Sleeve gastrectomy surgery

Transcription

1 Sleeve gastrectomy surgery

2 Surgery is a serious step forward and should only be contemplated after you have undertaken considerable research into the various options. You should have discussed other options with your GP. The decision for surgery is probably the most important decision of your life and should be considered as the last resort - only after all other reasonable alternatives have failed. You must take an active part in the surgical weight loss process in order to maintain nutrition and optimise weight control. What is the laparoscopic sleeve gastrectomy operation? The operation is performed with keyhole surgery. While you are asleep, instruments are passed through about 5-6 small holes in the skin. The surgeon then performs the operation by viewing the abdominal cavity on a monitor (TV screen). The basic principal behind the operation is to remove about 80% of your stomach and therefore decrease your capacity to eat. How the sleeve gastrectomy operation works This operation works mainly by restricting the amount of food that you can eat. This means you remain satisfied for longer, after eating a small amount of food.

3 What are the benefits of having laparoscopic sleeve gastrectomy? Apart from obvious effective long-term weight reduction and improvement in mobility, surgery can result in improvements in: Cholesterol levels Coronary heart disease Diabetes High blood pressure (Hypertension) Obstructive sleep apnoea Osteoarthritis What are the risks associated with this operation? Obesity is a serious health problem and surgery is serious therapy designed to combat this disease. Most operations are straightforward, however as with any operation there are risks associated with having a general anaesthetic. Specific to this procedure, there is a small risk of: Deep vein thrombosis (DVT or blood clot in the leg veins) Pulmonary Embolus (PE or blood clot on the lungs) Chest infection Wound infection Leakage from staple or stitch line Intestinal blockage from narrowing of the new joins, or a twisting of the bowel (internal herniation or adhesions) Bleeding requiring transfusion or another operation

4 The risks increase if you already have other medical conditions such as heart disease or high blood pressure. However, any problems that do arise can be rapidly assessed and appropriate action taken by our team of experts. There is in the region of a 1 in 500 risk of death and around 5% risk of side-effects or complications such as those mentioned above. Long-term complications can arise several years after the operation. Therefore it is vital that you commit to long-term clinical appointments with our team. Long-term complications can include formation of gallstones, thinning of hair, twisted bowel causing pain or blockage, stomach ulcers leading to perforation or bleeding, nutritional and vitamin deficiencies that can lead to anaemia, osteoporosis or conditions affecting the nervous system. The new stomach sleeve can gradually stretch over time, resulting in weight regain. This is a particular risk if you fail to make the appropriate changes to your eating habits. Patients may require a further surgical procedure to help maintain their weight loss. Due to an excessive amount of loose skin, patients may also develop problems that include infection or irritation. Some patients may require plastic surgery to remove excess skin. It is important to note that access to this on the NHS is severely restricted and is unlikely to be available to you.

5 What are the alternatives to laparoscopic sleeve gastrectomy? The alternatives are non-surgical and surgical: Non-surgical alternatives are lifestyle changes, drug treatments and low calorie diet programmes. Most of the patients referred to us have already undergone these treatments. Once your BMI is above 40 these measures do not usually result in a sustained weight loss. Surgical alternatives are a laparoscopic gastric banding operation or laparoscopic gastric bypass. Your consultant will explain these alternatives in detail along with reasons as to why a sleeve gastrectomy operation may be a more suitable procedure for you. We aim to provide you with all the necessary information, enabling you to make the correct choice of procedure specific to your needs. Remember an option that you can take includes not receiving any treatment at all. The consequences of not receiving any treatment can be further weight gain, shortened life span and an increase in obesity related diseases. If you would like more information please speak to your consultant or the nurse caring for you. If you would like information on counselling with regards to any matters addressed in this booklet please speak to your GP. Access to a clinical psychologist is available in Derby for anyone who feels they would benefit from this service.

6 Getting ready for your operation It is very important that you are as healthy as possible before the operation and that you continue to do your best to lose weight. You will not be accepted for surgery if you smoke. Following referral by your GP you will be invited to attend a clinic where you will be seen by a consultant surgeon and a dietitian. The surgeon will evaluate your history and discuss different treatment options with you. The dietitian will take a diet history and give you dietary advice for before and after the operation. Sometimes there are significant changes that you need to make to your lifestyle and to your diet. You may be asked to attend the clinic a few months after this to see if you have been successful in making these changes before a recommendation for a surgical procedure can be made. Food provides not only nourishment, but also comfort and support that help us deal with the daily stresses of life. Food sometimes is our best friend. It is difficult to anticipate the emotional effect this type of surgery will have on you. Just being aware of the role food plays in our emotional well-being is not enough. Before we can make a recommendation for surgery, we must be assured that you have a realistic understanding and expectations of what will happen after surgery. For these reasons, you may be required to have a formal psychological evaluation before surgery. This is by professionals who thoroughly understand this process as it applies to you. For those who are not ready for surgery, specific recommendations will be made. Only once we are satisfied with your evaluation will surgery be agreed as an appropriate treatment for you.

7 You will be asked to attend the pre-operative assessment clinic. You will need to have some blood tests including tests to check the level of nutrients in your body. You will also undergo some routine tests including a heart trace (ECG) and may be an x-ray. You will be required to follow a strict diet for 1-2 weeks before the operation. If you have diabetes you will also be given a patient information leaflet detailing what to do with your diabetes medications whilst on this diet. On admission You will generally come into hospital on the morning of the operation. For a time before certain types of anaesthetic you will need to stop eating, drinking and chewing gum. This will be explained to you and you may also be given a booklet about this. If you have any questions please contact the hospital - telephone number on your admission letter. You will be asked some routine questions about your general health, the medicines you take at the moment and any allergies you have. You will be asked to sign a consent form to say that you understand what you have come into hospital for and what the operation involves. You will be given a theatre gown to wear. A nurse or porter will walk you to theatre. If this is not possible you will be taken on a wheelchair or trolley. What type of anaesthetic will I have? The operation is performed under general anaesthetic, which means you will be asleep throughout. You will meet your anaesthetist before the operation. If the anaesthetist has any concerns about you having a general anaesthetic you will undergo a specific anaesthetic assessment well in advance of your surgery.

8 What should I expect after the operation? The operation usually takes 2-3 hours. After the operation you will be transferred to the bariatric bay on the general surgical ward. This is a designated area where the nursing staff are trained to look after patients who have had weight loss surgery. You will be encouraged to get out of bed on the day of your operation. You are also expected to perform breathing exercises. You will have your pulse, blood pressure, breathing and wounds checked regularly by a nurse. This is called the enhanced recovery programme. Anaesthetics can sometimes make people feel sick. It is important that you inform the nurse immediately if you feel sick. They may offer you an injection that will help. It is usual to feel drowsy for several hours. You will be given oxygen through a face mask until you are more awake. You will have a drip running into a vein in your arm/hand to give you fluids. This will continue until you are able to drink a sufficient amount of liquids to keep you hydrated. You will be allowed to start drinking small amounts of clear fluid soon after your operation and progress on to tea, coffee and similar fluids the next day. You will have daily injections and wear compression stockings to further reduce the risk of blood clots. You may have a tube in your nose to empty your stomach, and a urinary catheter. In most cases these will be removed the day after your surgery. If you currently use a CPAP mask for sleep apnoea, bring this with you; you should be able to use it at night, as you would at home.

9 Wounds and dressings (stitches) You will have 5-6 small wounds. Wounds are usually glued but may have staples (metal clips) or stitches to keep them together while they heal. Staples will be removed after 10 days and stitches will be removed after 7 days. No treatment is required for glued wounds, not even plasters. If there is oozing from your wounds a dressing will be applied. In most cases you are allowed to take a shower 24 hours after the operation - do not have a bath until the wounds have fully healed. Pain relief If you experience pain it is important to inform the nurse who can give you painkillers. These can be in the form of injections, tablets or a combination of the two. Pain due to trapped wind can usually be relieved by moving about (mobilising). Shoulder tip pain is usually the result of gas under the diaphragm and improves once you start moving. Mobilising As soon as possible after your operation you will be encouraged to get up and move around. This is important as it also helps to reduce the risk of blood clots forming. At home we expect you to continue to take regular, short walks for exercise. Going home You will be expected to stay in hospital for 2-3 days, depending on your recovery. Sometimes it is not possible to perform this operation using a laparoscopic (keyhole) technique and a larger incision has to be made. This may be the case if you have had previous surgery on your abdomen. If this happens you will generally have more discomfort after the operation. You will need to stay in hospital longer and it will take longer before you are able to return to normal activities.

10 DISCHARGE INFORMATION AND AT HOME ADVICE During your stay in hospital one of the bariatric team members will see you and explain your expected recovery following discharge from the hospital. You will be supplied with detailed information and instructions, both verbal and in writing. You will also receive contact phone numbers in case you have any questions or unexpected problems at home. If you need to be admitted to another hospital following your surgery at Derby, we would like to know about it as soon as possible. We provide a bariatric on call system, which means that there is always an expert surgeon available to deal with unexpected problems or complications. You are likely to feel tired and need to rest during the day when you get home but this will improve with time. Wound care Check the wounds for signs of infection - redness, pain and heat. If any of these occur, see your GP as you may need a course of antibiotics. Do not worry if glued wounds open slightly, this can happen and just require a simple dressing. Pain relief It is usual to feel some pain after this operation and you may feel bloated. Take the painkillers you were given from the hospital, follow the instructions and do not exceed the stated dose. People rarely have problems taking tablets, however soluble forms can be taken if necessary in the early period following the operation.

11 Diabetes If you have diabetes it is generally expected that it will improve after your operation. It is important for you to closely monitor your blood sugars. Your diabetes medication will need adjusting and this will be done initially before you are discharged from hospital in accordance with the protocol. If you have type 1 diabetes you should never stop taking insulin. On discharge from hospital you should contact your own diabetes team within the first week and arrange an appointment. In the case of a diabetic emergency you should contact your own diabetes team urgently or attend your local Emergency Department. The following details will be completed as you leave the hospital, and it is therefore important that you bring this booklet into hospital with you. Stitches (ward staff to complete as appropriate) Your wound has been glued. Your stitches will dissolve - you do not need to have them taken out. Your staples/stitches will need removing in by the practice/district nurse.

12 Time off work Most patients are able to return to work within 2-3 weeks after surgery if their occupation does not require strenuous activities. Your particular occupation and recovery will dictate when you will be able to return to work. Returning to normal activities We would normally expect you to take about 3-4 weeks to get back to normal. You should avoid heavy lifting for 4 weeks. Driving Do not drive until you can wear a seatbelt comfortably and feel able to perform an emergency stop. Your insurance company may refuse to meet a claim if they feel you have driven too soon. It is advisable to contact your insurance company with regards to cover following a general anaesthetic. Diet How you eat after this operation will determine how successful you will be at losing weight. Following the dietary guidelines will also reduce your risk of complications. Your dietitian will provide you with detailed information before you leave hospital. The following information gives an overview.

13 Liquids will pass through your smaller stomach quite quickly, but solids will stay for a longer period. The key is to be patient. Your stomach is still going through a healing process and will empty faster with time. This will make it possible for you to eat larger portions of food at a later stage. WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5 AND BEYOND Liquids - anything that can be sucked up through a straw. No lumps or bits. Avoid fizzy drinks at this stage. You may progress to pureed foods. Continue to avoid fizzy drinks. You will need to separate solid foods from liquids. Avoid drinking within 30 minutes of a meal. Start including soft foods now. Most patients progress to a fairly normal diet at this stage, although in small amounts and very well chewed. You may find rice, white bread and tougher cuts of meat a problem at this stage. Limit fatty and sugary foods and drinks. The key to good nutrition is variety. We want you to experiment with food. Try to add one new food type at a time. It is still early days and foods you cannot tolerate now may be quite enjoyable 6 months later. It is really important at this early stage to develop a habit of eating 3 meals a day and limiting any in between snacking. The most dangerous habit after weight loss surgery is snacking all day long. Exercise It is important to introduce gentle exercises such as walking as soon as you feel better. This will help you lose weight and tone muscles. If you don t exercise and move your muscles, your body will think they are unnecessary and will burn your muscles for its fuel long before it touches your fat.

14 Further appointments You will have an appointment with the consultant surgeon and dietitian 6 weeks after leaving hospital. We expect you to contact us if you have any problems or questions. After undergoing surgery the following points must be taken into account at all times. The capacity of the stomach is greatly reduced. You will need to take regular sips of fluids throughout the day. You must chew all food more thoroughly. You should wait approximately 30 minutes after eating before having a drink. You will need to eat regular small meals. Use a tea plate instead of a dinner plate. Drinking too fast or eating too much food too quickly may cause vomiting. Choosing the wrong texture could cause vomiting so it is important to follow the advice given to you by the dietitian. As these dietary changes will have an effect on your social and family life you must consider the impact on events such as dining out, holidays etc. Success with weight loss surgery is dependent upon attending all follow up appointments as well as modifying diet and behaviour. If you do not attend for follow up you can develop nutritional deficiencies, which can have very serious consequences for your health.

15 Frequently asked questions Will I have to follow a special diet before my surgery? Yes. You will need to follow a special diet for 2 weeks before your surgery. The purpose of this diet is to shrink your liver. Over a number of years, as you have eaten more calories than your body has used, you have converted this energy into a substance called glycogen and stored it. One of the places it is stored is in your liver causing it to become enlarged. The liver is positioned across your stomach and so obscures the surgeon s view. Therefore he will gently lift it out of the way. This is much more difficult with an enlarged liver. This diet reduces your calorie and carbohydrate intake which encourages your body to use the stores in your liver, causing it to shrink. This makes it easier and safer for the surgeon to move your liver out of the way. A diet information sheet will be sent to you when you are given a date for surgery. Will I need to follow a special diet after my surgery? Yes. As a result of your surgery you will have stitches and staples along the length of your new stomach. It is essential that you protect these and allow them to heal. In order to do this you will need to follow a liquid diet followed by a soft diet for several weeks. See Diet section for more details.

16 What about medication? You should be able to manage your normal prescribed medication. Large tablets may need breaking in half (i.e. Metformin). In addition as you lose weight, the dosage of certain medication will need to be adjusted. At the time of your discharge you will be prescribed antacid tablets for 6 weeks, blood thinning injections for 2 weeks and painkillers. Do I need to take any supplements? Yes. Because the volume of food you can eat is small, we suggest that you take a complete multivitamin and mineral supplement. Some people will also need an extra iron supplement. Does a sleeve gastrectomy limit the exercise I can do? No. You are encouraged to walk as soon as possible. Once your wounds are dry you can swim. After 6 weeks you will be able to continue with any activity or exercise you wish to do. A sleeve gastrectomy will not restrict any aerobic, stretching or strenuous exercises. Remember the more active you are the better weight loss you will see.

17 Will it hurt? You may suffer with wind pain for up to 2 weeks. This pain may move up into your shoulder (this is perfectly normal after laparoscopic surgery). Getting up and moving about as soon as possible is the best way to relieve this. What about pregnancy? You should inform us if you think there is any chance you could be pregnant at any stage whilst you are considering or once you have had the sleeve gastrectomy. It is possible to have a healthy pregnancy following sleeve gastrectomy. You may need to adjust your supplements during pregnancy and may require more frequent blood tests for estimates of nutrients. It is recommended that you should not try to become pregnant for the first 18 months following surgery. How much weight can I expect to lose after my surgery? The average weight loss after a laparoscopic sleeve gastrectomy operation is 50-55% of your excess body weight. For example if you weigh 22 stone and your ideal body weight is 12 stone, your excess body weight is 10 stone. You can expect the operation to help you to lose about 5 stone of this. If you follow all the guidelines and advice we offer you may be able to lose more. You will always need to work hard to lose your weight even with surgery.

18 Will I be sick a lot after the surgery? Sleeve gastrectomy limits the quantity of solid food you can eat. If you are feeling sick or vomiting regularly it may mean that you are either eating too much or you are not chewing your food properly. What are the differences between the laparoscopic and open procedures? Laparoscopic patients have less pain, better cosmetic results and less chance of wound or hernia problems following surgery. The risk of breathing complications is lower following laparoscopic surgery. Life after surgery After the initial settling period you will develop certain routines. You will not be able to eat nearly as much food as you were used to eating. Although most patients are no longer hungry, it is difficult to predict how much this volume restriction will affect your life. Especially as many social and family events centre on food. Weight loss reaches a peak 1-3 years following surgery. After this, patients can continue to re-model themselves, losing inches as opposed to weight; changing body fat composition, muscle mass, etc.

19 Remember some basic principals about sleeve gastrectomy surgery Sleeve gastrectomy surgery is not a cure for obesity, but can be used to control obesity and related diseases. You should aim to achieve optimum health and avoid longterm complications rather than focus primarily on weight loss. Eat slowly. The slower you eat the more time your brain has to realise there s food in your stomach. Stop eating when you are satisfied not when you are full. Drink plenty of liquids (mainly water). Always start your food with a protein. It fills you up and helps curb cravings. Do not drink while you are having your meal. Remember to take your supplements daily. Attend your follow up appointments including blood tests. Exercise plays an important part in helping you achieve successful weight loss following surgery. Attend a support group regularly.

20 Trust Minicom Any external organisations and websites included here do not necessarily reflect the views of the Derby Hospitals NHS Foundation Trust, nor does their inclusion constitute a recommendation. Reference Code: P1407/1529/ /VERSION3 Copyright All rights reserved. No part of this publication may be reproduced in any form or by any means without prior permission in writing from the Patient Information Service, Derby Hospitals NHS Foundation Trust. (P1101/ /V2)