Why treat obesity?
The main concern around excess weight is the impact it can have on our health. We know that being obese can increase the chance of developing many other diseases such as diabetes and heart disease.
Bariatric surgery has been shown to prevent or improve conditions and diseases such as:
• Type 2 diabetes.
• High blood pressure (hypertension).
• High cholesterol.
• High triglycerides.
• Heart disease.
• Asthma.
• Sleep apnoea.
• Certain cancers such as breast, colon and endometrial cancer.
• Polycystic ovary syndrome.
• Osteoarthritis and joint problems.
• Infertility.
• Stress incontinence.
Bariatric surgery can also improve quality of life and increase life expectancy.
Bariatric surgery is an option for people with a high body mass index (BMI), who are well informed, motivated and have realistic expectations about what surgery can achieve for them.
What is bariatric surgery?
Weight loss surgery is also known as Obesity Surgery or Bariatric Surgery and refers to surgical operations designed to help reduce excess body weight. The operations work by reducing the amount of food you can eat along with altering the hormonal signals from the stomach and intestine to parts of the brain that control hunger and body weight. This combined with a healthy diet and exercise will help in the reduction of weight and improve (and may prevent) some of the conditions associated with obesity.
Bariatric surgical options
The operations are performed under a general anaesthetic and usually take between one to three hours. A laparoscopic (‘keyhole’) technique is usually used where the bariatric surgeons will make five small incisions in the abdomen. The abdomen will be inflated with gas to enable them to move their instruments and have a better view of the stomach. Surgical instruments, along with a camera, are placed inside the abdomen and the surgery is performed using a television screen for guidance.
Currently there are three main surgical options available, gastric bypass, sleeve gastrectomy and the adjustable gastric band.
Gastric Bypass
This operation involves stapling a small stomach pouch away from the original stomach. The surgeon then measures a length of small bowel and attaches this to the small stomach pouch. After surgery food will follow the normal route into the small stomach pouch and then pass directly into the attacked small bowel.
The main part of the stomach is left inside the abdomen and continues to have a blood supply. Although there is no food passing through this part of the stomach, it still produces gastric juices that are very important for digestion.
The operation helps to reduce the amount of food you can eat and also alters some of the hormonal signals from the stomach and intestine to parts of the brain that control hunger and body weight.
Sleeve gastrectomy
This operation involves removing approximately 75% of the stomach, leaving behind a narrow tube (sleeve) which becomes your new stomach. After the surgery, food will follow the normal route into the smaller stomach and then into the small bowel. The operation helps to reduce the amount of food you can eat and also alters some of the hormonal signals from the stomach and intestine to parts of the brain that control hunger and body weight.
Adjustable gastric band
The gastric band is a ring placed around the top part of the stomach. There is almost no stomach above the band. When eating, you will get a sense of fullness from a very small amount of food. This feeling of satiety (a feeling that you are not hungry) is induced by the band pressing onto the surface of the stomach and stimulating the nerves leading to the brain. The band is attached to tubing that is connected to a port. This port is attached to the abdominal muscles under the skin. Fluid can be added (by injection) to the band to increase and decrease the sense of satiety.
After the surgery, food will follow the normal route passing through the band into the larger stomach.
Gastric balloon procedure
A deflated balloon is placed through the mouth and oesophagus into the stomach. The balloon is then filled with blue liquid. The balloon is designed to partially fill the stomach, giving you a feeling of fullness. This will help change eating pattern, reduce the volume of food eaten and inducing a feeling of fullness quicker. The balloon is designed to stay in place for a maximum of twelve months, after which it must be removed in a very similar way as to how it was inserted.
Eating after the surgery
Bariatric surgery is a tool to assist you to lose weight and improve their health. The operation can only be successful and effective if you commits to the necessary dietary and lifestyle changes.
How does the operation affect eating?
Surgery restricts how much food someone can eat at one time. This helps to limit food intake overall and therefore results in weight-loss. However the procedures do not alter a person’s choice of foods and they are still ultimately responsible for what food they choose to eat. High calorie and energy-dense foods such as crisps, chocolate, ice cream, cakes and biscuits are not restricted by the operations. These types of foods are a major cause for slow weight loss, early weight stabilisation and weight regain in the long term. We recommend that people start making changes to their diet and behaviour before surgery because surgery alone will not change bad habits.
What diet is recommended after having weight-loss surgery?
Following weight-loss surgery the bariatric dietitian and nurse visit patients on the ward to discuss dietary changes and provide patients with verbal and written information. Initially, patients are required to follow a fluid-only diet for a short period followed by a puréed diet and then a soft diet. Finally around eight weeks after the operation a patient can start to gradually progress onto normal textured food. The time it takes to move between the different stages varies from individual to individual. Most people return to eating normal textured food within two to three months.
In addition patients are encouraged to increase their activity levels. This will help prevent loss of muscle tissue whilst losing weight. It will also help to maximise weight loss and prevent weight gain.
Life-long patients will be encouraged to adopt a good routine of 3 small meals a day, trying not to eat in-between meals. We would advise that choices are health and rich in protein. A slow pace of eating along with not eating and drinking together will be necessary for comfort after taking food. The patient will learn to listen to their bodies signals and stop eating at the first sign of fullness. The bariatric team will support patients at regular intervals and equip them with the behavioural changes they need to make the surgery a success.
Support after surgery
Most patients will be able to go home one to two days following surgery, though everyone is different and some may require a longer hospital stay. It is normal for the abdomen to feel sore and bloated for a few weeks. During this time, pain killers are recommended and prescribed before a patient leaves the hospital. Patients are advised to check wound sites regularly for signs of infection (pain, heat and redness) and advised to see their GP if concerned.
Following discharge from hospital, it is common that a person may feel tired and need to rest but this will improve. It will normally take approximately four to six weeks to resume normal activity. It’s advisable to avoid heavy lifting for four weeks.
A person must not drive until they can wear a seatbelt comfortably and be able to perform an emergency stop safely. It is advisable to check with insurance companies first.
As a person begins to feel better, the team will encourage them to incorporate gentle exercise into their daily routine such as walking or swimming. As they start to lose weight, they will feel more energetic and able to undertake more exercise.
Follow-up
The dietitian or specialist nurse will contact patients by telephone within 48 hours of discharge from hospital. Following this, an outpatient appointment will be made between one and six weeks after surgery, depending on the operation. This is so that the team can assess recovery.
Patients are then seen by the nurse specialist and/or the dietitian at regular intervals for two years. These appointments can be either face to face or on the telephone.
Patients who have a laparoscopic adjustable gastric band will generally be seen in the outpatient clinic on a more regular basis for band adjustments.
Two years after surgery patents are discharged back to the care of their GP.
Life after bariatric surgery
As a person starts to lose weight after surgery, they can expect to feel much healthier however they must remember that these changes will affect their everyday life in terms of going out for meals, buying clothes, going on holiday etc.
Support from family and friends is important while they make adjustments to changes in their life. Many patients who lose a large amount of weight will have loose skin usually around the stomach and the tops of the arms and legs. Surgery to correct excessive skin is not part of the bariatric surgery agreement and is not guaranteed once a person start to lose weight.
The GP will need to refer patients separately for funding if the skin is to be removed. It is important to remember that this will only be considered when enough weight has been lost and is being maintained.
For our female patients, we advise against pregnancy until at least two years after the operation as the body needs an appropriate amount of time to adjust. It is also important to remember that bariatric surgery may reduce the effectiveness of some forms of contraception.
Following bariatric surgery if a person is planning to become pregnant it is important that the doctors, midwives and dieticians are aware that they have had bariatric surgery. If a patient does become pregnant, we advise them to contact the bariatric surgical team as soon as possible so that we can monitor them throughout their pregnancy.
Referral for bariatric surgery
The NICE (National Institute for Clinical Excellence) Guidelines state that a person may be offered a referral for a comprehensive assessment by specialist weight management services if they have a BMI of 40 kg/m2 or more, or between 35 kg/m2 and 39.9 kg/m2 with a significant health condition that could be improved if they lost weight (e.g. high blood pressure, diabetes, sleep apnoea) and agree to the necessary long-term follow up after surgery.
If you wish to be considered for bariatric surgery, make an appointment with you General Practitioner who will then refer you on to the local weight management service.
GP information
Link to the GP hub: Introduction to the BOMSS GP HUB
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