Gastroenterology - Having Bariatric Surgery

This leaflet aims to describe:

• What bariatric surgery is
• What will happen before surgery
• What will happen to you while you are in hospital
• What will happen for discharge
• Follow up care
• The surgeries and risk/benefits
• Additional information
• Further information and support

What is 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 leaflet 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. It is important that you are non-smoker and not dependent on alcohol. This should already have been a set goal prior referral due to increased risks after bariatric surgery.

Multi Professional Bariatric Clinic appointment

• Prior to your appointment you will receive an email with this and the nutrition booklet, a link for virtual education recording, a check list for self-assessment, a psychometric screening tool, invitation to a virtual live Q&A session and the contact numbers for the Specialist nurse and dietitian
• At the appointment you will have your height, weight and blood pressure measured
• You will have a blood test
• A Consultant bariatric physician assessment and/or bariatric surgeon assessment to discuss your history, your surgical options, risks and benefits associated with the surgery

Further Investigations

• 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)
• You may be seen and assessed by a clinical psychologist
• 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

What happens next?

Once everything is completed you will be added to the waiting list. Once a date has been offered and accepted, the bariatric secretary will write to you with the following details:

• Location of your operation and pre-operative assessment - you may have your operation at Salford Royal Hospital or at private hospitals as an NHS patient with our bariatric surgeons
• Pre-operative clinic appointment to assess fitness for surgery. You may also be required to see a Specialist Bariatric Anaesthetist
• Information about fasting before surgery
• Any medication adjustments required
• Hospital map and location of Surgical Admission Lounge (SAL)
• All patients are required to complete minimum of 2 weeks liver reduction diet found in the accompanying dietary information leaflet

While you are in Hospital

On the day of your surgery

• 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 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

When you return to the ward

• Your pulse, blood pressure, temperature and breathing will be regularly monitored
• You will be encouraged to mobilise as soon as possible to prevent post-operative complications such as blood clots and chest infections
• You will be able to have sips of water, which will be increased as directed by the surgical team
• You will spend the night on the ward where the nursing staff will regularly monitor you

On the day after your operation

• You will be encouraged to continue to mobilise as much as possible
• You will continue your prescribed pain relief
• If nauseous you will also be given anti-sickness medication as required
• We encourage you to take small sips of water regularly to keep hydrated. Please move on to fluids such as tea, coffee, milk or sugar free cordial when instructed to. You will need to be able to manage some clear soup before you go home
• 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
• The specialist bariatric dietician will see you to discuss your eating plans for the coming weeks
• 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
• 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

• You will continue to wear your stockings if they fit well and will be required to wear them for 2 weeks
• You will be given all the medication you require including a blood thinning injection, which the ward nurses will show you how to use
• If you have clips to the wound the discharging nurse will need to arrange removal in your local area

Self-checklist before going home

How do I progress with the liquid diet?

You already have information for your dietary stages. Be aware at first it can be difficult to reach the desired 1.5l daily. You can feel bilious and burpy, which is normal. It is important to sip, move, and rest in that order. Setting alarms on your phone to remind you to have drinks frequently, taking your time as you can no longer take bigger volumes I one go.

What medications do I go home with?

Make sure you are clear which medications are essential for you to have in the first 3 weeks after surgery before going home.
Preparations should be the size of a 5p piece or less. Not all medications are essential and can be resumed from week 3. If you have type 2 diabetes, you will not be on any medication for the first three weeks after surgery unless directed otherwise by the Specialist diabetes nurse.

You will also be prescribed a PPI (proton pump inhibitor), this reduces the amount of gastric acid produced whilst you have a healing join inside and gives protection against ulcer formation. This will be called lansoprazole, and it is a melt that you can place under your tongue or in your gum line to absorb through the capillaries in your mouth.

You will also be given blood thinning injections to do. If you had well-fitting anti-embolism stockings, you will go home with these to wear for 2 weeks, day and night.

What do I do if I suspect an infection?

It is unlikely you will develop an infection whilst in hospital. Once home, rarely, but can happen, a wound or chest infection can develop. If your wounds are red or angry or have any puss, or your chest feels tight and heavy, and you're coughing up discoloured sputum, then you should arrange an emergency appointment with your GP or out of hours GP via 111. If antibiotics are deemed necessary, remind them that you will need liquid version in the first 3 weeks after surgery.

When can I go back to work/drive?

2-3 weeks before going home if you require a sick note make sure you have this from our doctors. Our surgeons are happy after Laparoscopic surgery for you to drive then also, though it is worth checking with your insurance provider who may have their own policies for post abdominal surgery.

What do I do if I'm in pain?

It is normal to have gas pain after surgery, it is essential that you mobilise and increase movement so that you are passing wind by the back passage. Though you can take painkillers for this, the most effective treatment is movement and time. There may be pain and discomfort around the laparoscopic wounds, it is important you still complete your full range of movement to heal properly. You may notice a pulling pain or sharper pain as the days go by. This is not unusual.
 
Paracetamol is excellent for surgical pain. This can be taken as a liquid or caplets snapped in half. The best way to gauge when to take pain relief is if you are having difficulties completing an activity, for example, your deep breathing exercises, taking a shower etc. Take your paracetamol, rest, wait half an hour. If this hasn't eased off, take the stronger pain relief. Most people find pain is very manageable after the first 3-4 days.

If you are in pain, feverish, feel generally unwell, struggle to drink, feel dizzy, lightheaded attend A and E.

Follow Up Care

• Information and contact numbers are in this booklet and your original education email, for any advice and support you may need, the nurse and will initially make contact by phone in the weeks following surgery
• At 12 weeks you will be contacted by phone by the specialist nurse
• At 6 months you will be contacted by phone by our bariatric dietitian
• You will have an annual review with our bariatric physicians
• You have access to dietetic follow up for up to 2 years
• Phone appointments can be arranged face to face

The Surgeries we offer Sleeve Gastrectomy and Gastric Bypass:

What is a Sleeve Gastrectomy

 Sleeve gastrectomy is a type of weight loss surgery, which can be used as a tool for sustained weight loss. The surgeon removes most 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 enter 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, in the anaesthetic room before your surgery and in recovery after the operation.

How the operation is performed

• The procedure is done using a laparoscopic technique
• You are put to sleep using a general anaesthetic
• The surgeon then makes five small incisions (1-2cm) on your abdomen
• Gas is then introduced into the abdomen to enable the surgeon to see the internal organs more clearly
• A small tube-like camera is inserted through one of the incisions to view the area of the operation; this is then shown on a large screen
• The operation is then carried out using various instruments through the other incisions in your abdomen
• Your stomach is stapled to create a thin tube or sleeve, with the excess part of the stomach removed via one of the incisions, which will be slightly wider than the others and have an internal stitch
• The gas is then released from your abdomen
• The incisions are then closed with glue or surgical clips

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 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.

How is the operation performed?

• The procedure is done using a laparoscopic technique
• You are put to sleep using a general anaesthetic
• The surgeon then makes five small incisions (1-2cm) on your abdomen
• Gas is then introduced into the abdomen to enable the surgeon to see the internal organs more clearly
• A small tube-like camera is inserted through one of the incisions to view the area of the operation; this is then shown on a large screen
• The operation is then carried out using various instruments through the other incisions in your abdomen
• The top part of your stomach is stapled to create a small pouch
• Your intestine is then connected to the pouch, the greater part of your stomach and some small intestine (approximately 150-190cm) is then bypassed to complete the procedure
• The instruments are removed, and the gas is released from your abdomen
• The incisions are then closed with either staples or stiches
• 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

The alternative to the Roux-en-Y is the single anastomosis gastric bypass (be aware the exact same surgery is also known as one anastomosis bypass, omega loop bypass and mini bypass):

What is a Single Anastomosis Gastric Bypass

This is a variation on the surgical technique of gastric bypass and is carried out instead of a Roux-en-Y technique. Around
150-190cm 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. This 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 an anaesthetic reason a shorter operation is desired. However, a minority of patients may develop bile reflux and require conversion to a Roux-en-Y gastric bypass

How the surgeries work:

The surgery works in the following ways:

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

• Complications associated with the general anaesthetic
• Chest infection, it is important to deep breathe, cough and mobilise after surgery to avoid this, request pain relief if you are struggling to do this
• 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
• Wound infection: this is rare after laparoscopic surgery. Your laparoscopic incisions are closed using glue or 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.
• 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)
• 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
• 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)
• 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 intact. Leaks are a serious complication, and you would require prolonged inpatient care initially
• 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 the laparoscopic sites
• Bleeding internally can occur after surgery which is one of the reasons we monitor you in hospital overnight after surgery. You may require 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
• It is recognised that there is a higher incidence of gall stone formation after weight loss, including after surgery, to help prevent this we will request Ursodeoxycholic acid for a period of six months. This should not be prescribed if you have already had surgery to remove your gallbladder
• The national mortality rate is 0.08% for bariatric procedures (within 30 days Hospital Episode Statistics HES data 2009-2016)
• Smoking increases risks especially that of ulceration long term, if you stopped before surgery please do restart or become a smoker
• Weight regains long term from grazing or overeat potentially stretching surgery 

Benefit/results of the operations:

• 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
• Ability to do more, 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-existing conditions with your GP as medications may require adjusting or to be stopped

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.

You may resume driving 2-3 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.

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:

• Painkillers: Paracetamol and possibly codeine which should be sufficient on discharge
• 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
• 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
• Ursodeoxycholic acid for a period of six months to reduce the risk of developing gallstones. This should not be prescribed if you have already had surgery to remove their gallbladder
• 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
• 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

Additional information:

What will happen if I decide not to go ahead with surgery?

You will be referred back to your (medical) weight management team.

Becoming pregnant after surgery

Obesity 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.

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 a post-operative support that can be attended face to face or virtually, you will be invited to this after surgery.

For any administrative queries please contact your Surgeons secretary, the number will be on the letter sent from your Surgeon after the appointment. 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.

Specialist Nurse: 0161 206 5126
Specialist Dietician: 0161 206 1223

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.

Useful websites

British Obesity and Metabolic Surgery Society (BOMSS)
www.BOMSS.org

Drinkaware alcohol advice
www.drinkaware.co.uk

Quit smoking with support
www.nhs.uk