fromage frais, or
• 1-2 tablespoons pureed tinned fruit in juice
Dinner:
• 5-6 tablespoons (100g) cottage pie, blended, or
• 5-6 tablespoons (100g) bolognaise and mashed potato, blended, or
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•
•
•
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multivitamin such as Abidec. However, these are not complete and you should
switch to one of the multivitamin tablets listed above after the first 6 weeks. If you
find that you have trouble swallowing tablets, breaking the tablet into 2 or 3
pieces might help. Some people instead choose to crush their multivitamins and
taken them with drinks or food.
5-6 tablespoons (100g) fisherman’s pie, blended, or
5-6 tablespoons (100g) mashed potato with grated cheese, or
5-6 tablespoons (100g) baked beans with mashed potato, blended
Weeks 5 – 6 (29-42 days) – Mashed food.
Using the same foods as weeks 3-4 but mashed with a fork (toddler food consistency)
rather than pureed.
•
Extra calcium + vitamin D, for example Calcichew D3 Forte (available on
prescription) – 1 three times per day with meals. Calcium + vitamin D can also be
purchased over the counter, however, ensure that you take 1200-2000mg per day
of calcium + 10-20ug per day of vitamin D.
•
Vitamin B12 – After a bypass it becomes more difficult to absorb vitamin B12.
Your body stores will usually last for about 6 months from your surgery. After this
time you should arrange with your GP to have regular B12 injections.
•
Women who have periods may also need to take extra iron supplements (4065mg elemental iron per day). This is available on prescription and should be
organised through your GP.
•
Your GP may prescribe other supplements as well, depending on the results of
your blood tests.
From week 7 (43 days onwards) – Solid Food
From now on you will be able to eat a solid, low fat, low sugar diet in small quantities.
Eating guidelines for the first six weeks:
•
Avoid fizzy drinks because they may cause wind to be trapped in your stomach
which can be painful.
• Eat slowly and stop as soon as you feel full.
• If one food makes you feel nauseous, avoid it for a few days and then try again
and chances are you will be fine with it.
• If nausea persists, go back one stage - e.g. if you are feeling nauseous on
mashed foods, go back to puree for 24 hours and then try mashed food again.
• From week 2, eat 4-5 small meals per day (about 1-2 tablespoons at each).
• From week 2, drink between meals not with them – have a drink no later than ½
hour before your meal, and don’t drink for one hour afterwards to avoid overfilling your stomach pouch. You will need to drink small amounts regularly to
make sure you have enough fluid throughout the day.
Exercise
– most
loseshould
some be
weight
quite quickly
and feel
energetic
• From
weekpeople
3 all drinks
zero calories
– e.g. water,
tea,more
coffee,
diet
quite soon
after the operation. Start walking more as soon as you feel able. With
squash.
Vitamin and mineral supplements – There is a risk of developing certain vitamin
and/or mineral deficiencies with this type of operation, so the following should be taken
for the rest of your life:•
A daily multivitamin with minerals. Examples are: Sanatogen Gold A-Z, Centrum
Complete A-Z, or any equivalent A-Z multivitamin with minerals. These are
available to purchase over the counter at supermarkets, chemists, and health
food stores. Forceval is another good option but is available on prescription only.
It comes as a large capsule which some people may find difficult to manage.
For the first 6 weeks after the operation, it is recommended that your medication
is crushable but if that is not possible it will have to be in a liquid or chewable
formulation. During this time you may want to take a chewable mulitivitamin such
as Bassett’s Active Health Multivitamin with Minerals for Adults, or a liquid
Long-term dietary considerations (after all operations)
In the long-term after surgery, general healthy eating recommendations apply. It is
recommended to get into a routine of three small healthy meals per day: for example,
a meal should be about the size of a side plate. You may find that using smaller
plates helps you get used to smaller portions. It is okay to have healthy snacks
between meals if needed, eg a piece of fruit, a small pot of diet/light yoghurt. It is
best to avoid “grazing” throughout the day as this can lead to consuming more
calories than you realise, and poor weight loss or even weight regain. The Dietitians
are available to support you in making changes to your eating habits and activity
levels – don’t hesitate to ask for help if you are struggling. We recognise that it is
difficult to change eating habits, and you will need support long-term.
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Post-op Sleeve
surgery
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Gastrectomy diet – first 6 weeks after
General information
Before your operation
Eating and drinking
1.
In the first few days after the operation, the surgeon will probably instruct that you have
only 30ml of fluid per hour. This is to limit the risk of bleeding post-operatively. The
amount will be gradually increased so that by the time you leave hospital you will be
following the same guidelines as the gastric bypass patients. However, individual
patients may be given different instructions according to surgeon preference.
Anaesthetist – Your anaesthetist has been specially trained to treat obese people and
will look carefully at your medical history and tests that have been performed. If you
develop any sort of cough or cold or become unwell in the week prior to your
operation it is important to let the hospital know immediately so that your
operation can be postponed until you are better.
The most significant risk associated with this surgery is a blood clot in your lungs. For
this reason patients are encouraged to get out of bed as soon as practical after the
operation and drugs are given to prevent blood clots forming. If you are taking any
preparations containing oestrogen they must be stopped for at least 4 weeks prior
to your surgery, again to reduce the risk of developing a blood clot.
You should following the same post-operative supplementation guidelines as listed under
Post-op Gastric Band Diet (multivitamin with minerals and extra calcium + vitamin D).
Post-op Gastric
balloon diet
If your surgeon recommends you have a gastric balloon, a Bariatric Dietitian will discuss
your post-op diet in detail with you.
Cigarette Smoking – This surgery represents a turning point in your life so if you are a
smoker, now is an excellent time to give up. Smokers are much more prone to
experiencing problems with anaesthetics and recovery from surgery. Smokers, you
need to stop for at least 6 to 8 weeks prior to your surgery. Our Consultant
Anaesthetists will not allow you to have the operation unless you have given up.
Medication – If you are a gastric band, gastric bypass or sleeve gastrectomy patient,
you will need to have crushable forms of your normal medication for 6 weeks after the
surgery, or until you are back on solid food. You may want to buy a pill crusher from the
pharmacy to make this easier for you. If your doctor or pharmacist says that your
medicines are not suitable for crushing, you will need to have them in soluble or liquid
forms. You should then be able to resume taking tablets when you are back on solid
food, although you may want to break them into smaller pieces at first. If you do not see
your GP regularly, you should visit him/her prior to your admission to hospital to
discuss the medications you will need after your discharge. We write to your GP about
your medicines after you have seen the surgeon, nurse specialist, dietitian and
anaesthetist. Please bring your medicines in to hospital with you.
A number of patients find that they have wind-type discomfort after surgery. If so,
Windeze or Rennie Deflatine, which are available over-the-counter, can be helpful. Also,
taking peppermint tea can also settle any rumblings down. You may want to bring a
small supply of the wind medication and/or the peppermint teabags in to hospital with
you.
If you are a gastric balloon patient, you can take your medication in its normal form from
the date of the procedure.
Emotional Support – for many patients a big question is “Who should I tell about the
surgery?” Your immediate family and close friends should know because they will want
to support you over the period of the operation and afterwards. There are bound to be
days when you feel more emotional about your decision. You may find a diary helpful in
assessing your progress and it is good to start out with some photographs of how big you
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are at the time of operation. If you get a relative or friend to take a photo of you, stand in
a doorway – you will find the door frame a useful reference point for the “after” photos
you take later on.
sleep so it is a good idea to advise non-immediate family and friends to leave you in
peace. You will be sat up and you will find this the most comfortable position to be in for
a few days. While you are still recovering from the anaesthetic your blood pressure and
pulse will be monitored frequently.
Patient Support Group – This is a very important aspect of your care from the time you
make the decision to have this surgery, right through the years during which you are
losing weight. Talking to other patients who have been through the same experience as
you is the best way of finding out the most important details. They know far better than
any members of the multidisciplinary team what it is really like to undertake this
treatment. Locally, the support group provides a “buddy” for each individual patient. This
person will stay in contact with you before and after the operation and help to answer any
questions that you or your family may have (www.bospa.org).
2.
Your hospital stay
Admission – You will usually be admitted to hospital on the day of the operation,
although occasionally patients are asked to come in the day before. Here is a suggested
list of items to bring into hospital with you: sleepwear (one set for each day of your stay);
dressing gown, slippers, any medications, spectacles, toiletries. Please do not bring any
valuables in with you. When planning for your clothing to go home again in, choose
clothes which are not too tight around your waist and flat shoes. Please bring in your
normal medicines, either in their normal tablet form if they can be crushed, or in
soluble or liquid form (see note on Medications above).
Please make sure you have a thorough bath or shower before admission, concentrating
on the stomach area. This may help reduce the risk of infection.
You won’t have a catheter but occasionally patients may find they have a wound drain or
a naso-gastric tube down their nose to keep the stomach empty. Do not be surprised if
any fluid in these tubes looks blue or dark green (or if your hair or mouth has some blue
staining) – it is because dye is used during the operation to check for leaks and this is the
dye leaving your body.
Once you are awake you will be allowed to start taking sips of water and the staff will
encourage you to stand up and move around as soon as you are able. This is important
to prevent blood clots forming. Your intravenous fluid drip is usually taken out the
following morning.
Pain relief – many patients find that the operations are not as painful as they had
expected. Initially pain relief is given by injection but once you are drinking, it can be
given in dissolvable tablet form. Once home, if you need to take anything for discomfort
or pain, soluble paracetamol tablets are recommended – let them stand for 15 minutes
so that the fizz disperses before taking them though.
Discharge from hospital – When you are discharged, you will be taking
3.
the following medications.
•
Prior to your operation any remaining or repeat tests that need to be done will be
completed. If your operation is scheduled for the morning, you will not be allowed to eat
or drink anything from midnight the night before your operation. If your operation is
scheduled for the afternoon, you will not be allowed to eat or drink anything more after
breakfast. The surgeon and anaesthetist will also visit you to answer any remaining
questions that you may have and to ask you to sign the consent form for the operation.
•
•
•
Going to theatre – you will be given a theatre gown to wear that opens at the back.
Jewellery, make up and nail varnish must be removed. Most patients walk to the
operating theatre (so make sure you take a dressing gown and slippers to hospital with
you) and you will be put to sleep on the operating table so that you do not have to be
moved once you are asleep. It will feel as though there are several people buzzing
around and busy doing things to you, but don’t worry, you are in excellent hands. An
intravenous drip will be inserted into your arm and various other items including an
oxygen mask, oxygen saturation monitor and blood pressure cuff put into place.
Immediately after the operation – you will wake up either in the recovery room (part of
the operating theatre suite) or back on a ward. You will still be connected up to a number
of things including your drip, oxygen mask, oxygen saturation monitor and blood
pressure cuff. For the first few hours while you are still recovering from the anaesthetic
your blood pressure and pulse will be monitored frequently. You will mostly want to
You will need a medicine called a proton pump inhibitor to reduce the amount of
stomach acid that you produce. We recommend Zoton Fastabs (dissolvable)
30mg once daily for the first six weeks post-operatively. However, your GP may
want to prescribe the same drug (lansoprazole) in capsule form (30mg once daily)
instead, which our pharmacists say can be opened up and the contents emptied
into water for you to take for the first six weeks after the operation. After six
weeks you can take the whole capsule of lansoprazole. It is wise to ask your GP
to prescribe this for you pre-operatively so that you will be ready to take it after
surgery as follows:Gastric balloon – for six months (or duration of the balloon).
Gastric band – for one month
Gastric bypass and sleeve gastrectomy – for 3 months.
After you come to the first appointment with the surgeon, dietitian, specialist
nurse and anaesthetist we write to your GP to let him or her know what is needed
regarding your medicines but you or your GP are welcome to ring us at any stage
if there are questions.
•
Clexane – this is a small injection which thins your blood down to help prevent a
blood clot. If you are a gastric bypass or sleeve gastrectomy patient, you will
need to continue these at home for a total of 7 days from the day of the operation.
The nursing staff will show you or your chosen representative how to carry out the
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injections. If you need to have it after discharge, you will be sent home with
supplies of it and should also be discharged with a sharps box but, if not, you can
use a large screw top jar to dispose of the needles. When your injection course
has been completed, please check with your local surgery regarding safe
disposal.
•
Vitamin/mineral supplements – information on what is needed can be found
under the post-operative diet section of the individual operations. It may be a
good idea to buy the chewable multivitamins before you come into hospital so
that you have them ready to take once you go home. Bear in mind that the
chewable form is only until you are back on solid food, when you should switch to
the more complete tablet form.
Wounds – Following gastric band, sleeve gastrectomy and gastric bypass, the fivesix small wounds on your abdomen will either be glued or covered with waterproof
dressings after the operation. If dressings are in place, they should be left for seven
days from the day of the operation (only change if the wound is oozing or the dressing
has lifted off and is no longer waterproof). By that time, the wounds are usually healed
enough to remain uncovered. Any stitches used are dissolvable. If the wounds are
glued, the glue will disperse of its own accord after several weeks and you can shower or
bath as normal from the day after surgery.
If you notice any sign of wound infection (pain, redness, swelling or pus), you are advised
to visit your Practice Nurse for a wound check, redressing and swabbing of the wound.
There are no wounds following insertion of a gastric balloon.
Exercise – many feel more energetic quite soon after the operation. Start walking more
as soon as you feel able. With time you should gradually try to increase this until you are
walking for a total of 30 minutes per day. You should aim to walk at a speed that makes
you slightly short of breath and slightly sweaty.
Sleeping – you will find it more comfortable to sleep propped up with several pillows in a
semi-sitting position.
4.
Possible problems
Shortness of breath, chest pain or calf swelling and pain – Although rare, these
signs may indicate that you have developed a blood clot and you should seek medical
help immediately.
High fever, sweating, rapid pulse rate – If these symptoms occur and do not resolve
rapidly, please seek medical help immediately as they may indicate that you have a
problem at the surgery site.
Vomiting –
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•
Band – Contrary to some things you may have read about banding, vomiting is
not common because the band is restricted very slowly to the point at which you
are losing weight and able to eat a healthy diet. Occasionally, you may
regurgitate if you eat too fast, eat too much, or the food is not soft or chewed
enough. Remember, stop eating the minute you feel full.
•
Bypass – Occasionally, you may vomit or regurgitate if you eat too fast, eat too
much, or the food is not pureed enough. If you do, stick to soup and other liquids
for a day and then re-introduce food and eat small amounts, slowly. Stop eating
the minute you feel full. See also the comments about nausea in the eating
guidelines section.
•
Balloon – The balloon can irritate your stomach lining, especially in the first few
days after insertion but you will be discharged with a few days’ supply of an antisickness medication to help this settle.
Bowel disturbances – Your body will take a little time to adjust to the smaller quantity of
food you are eating and you may become constipated. To prevent or treat constipation,
drink more water – about a pint a day more than you used to. However, if you eat too
much fat at a meal, you may find that you develop explosive diarrhoea. Both problems
can be avoided by following the eating guidelines post-operatively. If these symptoms
persist then contact the dietitian or nurse specialist.
Dry skin – Many patients report developing very dry skin when losing weight rapidly.
You can help prevent and combat this by drinking plenty of fluids, taking your multivitamin and applying a good moisturising cream daily.
Hair loss - Some people who lose weight very quickly find they shed a lot of hair. As
your weight loss stabilises to a gentle pace, you should find the hair loss also slows.
Dumping syndrome (Bypass patients only) – this can occur if you eat too much sugar.
The body produces an excessive amount of insulin and this causes you to feel sweaty,
shaky and nauseous, sometimes with abdominal pain. Many people believe this is a
significant advantage of a gastric bypass, creating an in-built aversion to sugar! If this
happens, lie down and stick to fluids until the feeling has passed and then review your
eating patterns and reduce sugar intake. Dumping syndrome can also happen with fatty
foods, and if you don’t chew your food well enough or eat too quickly. It is not dangerous
but it can be very unpleasant. If it occurs, once you have recovered, think about what
may have caused it, to make sure you can avoid it happening again. If you are buying
food, get into the habit of checking labels and look for a sugar content of less than 5g per
100g of product.
Gallstones – rapid weight loss can lead to the formation of gallstones. If you suffer from
right sided upper abdominal pain, this can indicate that you have a gallbladder problem
and you should therefore make an appointment with your GP.
Hunger – When the gastric band is fitted, it is empty but you will probably feel some
restriction because of the swelling around the band from surgery. After a while (days to
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Page 24 of 29
weeks, depending on each person) the swelling goes down and you will probably feel
hungry again and be ready for the first band fill. However, it can take several
adjustments before you feel properly restricted so you may need to be patient. With the
gastric bypass, although your stomach will have been reduced to the size of a thumb
initially and some of your bowel will have been bypassed, you may still feel hungry from
the old part of the stomach which is sealed off. This can grumble with hunger pangs for
a few weeks and can be quite upsetting because you may feel that the operation hasn’t
worked. Be patient and things will settle down but you are welcome to ring the specialist
nurse or the dietitian to discuss it further if it is troubling you. On the other hand, many
gastric bypass patients find that they have little appetite from the time of the operation.
This can be a positive thing, but some people find it a bit upsetting that they don’t have a
desire for food. Again, talk to a member of the bariatric team if you are struggling with a
sense of loss and are grieving for food.
Blood tests post-op for life – It is essential that you know that after having any type of
bariatric surgery, you must have regular blood tests at your GP surgery to check that you
are not developing any nutrient deficiencies. The tests will be every 3-6 months in the
first year after surgery and then at least annually for life. We will write to your GP to tell
him or her which tests are needed, but you will need to make the appointment for them to
be done at the intervals we recommend. As mentioned before, gastric bypass patients
will need regular vitamin B12 injections.
Other things to take into consideration
Partying – being socially active is very important to positive emotional wellbeing but be
careful not to overdo it initially. Because you are eating only a small amount, you may be
much more prone to the intoxicating effects of alcohol than you used to be. Also bear in
mind that alcohol contains calories without any nutrients and can be high in sugar.
Length of hospital stay –
• Gastric balloon – usually a day case
• Gastric band – overnight stay
• Sleeve gastrectomy and gastric bypass – 2-4 nights.
Time off work – It is best to discuss this with your surgeon or the Bariatric Clinical Nurse
Specialist but generally gastric band patients have 1-2 weeks off work and the gastric
bypass patients have 6 weeks off work. Gastric balloon patients can go back to work
after a few days, once any initial nausea has worn off.
Follow-up regime – Gastric balloon patients will be given regular appointments with
the Bariatric Dietitian for follow up. Gastric bypass and sleeve gastrectomy patients
will be seen in Taunton approximately 6 to 8 weeks after the operation. After that, the
follow-up regime will vary and you will be given further details by the time of your
operation. It is important that you attend any follow-up appointment or let us know if you
can’t attend so that we can rearrange it for you and offer the original appointment to
another patient.
Band adjustments – Your first post-op appointment will be approximately six to eight
weeks after your operation. Your band is usually put in at the operation in a completely
un-filled state and at the first post-operative appointment, fluid will be injected into the
access port which has been positioned at the base of your breastbone. The procedure
should be only mildly uncomfortable. To check that the band is not too tight, you will be
given a glass of water to drink immediately after the fill. You will continue to have further
fills of your band approximately every 4 – 6 weeks until you reach the ‘sweet spot’ at
which you are losing weight, able to eat small solid meals and not feeling hungry. You
will also be seen periodically by the physicians and dietitian.
There may be times when you come to clinic and the doctor or nurse will not consider it
necessary to do a band fill but this will always be after discussing the reasons for this
with you.
Driving – After a gastric bypass, sleeve gastrectomy or gastric band you should be able
to drive after 1-2 weeks, but you must check with your insurance company first and make
sure you are safe to do an emergency stop by sitting in a car without the engine running
and practicing pressing the clutch and brake quickly. Gastric balloon patients should be
able to drive after 48 hours (but check with insurance company first).
Patient support group – Remember, the surgery is a tool and you will need to learn
how to obtain the best results. You will find the patient support group an invaluable
resource for learning from other patients and your success will, in turn, inspire other
people considering surgery (www.bospa.org).
Research – Members of the bariatric team are heavily involved in research into bariatric
surgery and you may be approached to enter into a research trial, although you do not
have to agree to take part.
Emotion – It is fairly common for any patient to feel tearful, irritable and vulnerable in the
first few weeks after surgery. This is a normal response as bariatric surgery is a life
changing event. If you are affected in this way, it is often temporary and improves once
you start eating more solid food and get back to your normal routine. Please contact a
member of the team if you need reassurance or are finding it difficult to cope.
Mental health issues – Bariatric surgery aims to help patients reduce their weight and
therefore improve their general health and extend their life expectancy. However,
although many patients do feel happier after their operations, the surgery cannot be
guaranteed to solve any existing psychological problems, relationship difficulties or any
other mental health issues.
If you are bulimic, if you binge eat or if you regularly overeat in response to how you feel
make sure you have discussed this with a health professional before the surgery.
If you are receiving care from a community mental health service, letting them know you
are about to have bariatric surgery will help you to receive the post-operative support you
need.
Problems with eating behaviours can come back after surgery and surgery does not
change habits driven by emotional problems.
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Not being able to use food as a comfort or a treat can be difficult so spend time before
surgery developing other ways of treating and comforting yourself.
If after surgery you feel that your mood has dropped or you have become excessively
worried about things, talk this through with your GP or your bariatric health professional.
It may be possible to refer you to the clinical psychologist at Musgrove Park Hospital who
works specifically with people pre and post bariatric surgery.
Pregnancy
Losing weight can increase fertility but we strongly recommend that you do not get
pregnant for 1-2 years after a gastric bypass because the rapid weight loss puts the
body under stress and can put your baby at risk.
If you get pregnant with a gastric band, the band can be deflated during the period of
pregnancy to ensure the baby gets sufficient nutrients and that you can breastfeed
afterwards, if you wish to. The band can then be re-inflated when the time is right.
Excess skin
Significant weight reduction in people who have been overweight for many years can
mean that the skin and underlying tissue do not naturally return to their original size.
This can lead to loose skin, particularly on the arms, legs and abdomen. Although there
are a number of surgical procedures for removing excess skin, these will not be routinely
funded through the NHS and plastic surgery following weight loss will only be considered
by the Primary Care Trust under exceptional circumstances. You will need to discuss
this with your GP if you feel that it becomes a major problem.
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Contact details of team
We aim to help you achieve your goals. If you have any questions about the operation
please ring one of the following people:Amanda Knight
Bariatric Service Administrator
01823 343514
Yasmin Ferguson
Bariatric Clinical Nurse Specialist
01823 343561
Ilana Alder
Bariatric Dietitian
01823 343394
Karen Coulman
Bariatric Dietitian
01823 343561
Anne Wheeler Bariatric Dietitian
01823 343394
Further reading:You are actively encouraged to find out all you can about weight loss surgery so that you
are absolutely sure that you have made the correct choice.
http://www.bospa.org (British Obesity Surgery Patients’ Association)
If you haven’t already done so, you are strongly advised to attend a Bospa meeting as
you will find it very helpful to talk to others who are going through the same process, or
who have already had surgery. The website has some useful information about types of
bariatric surgery.
http://somersetobesityservice.org.uk
Website written by Mr Richard Welbourn, Consultant Surgeon at Musgrove Park
Hospital, about aspects of bariatric surgery.
http://wlsinfo.org.uk
Web support group, discussion boards and information about obesity surgery in the UK.
http://www.buddypower.net
Online site which includes a forum for people interested in, or who have had, weight loss
surgery.
http://nationalobesityforum.org.uk
Information for patients and health professionals about the treatment of obesity
http://www.shrinkyourself.com
Online program to help with overeating issues.
http://www.nice.org.uk/CG43
The guidelines of the National Institute of Clinical Excellence, 2006
http://www.asbs.org
American Society of Bariatric Surgery – especially “History of Weight Loss Surgery”
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Appendix 1
Risks and benefits – Gastric band versus gastric bypass
Band
Bypass
Reversible
Not reversible
Adjustable
Not adjustable
Risk of death – 1 in 1000 (10-20% risk of reoperation at a future date).
Risk of death 1 in 200 (3-4% risk of needing a
return to theatre after the operation).
Specific risks – tubing leakage, stomach pouch
enlargement, erosion of band from outside to
inside stomach, infection, band slippage out of
position.
Specific risks – internal bleeding/leak at site of
operation, internal hernia, bowel blockage,
blood clot, chest infection, future gallstones,
temporary hair loss
No need to self-inject Clexane (to thin blood)
Need to self-inject Clexane (to thin the blood
post-op to help avoid blood clots) – total of 7
days needed
Frequent follow-ups for adjustments
(approximately 6-8 weeks post-op then at
regular intervals
Periodic follow up (approximately 6-8 weeks
post op, 6 months post-op, then clinic visits or
telephone follow up by negotiation)
Weight loss not immediate (first fill at 6-8 weeks
post op)
Weight loss from immediately post-op
Type 2 diabetes resolution in 8%-45% of
patients
Type 2 diabetes resolution in 70% of patients
50-60% excess weight loss 2 years post-op
60-70% excess weight loss 2 years post-op
Weight loss gradual
Weight loss rapid initially
Appetite still present
Appetite reduced for up to a year and a half
post-op
Keyhole operation – 5 small wounds over
abdomen including one slightly larger access
port wound below breastbone. Dissolvable
stitches or glue to wounds.
Keyhole operation – 5 small wounds over
abdomen. Dissolvable stitches or glue to
wounds.
Overnight stay
2-4 days in hospital
Less risk of nutrient deficiencies
Need for 6-monthly vitamin B12 injections
Recommended to have regular blood tests,
every 3-6 months
Need regular blood tests, every 3-6 months
Recommended to take daily multivitamin and
mineral, and calcium supplement
Need to take daily multivitamin and mineral,
and calcium supplement
Patient progress chart
(ask a member of the team to give you the ideal weight, 50% and 70% excess weight loss)
Start date
Weight
and height
on referral
Date of follow up
Body Mass Ideal
weight
Index
(BMI)
50%
excess
weight
loss
Weight at follow up
70%
excess
weight
loss
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Appendix 2
Gastric band patients – record of band fill volume
Date
Amount in band
Comments/problems
eg 16.9.09
eg 4 ml
eg First fill
Bariatric Team/Oct10reviewOct12