What does the evaluation for obesity surgery involve?

As part of our preoperative assessment you will see the bariatric nurse and dietitian. Accurate preoperative assessment of your knowledge about nutrition, personal habits, and commitment to change are essential for a successful long-term outcome.

You will be called to the outpatient preoperative assessment unit a few days/weeks before the planned operation and will receive general medical evaluation. This will include some blood tests and where indicated an ECG and a chest X-ray.

If you have breathing problems, or if we are concerned that you may be suffering with some degree of obstructive sleep apnoea (OSA) we might need to consider the need for a sleep study. If the test shows severe OSA, you will need to have CPAP machine to help you with breathing for a few weeks in order to reduce strain on your heart and to make the surgery safer for your body to tolerate. We will need to keep you on the High Dependency Unit overnight after surgery for closer monitoring.

If you suffer with angina or have had a heart attack in the past, we will need to consider an opinion from a cardiologist and a test to investigate and if necessary treat any significant narrowing of the coronary arteries that supply the heart in order to reduce the risk to your heart.

If we feel necessary, we may recommend that you see a psychologist to make sure that an operation would be advisable and that you are mentally and emotionally prepared for the restriction on the amount of food that you will be able to at after the operation.

We may also recommend that you see an endocrine doctor if we are concerned that you may have an endocrine illness causing the obesity and possibly the diabetes and requiring treatment with medications.

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Who is suitable for weight loss surgery?

Weight loss surgery is indicated for the following groups of people:

When appropriate non-surgical measures have been tried but failed to achieve or maintain adequate, clinically beneficial weight loss in patients whose:

BMI is 40 kg/m2 or more
Or between 35-40 kg/m2 in association with other significant disease (for example, type 2 diabetes, heart disease or high blood pressure)
It is also recommended as a first-line option (instead of lifestyle interventions or drug treatment) for adults with a BMI of more than 50 kg/m2 in whom surgical intervention is considered appropriate (National Institute for Clinical Excellence (NICE)).

In March 2011, The International Diabetes Federation (IDF) recommended bariatric surgery to patients with BMI 30 kg/m2 (Asians from BMI 27.5 kg/m2) if their diabetes was poorly controlled.
However, the need for surgery to aid weight loss is dependent on discussion with the bariatric team who will provide you expert and comprehensive advice.

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How long is the surgery? and how long will I stay in hospital?

On average, the gastric banding procedure takes 20-30 minutes, the sleeve gastrectomy takes 25-40 minutes, while the bypass requires 60-90 minutes. Most patients begin liquids on the same day after the surgery and take liquid diet the following day. Almost all band patients are discharged home within 24 hours, while 80% of patients who have had sleeve or bypass are discharged the following day. The remainder may stay a day or two longer, especially if the had travelled a long distance, if they had mobility issues or if they had no support at home.

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Why consider an operation if there is some risk?

Patients who are morbidly obese have a greatly increased risk of premature death from a number of causes, especially diabetes, high blood pressure, heart and lung disease, as well as cancer. Weight loss surgery has been shown to reduce the risk of death, to improve or reverse the weight-related complications, and to improve quality of life. In the large majority of people, the benefits of surgery far outweigh the risks, but that balance has to be discussed with the surgeon and possibly the anaesthetist.

For further reading:
Read Graham’s story with the gastric bypass under the care of Mr. Ammori

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How soon will I return to normal activity?

You may be able to do most light activities within few days of surgery and as you feel comfortable to do them. We advise that you avoid driving for an average of 10-14 days as you need to be off all painkillers, full mobile and able to confidently make an emergency stop before you start driving. Most people can return to an office job within 7-14 days after surgery, while those in a manual job might require up to 4 weeks. You will normally be given an appointment to be seen in clinic 4-6 weeks after the surgery to discuss your progress and to assist you with your food choices.

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How much weight will I lose after the operation?

After surgery, the initial weight loss is rapid and gradually slows down with time as you approach your target weight. Weight loss after the gastric banding operation is slower than that after sleeve gastrectomy or gastric bypass, but can be increased by adjusting the band. On average, people lose 40-50% of their excess weight, 60-65% after sleeve gastrectomy and 65-75% after gastric bypass over a course of 12-18 months. Generally speaking, what one loses in the first 4-6 months, it will take another 8-12 months to lose the same amount of weight again. It is possible to lose more weight by a combination of regular exercise and additional dieting usually by reducing high calorie snack foods or fluids rather than reducing the meal size.

Unlike ordinary dieting, where weight is regained very rapidly when the diet stops, weight loss after the surgery is more permanent and once lost, weight tends to stay off.

However, there are failure rates with each operation, and this means that some people don’t get to lose much weight or rarely none at all. On average, 10-30% of patients having gastric band will fail to lose much weight, while 5% of patients or less will fail after sleeve gastrectomy or gastric bypass. One has to work with the surgery in order to achieve the weight loss desired, and should look at surgery as an aid to weight loss rather than the answer. There are factors that predict poor weight loss, such as diabetes (especially when it has been long-standing and harder to treat, perhaps requiring insulin), polycystic ovary syndrome, older-age and sweet eating, as well as a very high BMI; people who have some of these factors are advised to consider operations that are more effective in achieving weight loss such as the gastric bypass or the sleeve gastrectomy.

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Will I ‘overshoot’ and get too thin?

This is extremely rare, and when it occurs there are usually other factors that are contributing and should be addressed such as excess alcohol intake with associated alcohol-related liver disease and occasionally psychological issues that result in anorexia (severe lack of interest in food).

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Is the operation reversible?

The gastric band is easily reversible as the band could be removed by keyhole surgery, and this may rarely be required if there are complications related to the band such as band erosion, pouch dilatation, band slippage, severe reflux or band infection. It is technically possible to reverse the gastric bypass, and this could be accomplished laparoscopically (keyhole surgery), though it is extremely rare to need to do that. The sleeve gastrectomy cannot be reversed as some 75% of the stomach is actually removed; however, someone could potentially reverse the effect of surgery if he/she stretches the stomach over time and increase their portion size and calorie intake.

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What is the follow-up after the operation?

Our team that includes the surgeon, the dietician and the bariatric nurse will see you at regular intervals after the surgery within a structured follow-up program, and for up to two years as minimum. This often involves reviews at 6 weeks, 3 months, and then 6-monthly, but more often if necessary and particularly so after the gastric band in order to perform band adjustments and achieve an optimal degree of restriction.

Surgery is but one piece of your lifetime commitment to weight control and altered habits. Psychological counseling are available after surgery as needed.

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Will I need blood tests after the surgery?

If you had a sleeve gastrectomy, a gastric bypass or a duodenal switch, you will need to have regular blood tests to check on various minerals and vitamins and to ensure all is in order and that you are not anaemic. We will do these blood tests during the initial 12 months after surgery, and then we ask your GP to check these every year. You should also continue to take the recommended supplements.

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Will I need to have my gallbladder removed?

Obesity as well as weight loss by any means (including diet) promotes the formation of gallstones. If you are known to have gallstones before your operation, then it is our preference to remove the gallbladder at the time of the gastric bypass or sleeve gastrectomy, but prefer not to do so at the time of gastric banding least the band might get infected.

If, on the other hand, you are not known to have gallstones, then there is a 10-15% chance that you will develop gallstones after weight loss surgery and this will require a keyhole operation to remove the gallbladder.

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I am a diabetic; should I continue to take my diabetes medicine?

It is not uncommon for diabetic patients, particularly those who have had diabetes for five years or less and who were taking tablets rather than insulin to control their diabetes, to find that they no longer need treatment for their diabetes (this is called “remission of diabetes”). This happens gradually as the extra weight comes off. The chance of remission of diabetes is approximately 40-50% with the gastric band, 60-65% with the sleeve gastrectomy and 80-85% with the gastric bypass. In fact, it is common that we halve the dose of insulin or discontinue it and stop metformin and/or other tablets immediately after gastric bypass surgery.

It is important therefore for you to see your doctor regularly during the first 12-18 months after the operation to check your blood sugar. Your doctor will then decide whether the dose of your diabetes medicine should be reduced. This is important as your blood sugar may otherwise drop quite low (hypoglycaemia), which can be dangerous.

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Will I need plastic surgery?

A variety of factors including your starting weight, weight loss that you have achieved after surgery, location of excess weight and your age influence the need for plastic surgery. In general, skin elasticity is greater in younger patients and the need for plastic surgery is less. You may need an operation to remove what might become a very saggy abdominal skin (apronectomy) after your weight has leveled. This is usually two years after surgery. Some might also require arm and thigh lifts and cosmetic breast surgery.

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Can I become pregnant after bariatric surgery?

Yes. Thousands of women have become pregnant after bariatric surgery. We recommend that women of the childbearing age should practice contraception during the initial 12 months after surgery and preferably for up to 18 months until the weight loss has leveled, particularly if they have had a gastric bypass or a sleeve gastrectomy. This is because of concern for the nutrition and growth of the baby if the mother is still losing weight during pregnancy. This advice is also applicable to women who are infertile due to polycystic ovary syndrome; we have had a number of such women who didn’t follow advice and became pregnant within 3-6 months of gastric bypass surgery, though fortunately they had normal babies. We recommend that pregnant women who have had a gastric bypass should take one Pregnacare and one Pregnacare plus every day during pregnancy and should stop the iron tablets during the initial three months of the pregnancy. Women who have had a gastric band should have it fully deflated during pregnancy.

For further reading on pregnancy after gastric bypass surgery, click on the following articles:

Effective treatment of polycystic ovarian syndrome with Roux-en-Y gastric bypass

Read Monica’s story

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What does the aftercare include?

Our after care includes the following:

  • A 30-day price package guarantee*, so that should you require longer hospital stay, further tests or additional surgery in the very unforeseen circumstance and within the initial 30 days after your weight loss operation you won’t be charged any extra!
  • Regular follow up for two years with the surgeon, bariatric nurse and dietitian (additional longer-term follow up could be arranged at request for an added fee)
  • Blood tests following gastric bypass and sleeve gastrectomy at 6 and 12 months after surgery.
  • Three radiological and unlimited bedside band adjustments during the initial two years after surgery (additional radiological adjustments might be recommended to you if clinically indicated and will attract a fee of £150 per adjustment)
  • Email access to the surgeon for consultation and advice on long-term basis

*Terms and conditions apply

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How many operations have you performed? And what is your complication rate?

Professor Basil Ammori

Other Surgeons and Centres

Conversion from laparoscopic to open surgery

Professor Basil Ammori

0%

Other Surgeons and Centres

1-5%

Mortality

Gastric band

Professor Basil Ammori

0%

Other Surgeons and Centres

0.1-0.2%

Sleeve gastrectomy

Professor Basil Ammori

0%

Other Surgeons and Centres

0.0-1.0%

Gastric bypass

Professor Basil Ammori

0.18%

Other Surgeons and Centres

0.2-1.0%

Leak rate

Sleeve gastrectomy

Professor Basil Ammori

0%

Other Surgeons and Centres

1-5%

Gastric bypass

Professor Basil Ammori

0.25%

Other Surgeons and Centres

1-5%

Professor Ammori has performed over 3000 laparoscopic bariatric procedures including 1600 gastric bypasses, 500 sleeve gastrectomies, and 900 gastric bands

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Do I need to take any medications after leaving the hospital?

If you had the gastric bypass operation, then you will have been started on some tablets whilst in hospital, which you will go home on and which you need to keep taking. These consist of vitamin, calcium and iron supplements, to guard against dietary deficiency and a tablet called ranitidine (trade name Zantac), which reduces the amount of stomach acid that you make. All of these tablets can be bought over the counter at the chemists, but the ranitidine is much cheaper by prescription.

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What type of diet will I have after the operation?

If you had the Lap Band procedure, then you will be allowed drinks on the same day of the operation, and may take liquid and soup the following day.

If you had the Gastric Bypass operation, then your new stomach will be X-rayed 1-2 days after the operation, and provided that there are no problems you will then be able to take oral fluids. Immediately after the operation there is some swelling around the new opening between the new small stomach and the intestine, and initially only finely minced or pureed food can leave the pouch. Also, there is always some swelling in the wall of the new stomach pouch, and for that reason the restriction for food is very strict at the beginning; just a few teaspoons of food will make you feel full. Gradually you will be allowed to increase what you eat and will be given thin soup at meal times. Your dietitian will arrange small portions of pureed meals for you. It is essential that only 1-2 teaspoons, in total, of pureed food is eaten at each meal. Too large a portion or food that is too thick may cause discomfort or even vomiting.

With time there is some ‘give’ and the stomach pouch allowing you to eat larger amounts of more solid food, but there will always be a restriction to what you can eat at a mealtime. With time you will get used to how much you can eat at one meal. You will find that hunger pains are a thing of the past and your appetite will be much reduced. You will still enjoy your food but adopting a sensible and healthy eating pattern now will ensure that you get the most from the surgery. Eating in restaurants can be difficult. Most patients find that choosing a starter and a dessert avoids leaving large amounts of food on the plate.

When you are discharged the pureed diet should be followed for a further 4-6 weeks. The exact length of time varies and some people feel comfortable to increase the range of foods earlier than others.

Right from the start it is important to get into good eating habits. From the day of the operation you have to try to clear your mind of what you were able to eat before – things are very different now. We see the post-operative period as a learning period, from a fresh starting point – almost like weaning an infant. It is very important to realize that the body will take time to adapt to the changes of the operation and it is wrong to rush ahead through the different stages, which are described later. It is much better to go slowly and you are much less likely to need to go back a step if you do this. Eating too much or the wrong type of food will cause bloating, discomfort and occasionally sickness, but this can be avoided by following the rules. There is a lot of trial and error and if a particular food does not agree with you, avoid it and try it again a couple of weeks later and it will probably be fine. Long term, food intolerances are very uncommon.

The following points should be kept in mind:

Have an adequate supply of nutrients including protein, fluid, vitamins and minerals. a) Since you are unable to eat a large amount of food at one time, it is necessary to eat 4-6 meals a day to meet your nutritional needs.

b) Foods high in protein such as milk and meat are very important to aid the healing process after surgery and should be taken in the recommended amounts each day. If you find it difficult to eat pureed meat or fish have more of the protein as milk or dairy products.

c) It is essential to take your vitamin and mineral supplements each day. Take these with water as tea or coffee can reduce the absorption of essential nutrients.

All foods should be an applesauce consistency or pureed to this consistency.

Take fluids between meals only and sip these slowly. You won’t be able to drink a full mug in one go to start with, so have several small cups instead.

Try to drink a pint more fluid than you used to each day to make up for the water contained in food.

Fizzy drinks should be left to go flat before drinking.

Eat slowly and stop eating as soon as you feel full; that extra spoonful might be too much.

If you have problems with a particular food stop eating it for a few days and then try again. Many people find fish and eggs difficult to start with; so don’t worry if you cannot get on with these foods initially. You may find that your tastes change after the operation and you no longer enjoy food that you used to like. Experiment with other foods as you may now like them.

Pureed food can be very bland. After the first few weeks use herbs and spices to make it more interesting.

Do not eat sweets, chocolates or high fat snacks such as crisps as these may cause ‘dumping’ and/or diarrhoea, and will slow down the rate of weight loss.

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Can I exercise after the operation?

A month following your operation you should get into the habit of taking regular exercise such as swimming, brisk walking/jogging, or visiting a gymnasium; aim for at least 30 minutes a day, 3 times a week. It is safe to use toning tables after 6 weeks. You will notice that your ability to exercise improves very rapidly after the surgery. Apart from speeding up the weight loss by burning off more calories, exercise reduces blood pressure and blood cholesterol and improves muscle tone, which reduces the problems of sagging skin. Unfortunately, the operation does not cure the offensive and unkind attitude of some people towards those with a serious weight problem, but as patients get lighter they become less self conscious about their appearance and find swimming or jogging in the park more acceptable whereas before they might have been embarrassed and avoided it. Most people are able to return to work after 2-4 weeks. Driving should be avoided for two weeks after you get home.

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How much weight will I lose?

After the gastric bypass operation, weight loss is initially very swift – most patients will lose a stone a month. This will slow down with time as you approach your target weight. Weight loss after the gastric banding operation is slower, but can be increased by adjusting the band.

Patients are individual people and no two are the same. Of course different patients need to lose different amounts of weight and the dimensions of the bypass are adjusted to take this into account. As a rule of thumb however, most patients will lose about two thirds of their excess body weight in the first year, and about half of the patients will halve their weight after 12-18 months. After about 18 months the weight will probably have leveled off and most people are happy with their weight at this stage. It is possible to lose more weight by a combination of regular exercise and additional dieting usually by reducing high calorie snack foods or fluids rather than reducing the meal size. Unlike ordinary dieting, where weight is regained very rapidly when the diet stops, weight loss after the surgery is more permanent and once lost, weight tends to stay off.

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Will I ‘overshoot’ and get too thin?

This has not been a problem with any of our patients. The operation has been designed to reduce the calorie intake to a level that is adequate to nourish the patient at their correct body weight. The weight will fall until this point is reached, and will then stabilise.

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