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Weight Loss

Bariatric Surgery

Surgical procedures to try and help a person to lose weight are becoming more and more popular. This type of surgery, which is also known as bariatric surgery, is increasingly being recognised by GPs, and also by patients, through word of mouth and the internet as much more effective than any type of diet in terms of weight loss and improvements in the quality of a person's life.

The problem with dieting is that once a certain amount of weight is lost the body goes into a starvation type mode, and hormones are produced that cause a voracious appetite to occur and for the person to start craving foods high in sugar and fat.

For this reason it is very common for patients to be able to lose a certain amount of weight but to regain it quite fast and even put more on. This common dieting sequence is referred to as yoyo dieting and is a normal consequence of these appetite driven hormonal changes, which are very difficult to resist.

Bariatric surgery is highly effective in that the procedures will help a patient to lose weight, but also more importantly will stop the longer term urges to regain weight by modifying the appetite drives and food cravings.

In addition to bariatric surgery increasingly being recognised as the most effective weight loss strategy, it is also being accepted that it is a much safer form of surgery than previous public perceptions. In the hands of a surgeon and a surgical unit which is dedicated to this type of surgery, the complication rate is as low as routine gallbladder or hip surgery, and the stay in hospital is only one or two nights. People who have undergone this surgery are usually back to work after one or two weeks.

Bariatric surgery will help dramatically improve a persons' health, particularly if they suffer with conditions associated with their OBESITY. These include type 2 DIABETIS, high blood pressure, high cholesterol, sleep apnoea and joint problems. Once a patient has lost weight following bariatric surgery it is a pleasure to see them in the outpatients' clinic with their lives transformed, having finally being able to escape the trap of obesity that is all too common in our Western world.

Virtual Clinic

  • Gastric Bypass
  • Sleeve Gastrectomy
  • Gastric Band
  • Revisional Surgery
  • Golden Rules of Eating

Gastric Bypass

What does the surgery involve?

"The gastric bypass involves stapling the stomach to produce a much smaller stomach, which will reduce from the size of the stomach from that of a Galia melon to the size of an egg. The second part of the operation involves bypassing the digestive secretions that are normally involved in absorption of foods. A loop of the small bowel is bought up to the new small stomach and connected to this. This new configuration bypasses the digestive secretions for half of the bowel length. Eventually food and secretions will remix half way down the bowel.

The gastric bypass therefore works in three distinct ways:

  1. The amount of food that can be consumed is reduced.
  2. There is a degree of malabsorption of some of the calories and nutrition in the food that is eaten (this malabsorption readapts after one year).
  3. The reconfiguration of the bowel produces a profound decrease in the patient's appetite, and a change in the patient's food preferences away from sweet or fatty foods and towards healthier foods."

How long does the procedure take?

"The procedure is under general anaesthetic and takes on average one and a half hours."

What scars will I have?

"The procedure is laparoscopic or keyhole surgery, therefore there is no big scar. The procedure involves making five small cuts ranging from 5 mm to 12 mm long in the upper abdomen just below the rib cage."

How will I feel following surgery?

"The morning after surgery you should be able to walk around your private room, use the bathroom and shower. You should be able to sit comfortably and drink tea, smoothies or milk. Your pain should be well controlled with soluble painkillers. "

How long will I need to stay in hospital?

"Some patients will be keen to go home the day after surgery but most will prefer to stay and relax in the hospital and return home after the second night."

How long will I need off work?

"One or two weeks."

How long until I can Exercise?

"You will be able to walk around within hours of surgery. The morning after surgery I would expect a patient to be able to walk around relatively comfortably. On discharge from hospital I would recommend increasing activity levels on a daily basis including longer and longer walks. More active exercise such as at the gym can be introduced one week after surgery, with a gentle reintroduction to aerobic exercise such as light jogging, cycling or swimming. Any exercise involving heavy lifting should be avoided for one month."

How soon can I reintroduce solid foods?

"The dietician will give you a detailed description of your pre and post operative dietary instructions. Following surgery a liquid diet should be maintained for one week. This should be followed by a diet of pureed consistency food for one week. The third week should consist of mashed consistency foods and a slow introduction of well chewed solid food should be introduced thereafter. I advise patients to be particularly careful with bread and dried meat, such as chicken, for the first two months after surgery as these are the foods most likely to cause discomfort if not chewed properly."

What will my eating be like long term?

"Following a gastric bypass after the initial month where solid food is reintroduced, eating becomes much easier. Within two or three months you will be able to contemplate eating out. Clearly the amount of food will be much less and a starter portion will usually suffice, however patients report that the quality of life, as far as eating is concerned following a gastric bypass, is back to normal within a few months of surgery."

Will my appetite change?

"Following gastric bypass patients report profound changes in their appetite. The gastric bypass produces a reconfiguration of the digestive system, which tricks the brain into thinking that a person has eaten much more than they actually have. For this reason, after eating a small amount of food a patient will feel full and have a pleasant satiated feeling for many hours thereafter. Food is generally not an issue following gastric bypass and many patients will have to remind themselves to have lunch by setting a reminder alarm. The changes of appetite tend to last for at least twelve to eighteen months and in many cases for a longer term. In addition to this, most patients report that they develop an aversion to sweet foods and also to foods in high fat content. Sometimes this can be due to a syndrome called dumping which occurs after eating high fat or sugar foods. This causes a feeling of faintness, weakness and sweatiness and leads to the development of quite a rapid aversion to these types of foods, making weight loss much easier."

How much weight can I expect to lose?

"Following gastric bypass patients will lose about 80% of their excess weight. If a person weight 20 stone but their ideal weight is 10 stone, then the excess weight they are carrying is 10 stone. Following gastric bypass if they lose 80% of this excess weight, that will equal 8 stone of weight loss. Therefore following gastric bypass this persons weight will decrease from 20 stone to the 12 stone level within nine to twelve months of surgery and remain at this level long term."

What do I need to do to ensure long term weight loss?

"The gastric bypass is extremely effective in producing excellent weight loss in the first year and changing the patient's appetites and food preferences to help maintain this long term weight loss. However it is vital that after surgery a patient changes their lifestyle significantly to help maintain this weight loss for the years to come. This would include changes in their eating pattern to ensure that they have a regular healthy breakfast, lunch and dinner. The stopping or cutting down of unhealthy high calorie foods and finally the introduction of a more active lifestyle. These changes should ensure that weight loss is maintained long term."

Do I need to take vitamins after surgery?

"Following gastric bypass there is a malabsorptive component to the surgery and therefore we advise that people take a vitamin and a mineral supplement long term following surgery. We also advise that vitamin B12 levels are measured regularly and that supplements are given to prevent any deficiency arising in the future."

What health improvements can I expect?

"Following surgery there are dramatic improvements in most of the conditions that are associated with obesity.

Type 2 diabetes, if diagnosed within the preceding five years, will have a 90% chance of going into complete remission. If type 2 diabetes has been present for longer than five years then it is more likely that it will be improved dramatically by surgery with a significant decrease in the amount of medication required and an improvement in the sugar control.

High blood pressure will be improved dramatically within a few months of surgery and usually will resolve completely.

Sleep apnoea in 80-90% of cases will resolve with patients not requiring a sleeping mask, and being able to sleep and rest easier and feel much more revitalised the next day.

Joint pain and osteoarthritis: degenerative joint problems secondary to long term weight problems are not reversible, however once a person has lost a considerable amount of weight, the pressure on the joints is decreased and invariably a person will report a considerable decrease in the amount of painkillers they need to take.

Following surgery the person's quality of life dramatically improves. Patients generally feel fitter, healthier, revitalised and generally stronger after surgery."

What are the risks of surgery?

"Within the first day or two after surgery there is a 2% chance of complications occurring. These include leakage from where the stomach and the bowel are joined together, or bleeding from where the stomach is stapled. In these unlikely circumstances either a blood transfusion or a further laparoscopic operation is required and a patient may require a longer stay in hospital. There are also small risks of leg thrombosis and embolisms. These risks are minimised by blood thinning injections, compression stockings, the short operation time and the early ambulation after surgery.

The long term risks of gastric bypass are also uncommon. They include vitamin or mineral deficiency if supplements are not regularly taken. Other rare long term complications include a small hernia developing at the site of instrument insertion in the abdominal wall, or an internal herniation or twist in the bowel, which can cause colicky abdominal pain and need investigation. In patients taking anti-inflammatory painkillers such as Aspirin or Brufen for medical conditions, such as arthritis, we recommend that an acid blocking tablet is also taken to prevent the development of a stomach ulcer at the site of the join between the stomach pouch and the small bowel. Long term risks after surgery are in the region of approximately 2% and therefore very rare."

Sleeve Gastrectomy

Sleeve gastrectomy is a surgical weight-loss procedure in which the stomach is reduced to about 15% of its original size, by surgical removal of a large portion of the stomach along the greater curvature. The result is a sleeve or tube like structure. The procedure permanently reduces the size of the stomach, although there could be some dilatation of the stomach later on in life. The procedure is generally performed laparoscopically and is irreversible.

How does the sleeve gastrectomy work?

  1. Most of the stomach is removed except a small sleeve-shaped pouch. It can hold 1 ½ to 5 ounces, and is about the size of a banana.
  2. Patients are unable to eat as much food, fewer calories are absorbed into the body, and the hormonal signals between the stomach and the brain are changed.
  3. Typically, patients will experience weight loss and improvement in metabolic syndrome and overall health and well-being.

Gastric Band

A laparoscopic adjustable gastric band, commonly called a lap-band, A band, or LAGB, is an inflatable silicone device placed around the top portion of the stomach to treat obesity, intended to slow consumption of food and thus reduce the amount of food consumed.

To qualify for gastric banding surgery, you must fall into one of two categories:

  1. BMI of 40 Kg/M2, or higher.
  2. BMI of 30 Kg/M2 or higher, with at least one obesity related medical problem such as High Blood Pressure, Type II Diabetes, Sleep Apnea, severe cases of Arthritis, Acid Reflux Disease, Low Back and Joint Pain.

Revisional Surgery

"Some people have previously undergone bariatric surgery but the procedure that was performed did not suit them, and therefore they had disappointing weight loss results or have started to regain weight. This can happen in a small proportion of patients following either gastric band, sleeve gastrectomy or gastric bypass."

"In patients who have previously undergone gastric band surgery, complications of the band can mean that it requires removal. These complications include the band migrating into the wrong position around the stomach, the band eroding into the stomach, problems with the connection tubing, leakage from the band, and dilation of the oesophagus above the band."

"In these cases of failed bariatric surgery, revisional surgery may be indicated. The most common procedure would be removal of a gastric band and conversion to gastric bypass. Other common revisional surgeries include conversion of a sleeve gastrectomy to a gastric bypass and placement of a gastric band around a previous gastric bypass."

"Revisional bariatric surgery has a higher complication rate and therefore should be considered very carefully. Choice of an experienced surgeon working in a unit dedicated to bariatric surgery, and used to the more complicated revisional surgery, will significantly decrease the risk of complications occurring."

Golden Rules of Eating

There are six Golden Rules on how to eat following bariatric surgery. These apply to all types of surgery but are particularly applicable if the gastric band is to be effective in the long term to help reduce weight.

  1. Eat while sitting at a table, either with company or alone. Do not eat while distracted, i.e. reading newspaper or watching television. Do not eat in the street. This is to ensure that the food is eaten slowly and savoured.
  2. Use a small side plate to eat from. This will ensure an appropriate portion size.
  3. Chew each mouthful of food 20 to 30 times. This will ensure that the food is of the right consistency to pass through the gastric band or sleeve gastrectomy without blockage.
  4. Use a knife and fork and put the knife and fork back down onto the table while chewing your food. This will ensure that food is not eaten too fast and time is taken between mouthfuls of food.
  5. Do not drink any liquid from half an hour before to half an hour after eating.
  6. Have regular meals including a regular breakfast, lunch and dinner. Each small meal should have some protein content to ensure that the appetite hormones remains slightly suppressed. A small healthy snack can be taken between meals.

If the Golden Rules are followed then it should take 20 to 30 minutes to eat a small side plate portion of food. By the time the food has been finished a person will feel satiated.

Novel Procedures

There are many novel procedures that are being offered to promote weight loss. There is a lot of interest amongst surgeons and gastroenterologists regarding these procedures. However they remain either experimental in nature or have not been proven as yet to offer patients effective safe, cost effective, long term weight loss. Here follows a summary of these procedures:

POSE (Primary Obesity Surgery, Endoluminal)

"This procedure is performed by endoscopy where a flexible telescope is inserted through the mouth. Therefore no cuts in the abdomen are required. The flexible endoscope has been designed to deploy staples or clips to the floppy part of the stomach. The aim of the procedure is to try and reduce the size of the stomach by folding the stomach up using these staples that are fired from the endoscope."

"This procedure is an adaptation of several previous procedures which have attempted to reduce the size of the stomach via an endoscope. Many of the previously attempted procedures are now not available on the market because they either did not produce effective weight loss, or they had a significant complication rate including perforation of the stomach. At present there is no significant independent evidence that the POSE procedure is a safe and effective alternative to laparoscopic bariatric surgery."

SILS (Single Incision Laparoscopic Surgery)

"There has been great interest in SILS surgery over the last five years since the concept was introduced into the surgical scientific community. SILS surgery requires the surgeon to perform a traditional laparoscopic operation through a single port usually placed in the umbilicus. Despite the initial interest, many surgeons have tried this procedure and most would agree that the increased risk of surgery, including longer operating time and increased risk of complications, outweighs the benefit of one longer scar across the umbilical area, instead of three to five 5-10 mm scars. There has been no proven improvement in postoperative pain following SILS surgery. Most surgeons now will not offer this surgery for the reason that it confers a greater risk of complications, compared to the minimal benefits in cosmesis."

Robotic Surgery

"The use of an articulating robot to assist a surgeon in performing laparoscopic surgery has been received with much enthusiasm by laparoscopic surgeons. The robot as an aide to surgery is now used routinely for many types of surgery, particularly gynaecological and urological surgery."

"Some surgeons have used the robot to perform bariatric surgery such as the gastric bypass. However this has not been routinely popularised as most bariatric units are be able to perform relatively fast and very effective bariatric surgery without the use of the robot. The robot has as yet not been proven to confer any advantage in safety over routine laparoscopic bariatric surgery, and in fact will lead to an increase in the operation time. In addition to this, the robot is not designed to staple or join the stomach and bowel and therefore an assistant has to be used for this, where with laparoscopic surgery the primary surgeon will perform the stapling."

"Therefore in summary, robotic bariatric surgery does not confer any significant advantage over laparoscopic bariatric surgery and has the disadvantage of lengthening the time of the operation."

Gastric Balloon

"The gastric balloon has been a endoscopic option to help weight loss for several years now. Our experience of the gastric balloon is that many patients have major problems with intractable vomiting following the insertion of the gastric balloon. In addition, there are reports of significant side effects from the gastric balloon including gastric perforation. The procedure is only temporary and the balloon has to be removed or replaced after six months. Once the balloon is removed a patient will invariably regain any weight that has been lost. It is for these reasons that we do not offer this therapy as we do not think that it is cost effective in long term weight loss."

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Note: ** These are general overviews and information aimed for use by their specific patients and reflects their views, opinions and recommendations. This does not constitute medical advice. The contents are provided for information and education purposes only and not for the purpose of rendering medical advice. Please seek the advice of your specific surgeon for further information. **

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