Patient Information
Bariatric Surgery
Centred on You
2 PATIENT AND VISITOR HANDBOOK
Patient information This information leaflet is designed to provide you with an overview of the surgery for obesity service at St Vincent’s Private Hospital. This brochure, along with discussions with our team, should help you fully understand what is involved and help inform your decision on whether or not to have surgery.
What is weight loss surgery? Surgery for obesity is usually known as bariatric surgery. It is a safe and effective treatment for weight loss and health gain. Successful surgery requires a joint effort between the patient and their multidisciplinary team. The aim is to ensure healthy weight loss, and maximise the associated health benefits, while maintaining an optimum nutritional intake.
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What is the process? 1. Patient information evening/Online Seminar Your first appointment involves you viewing an online seminar. In this seminar you will receive information on the bariatric service. This will include information from all members of the multidisciplinary team which includes a surgeon, physician, dietitian, and psychologist. This seminar can be viewed on the website https://svph.ie/ metabolic-bariatric-services/bariatric-services/. Please note that you need to view this seminar and complete the paperwork to be considered for further treatment. 2. Pre-surgery assessment and preparation Following on from the group meeting should you wish to continue on the surgical pathway, you will be booked for an appointment with the physician, dietitian and psychologist. A second appointment is scheduled at a later date with the surgeon. This appointment will involve a detailed dietary and medical assessment. The Dietitian and/or Nutritionist will discuss the dietary aspects of surgery for obesity and help guide you through the various stages before and after surgery. The physician will complete a medical assessment that examines how obesity has affected your health. Many health problems are related to weight gain (for example type 2 diabetes, sleep apnoea, high blood pressure). A full medical assessment is necessary in deciding the safest and most effective treatment for each patient. The psychologist will help you to identify behavioural and psychological issues that might impact your ability to attain optimal weight loss after surgery and help you to understand
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the related challenges you may experience. An understanding of eating behavior and a willingness to discuss issues like overeating or binge eating with the multidisciplinary team is key to successful weight loss. Surgery can help you to eat less, but you may need more support to help change your psychological relationship with food. The psychologist will also provide additional background and assessment information for the other team members supporting you. An additional appointment with the surgeon will then be scheduled if you wish to proceed with surgery. The surgeon will discuss the types of surgery you are considering and assess your suitability for the different procedures. The surgeon will also discuss the risks and benefits of surgery, and together you will decide on which operation is right for you. If you decide you would like to proceed with surgery, you will be asked to sign a consent form for the procedure at this appointment. When contemplating weight loss surgery, it is important for people to consider personal goals and commitment to a lifestyle change. People can re-gain weight after surgery. Lifelong healthy eating and activity are important components in maintaining the weight loss achieved after surgery. 3. Pre-surgery preparation You will be contacted by the physician associate (PA) two weeks before surgery to review your regular medications and discuss what to expect post surgery. You will be required to follow a preoperative or “liver-shrinking” diet for at least two weeks prior to your surgery. This diet is typically low in fat and low in carbohydrate, with adequate
protein, fibre, vitamins and minerals. The purpose of this diet is to help shrink the liver before surgery which then makes the surgery safer by reducing the risk of liver injury and bleeding.
recovering. The physician associate (PA) will also be around to see you during your stay and can go over any queries that you may have, such as medications and recovery.
4. Day of surgery Admission on the day of surgery
5. After you leave the hospital
On the day of surgery, you will be asked to checkin at the hospital at a specific time. A nurse will then meet you and bring you to DOSAL (Day of Surgery Admissions Lounge). Here they will take a medical history and perform any pre-op tests necessary such as an ECG or blood samples. You will then be asked to prepare for surgery, by dressing in a hospital gown. All the other preparation will be done during the surgery and you won’t be aware of most of it. You may be accompanied by a partner or person close to you, up until you leave DOSAL. You will be brought to your assigned room on the ward after your operation. Surgery takes 1-2 hours approximately Hospital stay: 2 days on average The hospital is designed to accommodate bariatric patients and maximise their comfort. Special beds and chairs are available where needed. We plan to get patients moving as soon as practical after surgery as this reduces the risk of complications in the postoperative period. You may feel sick and groggy after the operation for a while. Pain and anti-sickness medications will be administered when needed. A nurse will be available for you 24/7 during your time in the hospital. Your surgeon will visit you daily during your admission to check on your progress and agree a day for leaving the hospital based on how you are
Following surgery, you will have scheduled followup appointments with the surgeon, physician and dietitian. It is important that you attend your post-operative appointments as this will help identify any issues early on. For example, it is not uncommon for patients following surgery to become deficient in essential vitamins and minerals, but deficiencies can easily be corrected if detected before they result in serious complications. In the first two weeks post-surgery you will be followed up by telephone by members of the multidisciplinary team. The dietitian will contact you within your first week and the physician associate (PA) in your second week. Appointments are then typically scheduled at 6 weeks, 3, 6 and 12 months, and annually thereafter. Prior to each appointment, you will be sent a form for blood tests, and we request that you have your bloods taken at least 2 weeks before your appointment, so that the results will be available for review. You may also wish to work with our psychologist, either one-to-one or in a group with other bariatric patients, to explore issues that may be impacting your recovery and weight management progress.
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6. Long term
Surgery for obesity pathway Attend patient information seminar includes information from surgeon/physician, dietitian/psychologist Attend appointment with physician and dietitian and psychologist Attend appointment with surgeon Pre-operative telephone clinic with physician associate Follow pre-operative diet pre surgery Attend hospital for surgery Follow post-operative diet for 6-8 weeks Telephone review after one week with dietitian Telephone review after two weeks with physician associate Surgical review after 6 weeks Dietitian review at 3 and 6 months Physician or Surgical review at 12 months Annual review /group meeting
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Bloods to be checked annually, 3 months, 6 months and 12 months post surgery and annually thereafter. Baseline
3 months
6 months
12 months
Annually Full blood count Ferritin Folate & Vitamin B12 25 hydroxy-vitamin D Calcium Parathyroid hormone Liver function test Fasting Glucose HbA1c Lipid profile Zinc, copper, selenium * Thiamine * *as clinically indicated
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The Surgical Options The vast majority of operations are carried out laparoscopically, which is also known as keyhole surgery. This means that you’ll usually have five small incisions (cuts) in the abdomen instead of one large cut, thereby enabling a faster recovery.
Sleeve Gastrectomy This operation works by enhancing how quickly food reaches the small intestine. This is done by removing two thirds of the stomach and creating a smaller stomach pouch which allows food to quickly enter the small intestine. It helps achieve weight loss by reducing hunger and creating fullness, thereby reducing the amount of food that you eat. This, together with changes to your diet and activity levels, results in long term weight loss and weight maintenance.
Advantages
Disadvantages
Reduces hunger and increases fullness
Irreversible
Effective (25-30% Weight loss)
Risk of Reflux
Improves Type 2 Diabetes
Requires daily multivitamin, calcium
Improves other obesity complications
and vitamin B12 injection to prevent
Safe
nutritional deficiencies 15-20% risk of weight regain
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Roux-en-Y gastric bypass
The Roux-en-Y gastric bypass procedure enhances how quickly food reaches the small intestine. It involves creating a stomach pouch out of a small portion of the stomach and attaching it directly to the small intestine, bypassing a large part of the stomach and the small intestine. This reduces hunger and creates fullness quickly, resulting in a reduction in food intake. This Advantages
together with changes to your diet and activity levels results in long term weight loss and weight maintenance. A consequence of the surgery is that fewer vitamins and minerals are absorbed as food passes through the intestine, so it is essential that dietary advice is followed as per the dietitian or nutritionist. It is also essential for people to take vitamin and mineral supplements every day for life to avoid nutritional deficiencies. Disadvantages
Reduces hunger and increases fullness
Surgical risks
Effective (25-30% weight loss)
Daily multivitamin, Calcium/Vit D, Iron
Remission/improvement in T2DM
supplements and Vitamin B12
Remission/improvement in other obesity
injections required
complications
Weight regain 8-10%
Better operation for those with pre-existing reflux An understanding and acceptance of the risks as well as the benefits of surgery is importnat. If you have any questions make a note of them and discuss with a member of the team at your next appointment.
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Frequently Asked Questions I’m nervous about going for surgery is it safe? Fortunately, complications are rare but it is important you learn about the potential problems before you decide to proceed with the surgery. Please ask the surgeon or physician for further information. Surgery for obesity is considered to be a safe operation. The risk of dying in the first 30 days post surgery for the sleeve gastrectomy is approximately 1 in 1000 and for the gastric bypass surgery is less than 2 in 2000. These rates are as low as for other common surgeries, for example gallbladder removal.
How much weight can I expect to lose? The expected weight loss is approximately 25 to 30 per cent of body weight. For example a person weighing 100kg could expect to lose between 25 and 30kg.
I have heard that excess skin is a problem? Following significant weight loss patients will develop excess skin. The amount varies from one individual to the next, and depends on the amount of weight lost. However, everyone will develop some excess skin. This is something you can discuss with the physician and/or surgeon when considering going forward for surgery.
Do I have to follow a special diet? Before surgery you will be asked to follow a low fat, low carbohydrate diet. The dietitian will give you instructions to follow. It is important that you follow this as the aim is to reduce the size of your liver to enable the surgeons to access your stomach more easily. It is important that you 10 BARIATRIC SURGERY
follow this diet as if your liver is not reduced the surgery may not be possible. After surgery you will have food introduced slowly from liquid to puree/soft and onto normal texture food by 6-8 weeks. This slow introduction of textures is vital to help the stomach to heal. The dietitian will provide you with dietary guidelines to help you. After about two months, the focus will be on balanced healthy eating, a regular meal pattern and appropriately sized portions. The dietitian will give you additional support and guidance as needed.
Are there any particular foods that I should avoid? In the first few weeks the texture is important, so keeping to puree and soft as advised is essential to avoid serious surgical complications. After the first few months, we expect people to be able to eat normal food (although in much smaller amounts). Certain foods can cause some discomfort for some people (for example stringy meat, fibrous vegetables (e.g. celery), bread, pasta and rice). However it is different for everyone. If a food causes discomfort leave it a while before trying it again in a smaller portion. Foods high in fat and sugar may lead to weight gain or lead to ‘dumping syndrome’.
What is dumping syndrome? Dumping syndrome occurs following weight loss surgery, in some but not all cases. It is more commonly seen after gastric bypass surgery, typically in the first year of surgery. It can occur if too much fat, sugar or alcohol is ‘dumped’ into the intestine at any one time. The symptoms include
nausea, vomiting, diarrhoea, sweating, feeling faint and weak. Dumping syndrome can sometimes result in low blood sugar. Other signs and symptoms of dumping syndrome can include: • Sweating • Flushing • Dizziness or light-headedness • Weakness • Rapid heart rate If you develop dumping syndrome, the symptoms can be minimised or avoided if you avoid foods high in fat and sugar. Sometimes medical treatment is needed to help with symptoms. If Dumping syndrome occurs then contact a member of the multidisciplinary team who can provide additional advice.
What foods should I eat? Once you have completed the post-operative dietary stage the focus is then on healthy eating. In the first year or so, there will be an emphasis on ensuring your protein intake is sufficient to keep your muscles strong and healthy. The dietitian will advise you on the foods that will provide adequate protein, vitamins, minerals, as well as fluid and fibre.
Are there any other side effects after surgery? Nausea and vomiting can be common in the first few months after surgery for obesity. These may occur after eating too fast, drinking liquids while eating, not chewing well enough, or eating more than your stomach can comfortably hold.
Vomiting that continues for more than 24 hours must be taken seriously, since vomiting can lead to severe dehydration and electrolyte imbalance. If you develop vomiting that persists for 24 hours or more, you must seek urgent medical advice. Constipation can also be a problem, particularly in the first few weeks after surgery. Taking adequate fibre and fluid will help. Sometime laxatives are needed. If constipation continues despite these measures, then contact a member of the multidisciplinary team who can provide further guidance.
I have heard that hair loss is a problem. Is this true? Many people experience hair loss during the weight loss phase after surgery (typically the first 6-12 months) as a result of rapid weight loss. This doesn’t continue long-term and hair will grow back. It is important that you are eating a healthy and balanced diet with adequate protein and taking any supplements prescribed to minimise hair loss and protect the long-term condition of your hair.
Do I need to stop smoking? Smokers carry a far greater risk of complications such as leaks, strictures, perforations or stomach ulcers after this type of surgery. It is important that you stop smoking and do not take up smoking again after the surgery. For advice and help with smoking cessation, visit the HSE QUIT campaign website https://www.hse.ie/eng/health/ hl/change/quit/help.html
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Can I drink alcohol after surgery? Alcohol can be consumed in moderation after surgery but it is important to note that it is absorbed more quickly and you will therefore feel the effects of alcohol at smaller volumes. Alcohol is also high in calories and may reduce the amount of weight you will lose. Studies show that some people may develop alcohol dependency after surgery for obesity. It is important to discuss with the team any past or present concerns with alcohol or if there is an increase in your alcohol intake after surgery.
Medications after surgery When you leave the hospital you will have a prescription for several medications. You may require some pain medication in the early stages such as paracetemol or solpedine. Some medications will be taken for a few months after surgery, and others you will need to take for life. If unsure, please discuss with a member of the team. Do not take non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen after surgery. These medications increase your risk of developing ulcers. After surgery for obesity, ulcers are more difficult to diagnose and treat. Check with your GP or pharmacist, when starting any new medication after surgery. After surgery, you should resume your usual medicines for other conditions unless advised otherwise by the surgeon or physician. It is important that medications for diabetes and blood pressure are regularly checked by the physican or surgeon and your GP as the doses may will need to be adjusted as you lose weight.
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Do I have to take vitamins and minerals? Nutritional deficiencies often occur after surgery. After gastric bypass surgery lifelong nutritional supplementation is required with a daily multivitamin, iron, calcium and regular vitamin B12 injections. Multivitamins, vitamin B12 and calcium supplements are also recommended after the sleeve gastrectomy and may require additional iron supplements. You will be asked to have blood tests every three months in the first year and annually thereafter. You will then be advised based on your blood tests results if additional supplementation is needed.
Can I become pregnant after surgery? Surgery for obesity can increase fertility, but the risk of miscarriage is high during the weight loss phase after surgery. Therefore, pregnancy should be avoided in the weight loss phase (typically up to 12 months after surgery). Once the weight loss has stabilised, it is safe to conceive, but additional medical and obstetric review may be needed during pregnancy. Additional nutritional supplementation will also be needed prior to conception and during pregnancy. If you plan to become pregnant, or if there is any chance of becoming pregnant after surgery, then you should discuss this with the Bariatric Team.
Are there any other things to consider? Surgery for obesity often leads to significant health and life improvements for our patients. The wide range of changes after surgery can be challenging, as well as being beneficial. Even a good thing can cause some stress. Some patients will miss being able to eat the kinds of and quantities of food they were used to. Some patients hit a weight loss plateau and may need extra help. Patients should feel as supported as possible during this time, so ask for help if you need it.
Emotional challenges
Very often your health indicators will improve significantly, and you will experience a range of welcome improvements in your life. Contact Details: Therese Coleman Bariatric Service Co-ordinator and Dietitian 087 715 4160 theresecoleman@svph.ie Jessica Maddock Physician Associate (PA) jessicamaddock@svhg.ie Useful websites: http://www.bospa.org/ http://www.wlsinfo.org.uk/
Sometimes, patients may experience emotional challenges after surgery. This is common for many types of surgery, not only bariatric surgery. In the aftermath of surgery, as patient’s health improves and activity often increases, some can experience changes in their personal relationships. Issues that may have been in the background before surgery, because of health priorities, may emerge and need renewed attention, including among couples. Also, the weight loss journey can coincide with other significant events and life transitions. These can also be challenging to navigate. Surgery for obesity is a tool to help with weight management. Changes can occur quickly and begin to impact you soon after surgery. You will probably feel a lot better in general a while after surgery: it takes a year or longer for you and your body to become used to the changes. Be tolerant of yourself, change is not always as easy or as quick as you want.
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St. Vincent’s Private Hospital Elm Park, Dublin 4 Ireland
T +353 1 263 8000 www.svph.ie
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