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© G19030803W. Design Services, Salford Royal NHS Foundation Trust, All Rights Reserved 2019. Document for issue as handout. Unique Identifier: SURG 22 (19). Review date: April 2021.

U n i v e r s i t y T e a c h i n g T r u s t

Having bariatric surgery

Hope BuildingUpper G.I. / Bariatrics

0161 206 5062


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This booklet aims to describe:

l What is bariatric surgery

l What will happen before surgery

l What will happen to you while you are in hospital

l What will happen for discharge

l Follow up care

l The surgeries and risk/benefits

l Additional information

l Further information & support

What is a bariatric surgery?Bariatric surgery (weight loss surgery) includes a variety of procedures performed on people with obesity. Weight loss is achieved by reducing the size of the stomach or through removal of a portion of the stomach (sleeve gastrectomy) or by resecting and re-routing the small intestines to a small stomach pouch (gastric bypass). The correct operation for you will be discussed in detail with our surgeons. The operation is a tool to help you lose weight; you need to follow the dietary and lifestyle advice given by the team to maximise weight loss and prevent weight regain. An accompanying booklet will be provided describing your dietary needs.

What will happen before surgery?Only referrals from your weight management service will be accepted to gain funding for you to have surgery as an NHS patient, once this is in place you will be invited to meet the team.

What will happen before surgery?l You will have your height,

weight and blood pressure measured

l You will need to have a blood test

l You will see a specialist nurse who will go through the operations with you and talk through your hospital stay

l A specialist dietitian will discuss your required pre and post-operative diet plan

l A bariatric physician will analyse your medical history and suitability for surgery

l A bariatric surgeon will discuss the surgical options, risks and benefits associated with the surgery

l This appointment can last up to 4 hours.


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l You may have to have some breathing tests (sleep studies) performed to check if you have sleep apnoea. If you do, you may require a special machine to help you breathe when sleeping (CPAP)

l You may be seen and assessed by a clinical psychologist

l If there are any issues identified during the Multi Professional Clinic appointment, you may be directed to other departments or your GP for further assessment.

Further investigations

l Location of your operation and pre-operative assessment - you may have your operation at Salford Royal Hospital or at private hospitals as a NHS patient with our bariatric surgeons

l Pre-operative clinic appointment to assess fitness for surgery – you will have blood tests taken and a heart tracing (ECG). You may also be required to see a specialist bariatric anaesthetist

l Information about fasting before surgery

l Any medication adjustments required

l Hospital map and location of Surgical Admission Lounge (SAL)

l All patients are required to complete 2 weeks of the liver reduction diet found in the accompanying dietary information booklet.

What happens next?

The bariatric secretary will write to you with the following details:

While you are in hospitalOn the day of your surgeryl You will be admitted by the

nursing team. Your Surgeon and Anaesthetist will see you to explain the operation and ask you to sign a consent form. You will be asked to wear a hospital gown and elasticated stockings to help prevent against blood clots in your legs. You may also be given a small injection in order to thin the blood and help to prevent blood clots

l You will be taken to theatre for your operation. Afterwards, you will be taken to the recovery area until you are awake and your pain is well controlled. You will then be transferred to the ward

l When you return to the ward your pulse blood pressure, temperature and breathing will be regularly monitored

l You will be encouraged to mobilise as soon as possible to prevent post-operative complications such as blood clots and chest infections

l You will be able to have sips of water, which will be increased as directed by the surgical team

l You will spend the night on the ward where you will be regularly monitored by the nursing staff.

On the day after your operationl You will be encouraged to

continue to mobilise as much as possible

l You will continue your prescribed pain relief; you will also be given regular anti-sickness medication if required

l We encourage you to take small sips of water regularly to keep hydrated. Please move on to fluids such as tea, coffee or sugar free cordial when instructed to. You will need to be able to manage some clear soup before you go home


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l You will be seen by the specialist bariatric nurse who will discuss your operation and answer any questions you may have and also discuss all the information you will need to know before you go home

l You will be seen by the specialist bariatric dietician to discuss your eating plans for the coming weeks

l You will also be seen by the pharmacist in order to ensure that all your medications are changed so that you can take them with a liquid diet

l You will be seen by the surgical team who will discuss your operation, its outcome and plan. Usually the surgeon will then be happy for you to go home later that day.

Before you are discharged

l You will continue to wear your stockings if they fit well, and will be required to wear them for 2 weeks

l You will be given all the medication you require including a blood thinning injection (usually for 5 days), which the ward nurses will show you how to use

l If you have clips to the wound the discharging nurse will need to arrange removal in your local area.

Follow up care

l Information and contact numbers are in this booklet for any advice and support you may need

l At 6 weeks you will be seen by one (or more) of the surgical team in an outpatient clinic. You will then be seen in an outpatient clinic by the specialist nurse and the dietician together at 4 months

l You will have an annual review with our bariatric physicians for life

l You have access to dietetic follow up for up to 2 years.


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Sleeve gastrectomy (also known as vertical Sleeve gastrectomy) is a type of weight loss surgery, which can be used as a tool a for sustained weight loss. The surgeon removes approximately 60-80% of the stomach, permanently reducing its size so that the remaining stomach resembles a tube or sleeve, the remnant stomach is then removed and disposed of.

Food and drink enters the new stomach Tube/sleeve and follows the same route as it did before (unlike the gastric bypass). The surgery takes approximately 1hr. However, you will be away from the ward for a longer period of time in the anaesthetic room before your surgery and in recovery after the operation.

The surgeries we offer sleeve gastrectomy, gastric bypass and gastric banding:Gastric banding works very differently to bariatric surgeries, a separate booklet is available

What is sleeve gastrectomy?

New stomachpouch

Stomachthat isremoved

l The procedure is done using a keyhole (laparoscopic) technique

l You are put to sleep using a general anaesthetic

l The surgeon then makes five small cuts (1-2cm) on your abdomen

l Gas is then introduced into the abdomen to enable the surgeon to see the internal organs more clearly

l A small tube-like camera is inserted through one of the cuts to view the area of the operation; this is then shown on a large screen

l The operation is then carried out using various instruments through the other cuts in your abdomen

l Your stomach is stapled to create a thin tube or sleeve, with the excess part of the stomach removed via one of the cuts, which will be slightly wider than the other cuts and have an internal stitch.

How is the operation performed?

l The gas is then released from your abdomen

l The cuts are then closed with glue, steri-strips or surgical clips.


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What is a gastric bypass?It is a type of weight-loss surgery that reduces the size of your stomach by stapling across the top creating a small pouch. A section of your intestine is then cut and reconnected to the pouch so that the food you eat bypasses part of your digestive system. A further surgical join is made (an anastomosis) to allow for other gastric juices further down the small intestine.

A Roux-en-Y Gastric Bypass has 2 anastomoses. None of your stomach is removed in the procedure. Chemical and biological changes happen within the body meaning you are less likely to feel hunger and can use the surgery, adhering to the dietary advice, as a tool for long-term sustained weight loss.

Proximal pouch of stomach

Duodenum

Bypassedportion of stomach

‘Short’ intestinal Roux limb

How is the operation performed?

l The procedure is done using a keyhole (laparoscopic) technique

l You are put to sleep using a general anaesthetic

l The surgeon then makes five small cuts (1-2cm) on your abdomen

l Gas is then introduced into the abdomen to enable the surgeon to see the internal organs more clearly

l A small tube-like camera is inserted through one of the cuts to view the area of the operation; this is then shown on a large screen

l The operation is then carried out using various instruments through the other cuts in your abdomen

l The top part of your stomach is stapled to create a small pouch

l Your intestine is then connected to the pouch, the greater part of your stomach and some small intestine (approximately 150-200cm) is then bypassed to complete the procedure

l The instruments are removed and the gas is released from your abdomen

l The cuts are then closed with either staples or stitches

l The operation usually takes approximately 2 hours however you will be away from the ward longer as you will also spend some time in recovery.


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This is a variation on the surgical technique of gastric bypass and is carried out instead of a Roux-en-Y technique. Around 200cm of small intestine is bypassed and attached to a slightly longer stomach pouch. The single anastomosis gastric bypass has been gaining popularity as it is a shorter operation and carries slightly lower risk of complications. This is characterised by having one surgical join (anastomosis) rather than 2. Although it is an option to any patient wanting a gastric bypass, it is particularly of benefit when there are technical reasons to avoid a Roux-en-Y technique. Such as in patients with a very high BMI likely to have a large-sized liver, when there are extensive adhesions (old scar tissue from previous surgeries) in the abdomen and when for anaesthetic reasons a shorter operation is desired. However, a minority of patients may develop bile reflux that rarely but may require conversion to a Roux-en-Y gastric bypass.

The alternative to the roux-en-y is the single anastomosis gastric bypass:

What is a single anastomosis gastric bypass

“New” stomach

Bypasssed section

Detached section

l Restriction by reducing the size of the stomach, only small amounts of food can be eaten at any one time, but your appetite is still satisfied

l Reduction in appetite as the hunger hormone called Ghrelin is greatly reduced

l Malabsorption: No longer having part of your stomach can mean less vitamins, minerals and calories are absorbed by the body. This means long term supplements (vitamin and minerals) are required to be taken long term to avoid deficiencies after surgery

l Dumping syndrome: Food will now travel quickly to the small intestine, when food that is too sweet, greasy or starchy dumping syndrome can occur. The partially digested food draws in increased amounts of fluid into the small intestine which can cause nausea, cramping, diarrhoea, sweating, feeling

How the surgeries work:

of light headedness and palpations. Onset of symptoms can last from when you ate or drank the cause to approximately 3hr after. The body quickly re-sets and you will feel fine but be very aware of what to avoid in future. This is more frequently reported in patients that have had a gastric bypass.

The risks and benefits associated with the operation

Risks:There are risks associated with any type of surgery. Some of the complications that may occur with these operations include:


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l Ulceration to the surgical joins. To reduce risk of ulceration certain medication cannot be taken for life after surgery for example anti-inflammatory medications such as ibuprofen. If you take any such medications you must discuss this with the team and then your GP for safe alternatives.

l Wound infection; this is rare after laparoscopic surgery. Your laparoscopic incisions are closed using glue and steri-strips or with surgical clips. Your discharging nurse will arrange for surgical slips to be removed in your local are around a week after surgery. At day 3 or 4 remove dressings and shower as normal, do not rub the area, allow to air dry or pat gently, be mindful not to wear clothing that may snag on surgical clips. If one or more of the wounds become inflamed, hot, painful or discoloured fluid is coming

from the wound contact your GP for an emergency appointment that day. If oral antibiotics are prescribed during the first 3 weeks after surgery, remind them you are on the liquid phase of the diet and will require a liquid suspension. If symptoms do not improve after 48hrs contact your GP for review as a different type of antibiotic may be required.

l Clots in the legs and/or lungs; to minimise the risk, you will be given elastic stockings to wear before the surgery and will be advised to keep them on for 2 weeks wearing them day or night therefore you should be discharged with a spare pair to wash. You will also receive a small injection to thin your blood before surgery and will be sent home on a course of injections for a minimum of 5 days (a nurse will show you how to administer this injection yourself)

l Some patients might develop gastro-oesophageal reflux disease (GORD) after restrictive operations (more likely with sleeve gastrectomy). This is more likely to occur if you stretch your stomach by eating too much or too quickly, adjusting your eating habits and taking medications that reduce stomach acidity tend to help. In extremely rare instances your surgeon might have to consider conversion to gastric bypass. If you already suffer with GORD, then a sleeve gastrectomy might not be the best choice, although reflux does indeed improve in some patients with weight loss. If your surgeon detects a hiatus hernia at the time of sleeve gastrectomy, this will may be repaired at time of operation or at a later date if deemed safer and in turn could bring about improvements in your reflux symptoms

l A small proportion of patients may develop a stenosis (healing with abnormal narrowing) to surgical join within, which later may require dilatation with a balloon using a camera (a gastroscope)

l There is a small risk of a leak from the newly-formed staple line along the stomach. This is tested routinely near the end of the operation by using a special blue dye to make sure that it is water-tight. Leak is a serious complication and you would require care in an acute setting

l Herniation after surgery is rare but can occur, in bypass surgery defects where potential herniation could occur, due the changes in your anatomy, are routinely closed to minimise risk. Rarely hernias could occur at


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of the reasons we monitor you in hospital overnight after surgery. You may require a scan to determine management. If a bleed is suspected often the body will correct this, a longer stay in hospital with possible blood transfusion required. Rarely you may require an emergency operation to find and stem off the bleed and/or remove any blood collection within

l The national mortality rate is 0.08% for bariatric procedures (within 30 days Hospital Episode Statistics HES data 2009-2016)

l Smoking increases risks especially that of ulceration long term, people who smoke will not be offered a bypass surgery due to this risk. You must stop for a minimum of 6 weeks before surgery; otherwise your operation will be cancelled on the day.

Benefits/results of the operationl On average people tend to

achieve approximately 60-75% excess weight loss (EWL) within the 12-18months after surgery. EWL is defined as any extra weight above the upper limit of the normal body mass index (BMI) of 24.9 kg/m2. Weight loss plateaus off after this time, it is possible to reach your ideal body weight however this may take some extra effort on your part towards the end of the two years.

l Ability to do more, often reported at 16-week follow up, you feel energy levels increase and an ability to engage in activities/exercise you found harder to do before surgery. A reduction in complications associated with obesity which can include but not limited to type 2 diabetes, high blood pressure, diabetes, heart disease, respiratory disease,

increased risk of cancer, infertility, improved self-esteem. Regular medication reviews will be required for pre-exisiting conditions with your GP as medications may require adjusting or to be stopped.

Patients may regain weight in the long term if they continue to overeat, stretching the pouch and thereby reducing the restrictive effect of the procedure.

Recovering from the operationIt is important to stay mobile after the operation and gentle exercise is very much encouraged. Your wounds will take approximately 1-2 weeks to heal and you are advised to avoid heavy lifting or straining during this time.

You should start to build your exercise tolerance such as swimming, brisk walking or going to the gym and aim for four 30min sessions per week. Your ability to exercise will improve dramatically following your surgery. As you are aware exercise helps weight loss by burning off extra calories and helps build muscle tone and to a lesser extent, excess skin that results from surgery.

You may resume driving 2 weeks following your operation. You should be able to competently carry out an emergency stop and no longer be on strong pain killers.

Most people return to work 2-3 weeks following their operation.


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Will I need medication when I go home?You will be given a discharge prescription before you go home. This will have all the medications you require. All your medications will be supplied in a form that will allow you to take them while on a liquid diet. At week 3 you can resume all medication under the guidance of your G.P. What you will be given at discharge from hospital:

l Painkillers: Paracetamol and possibly codeine which should be sufficient on discharge

l Antacid: This is given to reduce the amount of acid in your stomach which will enable your stomach to heal and protect against the formation of ulcers at the join between the stomach and the intestine, you will be asked to take these for a minimum of two years after surgery

l Anti-coagulation therapy: You will be given small injections of blood thinner to have once a day for a minimum of 5 days, in order to prevent clots in the legs and lungs. You will either be taught to give the injections to yourself before you go home or referred to the district nurse

l Vitamin and Mineral supplements: your G.P will be asked to start you on iron, calcium with vitamin D and specific multivitamin supplements approximately 3 weeks after your operation

l Your normal medications will be altered to allow you to take them on a liquid diet. Diabetes medications may be reduced immediately following your surgery. However as you begin to lose weight your G.P should review your medications on a regular basis.

competently carry out an emergency stop and no longer be on strong pain killers. Always check with your insurance provider as they may have their own policies after abdominal surgery. Risk assess your car journeys as a passenger after surgery due where the seatbelt lies if involved in an emergency stop.

Most people return to work 2-3 weeks following their operation.

Recovering from the operation

It is important to stay mobile after the operation and gentle exercise is very much encouraged. Your wounds will take approximately 1-2 weeks to heal and you are advised to avoid heavy lifting or straining during this time.

You should start to build your exercise tolerance such as swimming, brisk walking or going to the gym and aim for four 30min sessions per week. Your ability to exercise will improve dramatically following your surgery. As you are aware exercise helps weight loss by burning off extra calories and helps build muscle tone and to a lesser extent, excess skin that results from surgery. Excess skin can be an issue after surgery and something that exercise would not improve. Currently there are no surgeries funded by the NHS for removal of excess skin.

You may resume driving 2 weeks after your operation. You should be able to

Additional information:What will happen if I decide not to go ahead with surgery?You will be referred back to your weight management team.

What are the alternatives to this procedure?There are alternative surgical and medical treatments available. If you wish to discuss these further you should contact the consultant secretary to arrange a further appointment.


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Contraception after surgery

Ovulation and periods can recommence with weight loss and unplanned pregnancies have occurred. Please use appropriate contraception following surgery. If you are suffering with heavy flow period consult your GP as uncontrolled iron loss may cause problems, we advocate the mirena coil. If you use a contraceptive pill we are unable to guarantee that this will give the same contraceptive effect after surgery. The use of other contraceptive such as condoms should be considered.

Support Groups

We offer pre-operative and post-operative monthly support groups which you do not need to book to attend. You are required to attend a minimum of 2 sessions prior to surgery.

Becoming pregnant after surgeryObesity can cause infertility, but following weight loss surgery ovulation and periods can recommence. Pregnancy is safe after surgery, reduces the risk of miscarriage, high blood pressure and diabetes.

However patients are advised not to get pregnant for the first 12 months after surgery ideally 24 months, to allow the weight loss to slow down and establish a regular eating pattern. If you were to get pregnant it is advised that you should consult your dietician and G.P to ensure that you are having all the nutrients you and your baby require. Once you become pregnant you are advised seek medical advice on the medications you are taking to ensure they are suitable for pregnancy.

There is no reason why you should not have a normal delivery and be able to breast feed after surgery.

Further information:Further Information and support is available through the Salford Royal NHS Foundation Trust.

You will be expected to do your own research to feel happy about the informed choice you are making when having bariatric surgery. Please be aware the single anastomosis gastric bypass also has 3 other names though are essentially the same procedure; they are omega loop gastric bypass, mini gastric bypass and one anastomosis gastric bypass. Now you have met our team we are your support; for any surgical advice please contact the specialist nurse and for any dietetic advice please contact the dietitian.

For any administrative queries please contact our secretary. Essential communication regarding further investigations, appointments, pre-operative assessments and date of surgery will come to you in written form in due course. We politely ask that you be patient to receive this but contact us if concerned. If you have any change of address during this time or contact numbers you must update us.


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Useful websites:

Specialist Nurse

British Obesity Surgery Patient Association (BOSPA)

British Obesity and Metabolic Surgery Society (BOSS)

Weight Loss Surgery Information and Support (WLSinfo)

Drinkaware – alcohol advice

Weight Loss Resources UK

Dietitian

Secretary

Hospital switchboard

(voicemail service)0161 206 5062

08456 020 446

02073 044 786

0151 222 4737

020 7766 9900

01733 345 592

0161 206 1223

0161 206 1160

0161 789 7373

www.bospauk.org

www.bomss.org.uk

www.wlsinfo.org.uk

www.drinkaware.co.uk

www.weightlossresources.co.uk

[email protected]

Be aware that the above numbers have a voicemail attached please leave a message with your name and contact number and we aim to return your call as soon as possible though this may not be the same day.

Quit smoking with support

0300 123 1044www.nhs.uk/smokefree

Alternatively download app or speak with your local pharmacy and/or GP

Notes

For further information on this leaflet, it’s references and sources used, please contact 0161 206 5062.

U n i v e r s i t y T e a c h i n g T r u s t

© G19030803W. Design Services

Salford Royal NHS Foundation Trust

All Rights Reserved 2019

This document MUST NOT be photocopied

Information Leaflet Control Policy:

Unique Identifier: SURG 22 (19)

Review Date: April 2021

Copies of this leaflet are available in other formats (for example, large print or easyread) upon request. Alternative formats may also be available via www.srft.nhs.uk/for-patients/patient-leaflets/

In accordance with the Equality Act we will make reasonable adjustments to enable individuals with disabilities to access this service. Please contact the service/clinic you are attending by phone or email prior to your appointment to discuss your requirements.

Interpreters are available for both verbal and non-verbal (e.g. British Sign Language) languages, on request. Please contact the service/clinic you are visiting to request this.

If you need this information leaflet translated, please telephone:

or Email: [email protected]

Salford Royal operates a smoke-free policy. For advice on stopping smoking contact the Hospital Specialist Stop Smoking Service on 0161 206 1779

This is a teaching hospital which plays an important role in the training of future doctors. The part patients play in this process is essential to make sure that we produce the right quality doctors for all of our futures. If at any time you would prefer not to have students present please inform the doctor or nurses and this will not affect your care in anyway.

Salford Royal NHS Foundation Trust Stott Lane, Salford, Manchester, M6 8HDTelephone 0161 789 7373www.srft.nhs.uk

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