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WEIGHT LOSS SURGERY

Surgical procedures to try and help a person to lose weight (also known as bariatric surgery) are becoming more and more popular. This is because they are extremely effective when compared to trying to lose weight by dieting. The most popular procedures at present are the Sleeve gastrectomy and the Mini-gastric bypass.

Almost all patients will have tried dieting to lose weight. Almost all will have had short-term success with diets and then noticed that the weight always seems to go back on and they end up heavier than when they originally went on the diet!

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 lower your metabolism and increase your appetite. This means that despite you complying with a low calorie diet you do not see any weight loss after the first few weeks because your body has adapted a low metabolism to cope with the diet. You are tired and irritable (because your metabolism is artificially low) and you have severe cravings for any food containing lots of calories (because the hormones driving your appetite have taken over). It is because of your bodies totally normal reaction to food restriction that diets rarely work long term.

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 yo-yo 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 recognized 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 night. People who have undergone this surgery are usually back to work after 7 to 10 days. 

Bariatric surgery will help dramatically improve a persons' health, particularly if they suffer from conditions associated with their obesity. These include type 2 diabetes, 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 been able to escape the trap of obesity that is becoming all too common.

Sleeve Gastrectomy, Gastric Band, and Gastric Bypass are the common forms of bariatric surgery. These procedures are very safe and extremely effective in helping weight loss and most importantly maintenance of weight loss.

 

 

SLEEVE GASTRECTOMY

 

 

 

What does the surgery involve?

Sleeve Gastrectomy

"The sleeve gastrectomy works by reducing the size of the stomach. The stomach size is reduced from the volume of a Galia melon to the volume of a peeled banana. After the stomach has been divided, the excess stomach tissue is removed. "

Diagram showing the new tubular shape of the stomach following sleeve gastrectomy. The main part of the stomach, shown on the right, is removed. This part contains an appetite secreting area, explaining the reduction in appetite that is commonly reported following this procedure.

How long does the procedure take?

"The sleeve gastrectomy is performed laparoscopically by keyhole surgery and takes generally less than one hour to perform."

What scars will I have?

Sleeve Gastrectomy

"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."

Drawing showing the position of the 5 small scars after sleeve surgery

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?

"One or two nights."

How long will I need off work?

"One or two weeks."

How long until I can exercise?

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 postoperative 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 sleeve gastrectomy food has to be chewed very well and eaten quite slowly at least for six to twelve months after surgery. After this time most patients report that the amount of food that they can eat increases slightly and the ease of eating also improves. Within a year of surgery a patient's weight will have settled and they will report that they are comfortable eating a small starter plate of food before they feel full."

Will my appetite change?

Sleeve Gastrectomy

"Following sleeve gastrectomy most patients report that their appetite decreases significantly. This is usually in terms of a decrease in hunger feeling. When the stomach is removed an appetite hormone (called ghrelin) that is present in this part of the stomach is also removed. This causes a profound decrease in the amount of this appetite hormone that is secreted in times between meals. Appetite tends to return after approximately one year. It however will not be the voracious type of appetite that can occur following intensive dieting, and will be a more normal healthy hunger feeling."

Comparison of hunger feeling before and 6 and 12 weeks after sleeve gastrectomy. Time on x-axis represents time after a meal.

How much weight can I expect to lose?

"Following a sleeve gastrectomy, patients will lose approximately 70% of their excess weight on average. However a proportion of patients do very well following sleeve gastrectomy and will lose almost all of their excess weight. An example will be in a patient who weighs 20 stone but whose ideal weight is 10 stone, their excess weight would be calculated as 10 stone. Following a sleeve gastrectomy their weight would decrease by 7 stone to a level of 13 stone within nine to twelve months of surgery. With lifestyle changes this weight loss should be easily maintained long term."

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

"The sleeve gastrectomy 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 around significantly to help maintain this weight loss for the years to come. This would include changes in the eating pattern to ensure that they have a regular 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?

"We now recommend that following sleeve gastrectomy a patient take a multivitamin and calcium tablet for the first year after surgery whilst they are losing weight. As the sleeve gastrectomy does not involve any malabsorption of food, long term vitamin supplementation should not be necessary if a healthy diet is being taken."

What health improvements can I expect?

Health Improvements"Following sleeve gastrectomy there are dramatic improvements in all of the medical conditions that are caused by being obese. Approximately 80% of diabetic patients will have a complete remission of this condition or a dramatic improvement in the control of their sugar levels following surgery. Most patients who have high blood pressure will not require medications following their weight loss. High cholesterol is generally normalised. Sleep apnoea is almost always cured following weight loss and a patient will not require further sleeping mask therapy."

"In patients who did not have any medical conditions before surgery, they will notice a dramatic improvement in not only their underlying healthy but also their feeling of contentment and improved quality of life."

What are the risks of surgery?

"In the short term there is an approximately 2% chance of serious complications. These include bleeding from the staple line or leakage from the top of the staple line. These complications require either a blood transfusion or a further operation in the form of a laparoscopy to drain any leakage or stop bleeding. In the unlikely event of a leak then a patient can expect a longer stay in hospital."

"Occasionally patients can have difficulty with swallowing solid food and occasionally liquids in the early period after surgery. This generally settles down in time."

"Long term complications following sleeve gastrectomy are very rare but may include the sleeve gastrectomy tube re-dilating up, meaning a person can consume a greater volume of food and therefore increasing the possibility of weight regain."

 

 

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.

Gastric Bypass

Diagram showing the rout that food takes following gastric bypass. A small meal will initially fill the stomach pouch before entering the bypassed part of the small bowel. This stimulates release of hormones that cause a pleasant feeling of satiety and fullness.

The gastric bypass therefore works in three distinct ways:

  • The amount of food that can be consumed is reduced.
  • 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).
  • 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."

Gastric Bypass

Drawing showing the position of the 5 small scars after bypass surgery

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."

Exercise

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 postoperative 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 weighs 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?

Breakfast, Lunch and Dinner"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?

Health Improvements"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."

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