Laparoscopic gastric banding

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1 Laparoscopic gastric banding

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3 What is laparoscopic gastric banding? Laparoscopic gastric banding is one of 3 main bariatric procedures offered here at Derby. It has a restrictive component which helps to reduce the volume of food that can be eaten and also helps reduce appetite. The procedure is generally done laparoscopically (key hole surgery). This means that the instruments are passed through 5 small holes (ports) in the skin. The surgeon then carries out the operation by viewing the abdominal cavity on a monitor (TV screen). Occasionally the operation cannot be performed laparoscopically and a larger incision has to be made. If this happens you will generally have more discomfort after the operation. You will need to stay in hospital longer and it will be a longer period before you are able to return to normal activities. Pouch Lap-Band System Tubing Stomach Lap-Band System Access Port

4 The adjustable silicone band is placed around the top part of the stomach. Food is squeezed across the area where the band is placed stimulating nerves which send signals to the brain to generate a feeling of being full (satiety). A gastric band does not work by restricting or blocking food. The band will help you to eat small portions of food more slowly. The band can slow the passage of food, but should not stop you eating. If you continue to eat quickly, you can develop heartburn and vomiting and risk stretching the stomach pouch and misplacing the band. Once the band has been fitted it can be adjusted without further surgery depending on dietary intake and the amount of weight being lost. The band is adjusted by injecting saline through the skin into a small reservoir (access port). The access port is placed under the skin at the time of surgery usually on the left side of the abdomen. Adjustments are tailored to suit individual needs, but can take place from around 4 weeks onwards following surgery and then periodically to generate a feeling of being full (satiety) and help achieve optimal weight loss. Band adjustments take place in an outpatient setting. The appointment takes approximately 30 minutes. Local anaesthetic may be injected around the access port site before band adjustment.

5 What are the benefits of having laparoscopic banding? This operation can enable effective long-term weight loss, but only when combined with lifestyle and dietary changes. Reduces health related problems: Diabetes Osteoarthritis Hypertension (high blood pressure) Coronary Heart Disease (CHD) High cholesterol level As the procedure is performed laparoscopically there are fewer risks and a lower mortality (death) rate compared to other surgical treatment options. Becoming pregnant can be easier as you lose weight however, you need to wait 2 years after having surgery to try to conceive. What are the risks, consequences and alternatives associated with having laparoscopic banding? Most operations are straightforward, however as with any surgical procedure there is a small chance of side-effects or complications. These are listed below: Blood clots: Deep Vein Thrombosis (DVT) or Pulmonary Embolus (PE). The risk is reduced by the use of compression stockings and anti coagulant injections ie. enoxaparin whilst in hospital and at home following the operation. Bleeding. May require a further operation or blood transfusion. Wound/chest infections. Treated with antibiotics.

6 Perforation. There is a very small risk of damage to the stomach, liver or spleen which can result in the need for further surgery. Risk of dying. There is a risk of dying from any surgery. That risk is lowest from the band compared to the other surgical weight loss procedures. The risk is increased with a higher BMI and the presence of other medical problems. Overall, the risk of surgery is considered to be lower than the risk of remaining overweight. Stomach pouch enlargement/band leakage/slippage/erosion. Common symptoms to look out for are lack of band restriction, vomiting, intolerances to a number of food groups and weight gain without apparent cause. Please contact your obesity nurse/consultant for advice. Port related problems. The access port can leak, become disconnected or flip upside down. All these problems are easily corrected with minor surgery. Risk of needing a further operation. The band is designed to remain in place for life, but over that time it may require surgical readjustment or removal. There is a 10% risk of needing further surgery over the lifetime of the band. Failure to lose weight. If you learn to work with the band it can help you achieve good results, but up to 1 in 4 people fail to lose the weight they have aimed for. If you are concerned about any of these risks, or have any further queries, please speak to a member of the team. Your consultant has recommended this procedure as being the best option to aid weight loss. The other options available here at Derby are sleeve gastrectomy or gastric bypass.

7 There is always the option of not receiving any treatment at all. However, the consequences of not receiving any treatment are further weight gain, shortened life span, increase in obesity related diseases (as listed under benefits above), low self esteem or depression. If you would like more information please speak to your consultant or the nurse caring for you. If you would like information on counselling or weight management programmes please speak to your GP. Getting ready for the 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 you will be seen by a consultant surgeon and the dietitian. The surgeon will assess your suitability for surgery and provide general information about the procedure. The dietitian will take a diet history and give you dietary advice for before and after the operation. You will be required to follow a strict diet for 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. You will be asked to attend the pre-operative assessment clinic. You may need to undergo some routine tests before your operation eg. heart trace (ECG), x-ray, blood test. You will also be weighed and, if you have put on weight your operation will be cancelled.

8 Admission You will generally come into hospital the day before, or on the morning of, the procedure. 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 trolley. What sort of anaesthetic will I have? Your operation will be carried out under general anaesthetic, which means you will be asleep throughout. The anaesthetist will visit you before your operation and discuss the anaesthetic with you.

9 What should I expect after the operation? The operation takes approximately 1 hour. After the operation you will return to the ward. Occasionally patients may be required to spend 24 hours in the Intensive Therapy Unit (ITU). This is a unit, which provides more intensive nursing. You will have your pulse, blood pressure, breathing and wounds checked regularly by a nurse. It is usual to feel drowsy for several hours. You will be given oxygen through a facemask until you are more awake. Anaesthetics can sometimes make people feel sick. It is important you inform the nurse immediately if you feel sick. They may offer you an injection which will help to settle it. You may have a drip running into a vein in your arm/hand to give you fluids overnight. You will be required to have enoxaparin injections daily and wear compression stockings to prevent the risk of a blood clot. Dressings (stitches) 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. You may have plasters covering your wounds.

10 Pain relief If you experience pain it is important to tell the nurses who can give you painkillers to help. Trapped wind is often the cause of discomfort and pain after the operation. This can be relieved by moving about. Mobilising As soon as possible after your operation you will be encouraged to get up and move around. This is important as it helps to reduce the risk of blood clots forming. Diet You will start on a liquid diet 1 hour after surgery (a separate information sheet Your Diet after Laparoscopic Gastric Banding will be given to you by the dietitian). Going home If the operation was completed laparoscopically you would normally stay in hospital for 1-3 days. If the operation was not performed laparoscopically and a larger incision was made, you will need to stay in hospital for up to a week. You will be seen by the nurse specialist before leaving the ward, who will answer any questions you may have.

11 DISCHARGE INFORMATION AND AT HOME ADVICE 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 wound 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 often happens and just requires a simple dressing. Pain relief It is usual to feel some pain after this operation and you may feel bloated. A mild painkiller such as Paracetamol is recommended - follow the manufacturer s 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. Time off work We advise that you have 1-2 weeks off work. Returning to normal activities We would normally expect you to take about 1-2 weeks to get back to normal. You should avoid heavy lifting for 2-4 weeks. Driving Do not drive until you can wear a seat belt 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 also advisable to contact your insurance company with regards to cover following a general anaesthetic.

12 Tablets Please continue to take your tablets normally after leaving hospital. This includes the multivitamin that will be prescribed for you. If you experience problems please see your GP for advice. Your GP may be able to supply liquid alternatives to your tablets if necessary. 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. Diet You will continue on a liquid diet for approximately 1 week and follow the advice given to you by the dietitian (a simple multivitamin with iron is recommended at this time). A liquid diet may cause constipation. Make sure you drink at least 2 litres of fluids per day. Gentle laxatives eg. Senna can be taken at this time. Senna is available from any pharmacy, it is not necessary to see your GP.

13 Exercise It is important to introduce gentle exercise such as walking straight away after surgery. This will help you lose weight and tone muscles. Further appointments You will have a follow up appointment with the nurses and dietitians approximately 4 weeks after leaving hospital. We ask that your GP/doctor contacts us directly for advice or transfer if deemed appropriate. Your weight and nutritional status will be carefully monitored. The obesity nurse will also monitor your progress and be on hand to offer support, advice and help solve any problems that may arise. You will be given regular appointments with the Bariatric team that we expect you to attend. Gastric band adjustments will be made depending on appetite and weight loss. We ask that you contact us between appointments if you experience problems or feel that the band is not working optimally for you. It is important that you contact us immediately if you experience any problems following your surgery. We provide an emergency service for such occurrences - telephone

14 After undergoing surgery the following points must be taken into account at all times. The gastric band mainly works by inducing a sense of fullness. You will need to take regular sips of fluids throughout the day. You must chew all food more thoroughly. 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. 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, taking holidays etc. Success with a gastric band is dependant on attending all follow up appointments as well as modifying diet and behaviour. It may not be necessary to adjust your band at each appointment. The gastric band is intended to be in place permanently.

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. Your 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 swelling and stitches internally around the site of the band. It is essential that you protect this and allow it to heal. In order to do this you will need to follow a liquid diet for 1 week. As liquids will move straight through the band, no pressure will be put on it, so you will not be sick. Liquids must be thin enough to be taken through a straw. More details of suitable liquids are given in the diet sheet, which is sent to you with a date for surgery.

16 As it is difficult to meet nutritional requirements on a liquid diet, we recommend you drink 1 pint of milk per day. If you think this will be a problem for you please discuss this with the dietitian who will be able to give you further advice. During weeks 2 and 3 after the operation you will need to start introducing soft diet. From week 3 you should be eating textured food and following the information and advice you are given by the dietitian. What about medication? You should be able to manage your normal prescribed medication. Large tablets may need breaking in half (ie. Metformin). Please discuss any concerns about your medications with the nurse at your appointment. Do I need to take a multivitamin and mineral supplement? YES. You will need to take a multivitamin and mineral supplement for 6 months following surgery. This will ensure that you are receiving the right nutrients whilst you establish a healthy eating pattern. Does a gastric band 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 gastric band will not restrict any aerobic, stretching or strenuous exercise. Remember the more active you are the better weight loss you will see. 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.

17 What about pregnancy? You should inform us if you think that there is any chance you could pregnant at any stage whilst you are considering or once you have had a gastric band. It is possible to have a healthy pregnancy following a gastric band. We can remove fluid from the band, allowing you to eat enough for both you and a baby. The band can be tightened again at a later stage. It is recommended that you should not try to become pregnant for the first 2 years following surgery. How much weight can I expect to lose after my surgery? Weight loss will be slow. You can expect to lose approximately 1-2lb (½ - 1kg) per week initially. The average total weight loss with a band is 50% 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 band to help you to lose 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 a gastric band. Results with a gastric band are variable and dependent on your age, mobility and other medical problems. While many people do achieve good results with a band, some fail to lose significant weight. It is important that you keep working with us. If you fail to attend for follow-up, your results are likely to be less favourable. Will I be sick a lot after surgery? A gastric band limits the quantity of solid food eaten. 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. Vomiting should be avoided where possible as over a long period this will cause the pouch to stretch and the band becomes less effective. In some cases this can lead to another operation.

18 Ensure you: Eat 3 small tea plate portions of solid food. Eat slowly. Chew food thoroughly. If you are following the advice above and still feeling sick this could indicate there is a problem with your band so please contact the Bariatric team. Does the band stay in permanently? YES. The gastric band is not designed to be removed. However if there are complications, such as band slippage or band erosion, the gastric band may need to be removed. What about band adjustments? This varies from one person to another. Appointments will be sent routinely. It is your responsibility to contact us to arrange an appointment if you encounter any problems or weight gain. Useful contacts 24 hour Emergency Number Telephone: Bariatric Nurses Telephone: Page: telephone: and ask for page

19 Dietitians Telephone: Rita Mulvey-Goldsmith Sarah Brennan Lindsay Parry Jacqui Kurt Joanne Gregory Ward 311 Telephone: or Mid Trent Obesity Support Group Meets last Wednesday of every month, (not July, August or December). Room 2, Education Centre, Royal Derby Hospital, 7.00pm pm The nearest car park is car park 4. Bariatric Obesity Surgery Support Group (Boss) Meets third Sunday of every month. Thoresby Suite, Louth Hospital. Telephone Claire on Useful websites

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: P1249/1312/ /VERSION9 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/ /V8) Smoking is not permitted anywhere in the buildings and grounds of Derby s Hospitals. For advice and support about giving up smoking please call Free Phone

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