Bariatric Surgery. Your Guide to our Service. Page 24 Patient Information

Transcription

1 Bariatric Surgery Your Guide to our Service Page 24 Patient Information

2 INTRODUCTION We fully understand at Ashford and St. Peter s Hospitals that taking the decision to have surgery, to help with weight loss, is a major decision. In appreciation of this, we have designed this guide to inform you of the different types of surgery available, but also what you can expect on your visits. Referral To qualify for assessment for surgery we require a referral letter from your GP. Below are the NICE guidelines in regards to suitability for bariatric surgery. Guidelines BMI (Body Mass Index) greater than 50 kg/m 2 BMI of 35kg/m 2 or above, with co-morbidities such as diabetes, high blood pressure, heart disease etc or BMI of 40 kg/m 2 or more without any co-morbidities. These patients must first have attended a specialist weight management course for a minimum of 12 months. You must be able and willing to see our various specialists You must be fit for surgery and anaesthesia You understand the need for long term follow up and commitment You should have tried and failed with conventional dieting, exercise, and medication to lose and maintain weight Why surgery? It is well known that conventional weight loss measures often result in a 10% loss of initial body weight. Although this has been scientifically proven to lower cholesterol and death rates, for Page 2 Further Information We endeavour to provide an excellent service at all times, but should you have any concerns please, in the first instance, raise these with the Matron, Senior Nurse or Manager on duty. If they cannot resolve your concern, please contact our Patient Advice and Liaison Service (PALS) on or pals@asph.nhs.uk. If you remain concerned, PALS can also advise upon how to make a formal complaint. Author: Mr. Samer Humadi / Debbie Moyse Department: Bariatric Version: 2 Published: Nov 2014 Review: Nov 2016 Page 23

3 people with a BMI greater than 35 kg/m 2, this still does not reduce your risk factors enough. All types of surgery reduce the extra weight that you carry (your excess weight) by 50-80%, thereby helping medical conditions and improving your quality of life. Which Surgery? Determining which surgery is best for you is always going to be difficult and will be dependent upon many things. Useful questions to consider when deciding are: 1. How much weight do I want to lose? Realistically the gastric band and gastric sleeve can help you lose 50-60% of your excess weight, whilst the bypass can result in 60-80% excess weight loss at months. 2. How quickly do I wish to lose weight? For most people, weight loss is slow or minimal for the first weeks of the band until it is inflated. Thereafter, weight loss is expected at 1-2lbs (0.5-1kg) per week. With the bypass and sleeve gastrectomy, weight loss is immediate and is much quicker for the first two years than with the band. 3. How limited is the diet after the operation? Due to the restrictive nature of all the surgical options, certain foods may cause difficulties. All should reduce your meal size. With the bypass, there may be unpleasant side effects if you eat high sugar and fatty foods. All the operations involve making long term changes to your eating and lifestyle habits to ensure that surgery is successful. Page 22 Page 3

4 Gastric Balloon Surgery Options Sometimes the surgeon may suggest that you have a gastric balloon inserted as a temporary measure. This is often to help you lose weight prior to surgery to reduce your surgical risks or to provide an idea of the expected restrictions with other surgery. This is a silicone balloon, which is fitted in the stomach via the mouth (endoscopically) as a day case. This is usually under light general anaesthetic or sedation. Mindful eating, mindful life. Thich Nhat Hanh and Dr Lilian Cheung. Savor Mindfulness for Health. A practical guide to relieving pain, reducing stress and restoring wellbeing. Piatkus. Vidyamala Burch and Danny Penman. Weight Loss for Dummies - American based book, mainly discusses bypass, but has some banding advice. Recipes appear to be for bypass patients. The Pocket Gastric Band Guide Trudy Williams (info@obesityservices.org) Overcoming Binge Eating, Dr. C G Fairburn, 1995, The Guildford Press As with the other bariatric procedures, you will be expected to follow a special postoperative diet whilst your body adapts to the balloon. After 6 months, it will be removed. Unfortunately it is only a temporary measure and has a lifespan of 6 months. Page 4 Page 21

5 Additional Information There are many websites and books on weight loss surgery and unfortunately we don t have enough space to provide full details. Below are just some of the sources of information you may find helpful. You may find some of the information contradictory; if you are ever in doubt please contact our team to discuss this. - The British Obesity and Metabolic Surgery Society Books The Weight Loss Surgery Workbook: Deciding on Bariatric Surgery, Preparing for the Procedure, and Changing Habits for Post-Surgery Success. Develop Your Personal Plan for Weight Loss Surgery Success Doreen Samelson. New Harbinger Publications. The Diet Trap: feed your psychological needs and end the struggle with weight loss using Acceptance and Commitment Therapy Jason Lillis, JoAnne Dahl and Sandra Weinland. New Harbinger Publications. Weight Escape Workshop Book. Stop fad dieting, start losing weight and reshape your life using cutting edge psychology Joseph Ciarrocci, Ann Bailey and Russ Harris. Penguin books. What are the benefits and drawbacks of having a Gastric Balloon? Benefits You can expect to lose 20-30% of your excess bodyweight in 6 months If you lose weight it should reduce your medical and surgical risks, therefore making further surgery easier It gives you an impression of the lifestyle changes expected for all other bariatric surgery without undergoing the risks involved with these You are expected to return to a normal healthy eating diet within a week of insertion Drawbacks The weight of the balloon and the presence of the balloon can cause the stomach to become irritated and as such cause nausea and vomiting Usually it takes a few days for nausea and vomiting to reduce It is only a temporary solution You will still need will power and to keep to healthy eating guidelines The balloon can rupture, however, it is filled with blue dye so if this happens your urine will turn a blue / green colour Susan Albers. Eat, drink and be mindful. Page 20 Page 5

6 Gastric Band The gastric band works by restricting the amount of food and drink that can be taken at one time. The band is placed around the upper part of the stomach creating a small pouch above the band and leaving the main part below it. The band is only able to hold a couple of teaspoons of well chewed foods, which leads to a feeling of fullness. The speed at which the food passes through the band is determined by how tight the band is. Initially the band will not be inflated, however you would expect the first band fill around 6 weeks after the surgery. This will involve an injection of saline into the port which is sited just under the skin, usually just below your breastbone. As you lose weight, your band will need adjusting. You and our team will determine this in the outpatient clinic and you will be expected to attend regular checkups. Who is the team at Ashford and St. Peter s Hospitals? Mr S. Humadi Bariatric and Upper G.I. Consultant Mr S. Irukulla Bariatric and Upper G.I. Consultant Dr D. Cartwright Consultant Chemical Pathologist and Metabolic Medicine Dr A Miles Consultant Anaesthetist Dr Lorraine Nanke Clinical Psychologist Natasha Smith Specialist Bariatric Nurse Deborah Moyse Specialist Bariatric Dietitian Natalie Mandeville Bariatric Co-ordinator Pre-operative assessment team Other members of the team who you may meet or have dealings with include: Liz Moghtader Secretary to Bariatric Surgeons Claire Holland or Emily Giuliano Dietetic Secretaries Hayley Cargill Bariatric Dietitian Contact Details Bariatric Co-ordinator Bariatric Clinical Nurse Specialist or , pager 8971 Bariatric Surgeons Secretary Dietitians Office Page 6 Page 19

7 What happens in the event of an emergency with bariatric surgery? In the event of an emergency, please contact the Bariatric Clinical Nurse Specialist on pager 8971 during working hours or the Surgical Assessment Unit at St. Peter s Hospital on or What happens if I decide not to have surgery? If you decide surgery is not for you, due to any reason, please tell us at any stage. We will endeavour to see if there is an alternative we could organise for you, although, this is likely to be limited. If at a later date you decide that you DO want surgery, you need to contact your GP and ask for a re-referral. Depending on the time that has elapsed, you may or may not have to repeat assessments previously carried out. Is there a support group? We run a monthly support group gathering at Ashford Hospital. The support group is attended by some of our patients who have had their surgery and our new patients who are waiting to have surgery. The Bariatric Clinical Nurse Specialist, and dietitian, lead this assembly. Remember, the surgery is a tool and you will need to learn how to work with it to obtain the best results from your surgery. You will find the patient support group an invaluable resource for learning from other patients and your success will, in turn, inspire other people considering surgery. For those unable to attend fact to face, we also offer a Facebook page Bariatric Buddies site. For further details please contact the nurse specialist Support group dates can be found at: Page 18 What are the Benefits and Drawbacks of having a Gastric Band? Benefits It restricts the amount and types of food you can eat For diabetics, it provides a 50% remission rate The band is flexible, therefore it can be inflated or deflated as required The band can be removed if absolutely necessary You can expect 50-60% of your excess weight to be lost over 2-5 years Weight loss is slow and controlled, thereby reducing potential problems Food is fully absorbed, so nutritional deficiencies are rare Drawbacks In comparison to the bypass the weight loss is slower initially The band can erode or slip You may simply not lose weight You can still cheat on the band You may have to take medication in a liquid, chewable or crushable form, so please consult your GP for advice beforehand The port may twist or flip, requiring surgical adjustment If you try to overeat your pouch may stretch You will still need to make significant changes to your lifestyle You will be expected to commit to regular follow ups Page 7

8 Gastric Bypass During this surgery, the surgeon creates a pouch similar in size and location to the pouch for the band; therefore a restrictive effect is created. However, this is detached from the main part of the stomach. The lower part of the small bowel is then cut and moved up to and attached to the pouch. The bowel that has been bypassed is then attached to the small bowel, thereby allowing the digestive juices from the pancreas to be mixed with the food coming from the small pouch. The bypass works in two ways: It restricts the amount that can be eaten and the by-passing of some of the small bowel means that there is a reduction in the amount of calories, protein, vitamins and minerals absorbed. To try to prevent vitamin and mineral deficiencies, you will be required to take a daily vitamin and mineral supplement for life. You may also have to have a B12 injection every 6-12 months. You will be expected to have regular blood tests to ensure nutritional adequacy, which may require further supplements such as iron and calcium. Page 8 could impact on their success with surgery. If this is the case, they may see a psychologist or specialist consultant doctor. Surgical Assessment Our surgeon will have all your reports and will meet up with you to describe the surgical side of the operation and risks in more depth. Your case will then be discussed during a team meeting and the most appropriate way forward will be decided. You will be contacted to be informed of the outcome of the team meeting. MDT Meeting Once you have attended all your appointments, your case will then be discussed during a team meeting and the most appropriate way forward will be decided. You will be contacted of the outcome of that team meeting. Pre-Op Assessment All surgical patients now have to undergo this procedure. This assessment is to check that you are fit and well for surgery. It may mean you have to undergo further blood tests. Follow ups Follow up after bariatric surgery is essential for monitoring of potential complications. We therefore expect you to attend regular follow up appointments. The clinical nurse and or surgeon and Dietitian will try to see you at 8 weeks after surgery. You will then be given regular follow up appointments so we can monitor your progress until 2 years after your surgery, when you will be referred to a Tier 3, weight management service or if you prefer, your G.P. Page 17

9 Your Care Plan - What does it entail? You should have already received a medical and a psychological questionnaire with your group forum appointment. These forms are important and need to be completed in as much detail as you can. You will receive a nutritional questionnaire with your dietetic appointment. Initial Appointment This is the group forum meeting with our clinical nurse and dietitian Our nurse will describe the surgical options available to you and will go through the risks associated with each procedure in further detail. Whilst the dietitian will go through the dietary changes expected with surgery. You will be able to ask questions and meet others in a similar situation to you. The nurse will see you individually after this meeting and request you undergo an ECG and blood tests. This is routing. It is a good time to decide whether surgery is for you and for our nurse to get to know you. If you both think it is appropriate to continue, further appointments with the team will be organised. Dietetic Assessment The dietitian will assess and discuss your current diet and the dietary implications of surgery for you in depth. This will mean changing some of your lifestyle habits and you will be encouraged to lose some weight prior to surgery. You will be provided with diet sheets immediately before and after surgery. What are the Benefits and Drawbacks of having a Bypass? Benefits You can expect to lose 60-70% of your excess body weight after 2 years Average initial weight loss is quicker than with a band Has a high-resolution rate of diabetes (75%) Drawbacks Has a higher mortality rate and more serious complications than the band It will be necessary to take a multivitamin and mineral supplement, as well as having to have a B12 injection periodically for life Dumping syndrome can occur after eating foods with too much sugar or fat, with symptoms including; nausea, sweating, faintness, vomiting and potentially diarrhoea It is effectively irreversible Medication needs to be reviewed to ensure adequate absorption At 5 years post surgery, weight loss is comparable to the band You may not lose weight if you do not stick to healthy lifestyle guidelines Alcohol intake may be limited Other Assessments Some people may need to see other specialists prior to surgery to assess whether there are medical or psychological issues that Page 16 Page 9

10 Sleeve Gastrectomy Page 10 Originally, this surgery was suggested to patients as a halfway house, in order to reduce weight and surgical risks. This would then be converted to a full bypass once the patient had lost a significant amount of weight. Due to its success, this surgery is now available as a stand alone treatment or as an operation prior to a full bypass. During this surgery, the surgeon removes ¾ of your stomach, leaving a small narrow tube. It works by reducing your stomach size and therefore restricting the amount of food that can be eaten. It can also affect the hormones which regulate your appetite, making you feel less hungry. This will give you the opportunity to discuss these issues and look at ways o in which you can develop strategies to manage your emotional eating and improve your chances of successful surgery. If you are receiving care from a community mental health service, please inform them that you are to have surgery so they can provide you with any extra help you need. Pregnancy Losing weight can increase fertility. However, we recommend that you do not become pregnant for 18 months after the gastric bypass or sleeve gastrectomy. The associated rapid weight loss with both places the body under a great stress, depletes its stores and also restricts what you can eat. This can put the baby s development at risk. Although weight loss is slower with a gastric band, and therefore the risks to the baby are lower, we still recommend delaying pregnancy for one-year post operatively in order to give you time to adapt to all the changes required with the band. The band can be deflated through pregnancy and then re-inflated after breastfeeding if required. Excess Skin Significant weight loss in people who have been extremely overweight for many years often results in skin becoming loose as the skin and underlying tissues can not return to their previous state. This is particularly true of skin on the stomach, arms and legs. Although there are several surgical procedures to remove excess skin, these are not routinely funded through the NHS. Currently plastic surgery following weight loss in only considered and funded in exceptional circumstances. Page 15

11 Time Off Work It is best to discuss this with the bariatric surgeon or the clinical nurse, but generally a gastric band patient would be expected to have 1-2 weeks off work, whilst a gastric bypass patient would expect 4-6 weeks off depending upon your occupation. Gastric balloon patients would be expected to be able to go back to work within a few days, generally once nausea and vomiting has subsided. Mental Health and Well-being Bariatric surgery aims to reduce patients weight, therefore improving their general well-being and health, and extending their life expectancy. Although many patients report improvement in mood post operatively, surgery cannot guarantee to solve any existing psychological, career or relationship difficulties or other mental health issues. Often eating behaviours driven by emotions and the inability to deal with difficult situations will come back after surgery. Surgery does not change habits driven by emotional problems, so these habits and behaviours will need to be challenged and changed by you in the long term in order to get the best from surgery. Sometimes, counselling or professional psychological input may be required to help you overcome these difficulties. What are the benefits and drawbacks of having a Sleeve Gastrectomy? Benefits You can expect to lose 50-60% of your excess body weight after 2 years It can be converted to a full bypass if needed Evidence suggests that gut hormones can be altered which can affect appetite Unlikely to suffer nutritional deficiencies unless diet is not balanced Drawbacks It is a relatively new procedure as a stand alone treatment, so long term data is not yet available It is non-reversible There is a higher mortality rate and more serious complications than the band Able to cheat If you eat inappropriate foods, you may not lose weight It s effects on appetite may only be temporary Alcohol intake may be limited If you have a history of bulimia, binge eating or overeat regularly in response to difficult situations or feelings, you need to speak to a health care professional about this prior to any bariatric operation. Page 14 Page 11

12 Comparison of bariatric surgical procedures Gastric Sleeve Gastric Band Gastrectomy Bypass Time of Operation 1 hour hours 2-4 hours Hospital Stay Page 12 Day surgery or 1 night Wounds Minimal Keyhole surgery Food Intake Nutritional Deficiencies Potential Side Effects & Complications Expected weight Loss after months Reversibility Death Rate (within 30 days of surgery) Follow Up Amount and some foods may be restricted 2-3 nights 2-3 nights Minimal Keyhole surgery Amount Restricted Minimal keyhole surgery Food range may be less restricted, amount is restricted Unlikely Unlikely Potentially iron, fat soluble vitamins, calcium, vitamin B12 Vomiting Band slippage, leakage, erosion Port site infection 50% of excess weight Possible but can be associated with complications Vomiting, Bleeding, infection, clot formation, staple-line leak, Reflux 50-60% of excess weight Permanent Vomiting, Bleeding, infection, clot formation, Anastomotic leak, Dumping Syndrome Possible change in bowel habits 60-80% of excess weight Essentially irreversible 1 in in in 1000 Long term frequent follow ups Long term commitment Long term commitment Other things to take into consideration The Pre-operative Diet You will also be expected to follow a liver shrinkage diet for 2-3 weeks before any bariatric operation (except the gastric balloon) to prepare your body for surgery. When you are overweight, your liver can become enlarged through excess fatty and glycogen (sugar) deposits. This enlarged liver can make surgery difficult. This diet encourages your liver to use up the excess glycogen and fatty stores, thereby making surgery easier by shrinking the size and weight of your liver. It is essential that you follow this diet to reduce the risk of damage to the liver. If you do not strictly adhere to it, the surgeon will be able to tell and they may decide it is too risky for the operation to go ahead. This will be discussed with the dietitian in more depth at your dietetic assessment. The Post-operative Diet You will follow a special diet for approximately 6 weeks after any bariatric surgery (except for the gastric balloon). This allows your body to recover and heal after the operation, and for you to become used to the restrictions. After 6 weeks you should be on normal food consistencies. This will be discussed at your initial assessment and a detailed booklet provided. Page 13