Weight Loss (Bariatric) Surgery Pathway

  • Reference Number: HEY-867/2017
  • Departments: Bariatric Surgery

Introduction

This leaflet has been produced to give you general information about the weight loss surgery service at Castle Hill Hospital.  The service is provided by Hull and East Yorkshire NHS Trust and is funded under strict criteria by NHS England and Clinical Commissioning Groups. This is based on NICE CG189 / CG 43 and Clinical Commissioning Policy Complex and Specialised Obesity Surgery (NHS England/A05/P/a).

Only patients who have met with their GP and found to have a Body Mass Index (BMI) more than 50 can be referred directly to the bariatric service for assessment.  If accepted, patients must complete 6 months of assessment and stabilisation preparation within the service before an operation can be performed.  Those patients who meet NICE criteria for bariatric surgery with a BMI of 49 or below need to be referred for a minimum of 12 months under the supervision of a Tier 3 Weight Management Programme before referral to Tier 4 Bariatric Surgery Service can be accepted.

Specific Information about the types of operations and dietary advice are provided in separate leaflets.

Is weight loss surgery right for me?

You have probably struggled with your weight for a long time and tried several different methods to lose weight.  After careful consideration and consultation with your GP you have requested referral to the bariatric surgery service for assessment as to whether surgery can help you to lose weight and help prevent weight regain in the future.  This surgery may also help with other medical conditions, which your surgeon will discuss with you.

What will happen at my first appointment?

You will be invited by letter to attend a specialist bariatric clinic, during this first visit you will see the bariatric specialist nurse, who will talk to you about how the service works, explain the bariatric pathway and will outline who you will see and when.  You will also be seen by the specialist dietitian who will talk to you about dietary changes before surgery.

Lifestyle, emotional factors and historical events can all contribute to weight gain and not being able to lose it.  You will meet or be contacted by a psychology professional at this appointment.  Evidence tells us that long-term weight loss surgery results are far more successful when patients are seen and supported by a trained psychological professional.

The final person you will see at this initial visit is the bariatric surgeon; they will discuss your surgical options and speak to you about issues which are specific to you, for example, weight history and medical problems.  You will be able to ask any questions or discuss any concerns you may have about surgery.

Your first appointment may take 2-3 hours as you will see four different members of the bariatric team.  Future appointments will not be as long and we will always try to keep your waiting time to a minimum.

What happens after my first appointment?

After your first appointment at the specialist bariatric clinic you will be asked to complete the following:

  • Attend your local weight loss support group for further help and information. This allows you to speak to patients who have had weight loss surgery, which may help you to understand what it is truly like to live with the experience and effects of this.  The bariatric specialist nurse will give you the information required to access the group.
  • You will see the dietitian at least twice, once as part of a group and then on a one-to-one basis. This will help you make essential changes to your diet so that it is suitable before surgery and also after your operation.  To make appointments with the dietitian, you should ring telephone number (01482) 674133.
  • If your health is not considered safe for surgery, the surgeon may request that you see another specialist for treatment prior to you having your operation. This could be a cardiologist, anaesthetist or psychology professional for example.
  • You will be expected to lose some weight prior to surgery. We realise this may be difficult for you, but if you show the commitment by following the dietary advice given to change your diet prior to the operation, some weight loss will be possible.
  • For bariatric surgery to receive funding, NHS England expects all patients to be within the surgical pathway for at least six months prior to going on to the waiting list. This is described as the stabilisation and assessment period.

If you put on weight at any time after your first appointment, or do not complete these steps, we may suspend or cancel your surgery.  The period between your first appointment and second is usually 2 – 3 months to allow you to complete these arrangements.   If you do not attend a follow up appointment and fail to notify us or cancel it, you will receive a letter discharging you back to your GP.

When will I have my surgery?

After you have completed the assessments by your surgeon, dietitian and psychological professional, the bariatric team meets as a multi-disciplinary team (MDT) to discuss your progress.  Here we individualise your care and ensure:

  • You are making lifestyle changes and losing weight
  • You are preparing for the effects of surgery
  • You are as fit as possible for surgery

You will then be invited back to the clinic to discuss the MDT’s recommendations.  Should any further care, tests or changes be required, we will discuss these with you. If we are satisfied that you are in a position to move forward with surgery, you will then be asked to make an informed decision as to which operation you would like to have.

At this point, your name will be added to the waiting list for your operation and you will be provided with a 2-stage consent form (see section on “General Advice and Consent” under specific operation information sheets). This has detailed information on the risks of surgery and we would like you to read and sign each section of this before your operation.  It is not possible to tell you exactly how long you will have to wait, but we are committed as a Trust to try to provide your surgery within 18 weeks after you have completed the required 6-month stabilisation period.

Pre-assessment and the pre-operative diet

You will be contacted by the waiting list clerk with a date for your surgery.  Your pre-assessment appointment will also be arranged for you which will take place about 4 weeks before your surgery date.  At this appointment you will have a full blood and health screen to make sure you are in good health prior to your anaesthetic.  You will be able to ask any questions you may still have.

You will be advised when to start the 2 week liver shrinking diet; you will be required to complete this before coming into hospital for your surgery. This diet is very important as it will help to reduce the size of your liver prior to surgery to ensure your liver does not get in the way of your stomach, which will allow your surgeon the room needed to operate on you successfully.  A separate information leaflet will be made available to you, which summarises the liver shrinkage diet options.

You will be sent a letter asking you to come to a ward the afternoon before or the day of surgery and if everything progresses as planned, you will spend two further nights in hospital after your operation.

You must commit to being followed up in the clinic for at least 2 years after your surgery; this will usually be with the bariatric specialist nurse.  You will be given a patient information leaflet on what to expect after surgery.

Bariatric Specialist Nurse

You will be visited on the day of your operation and the following day by the bariatric specialist nurse who will discuss any concerns or queries that you may have. The bariatric specialist nurse will contact you at home by telephone within two weeks of your discharge to discuss your progress and any ongoing concerns that you may have.

Your stay in hospital after weight loss surgery

When you have had your surgery, you may spend some time within the recovery area of the operating department.  The team make sure you are not in pain and awake enough to be transferred to the High Dependency Unit (HDU) where nursing staff can monitor you carefully, usually for your first night after surgery. You will have your blood pressure and other vital measurements taken regularly throughout the night.

When you need to use the toilet, a nurse will help you get up to go if necessary. A catheter is NOT routinely needed. It is important to start moving and walking as soon as possible after your operation, to reduce the chance of a blood clot or a chest infection developing.  You will be wearing compression stockings and/or mechanical compression boots to encourage circulation after surgery.

Please make sure your friends and relatives are aware you will not be on the ward for your first night after surgery and that it is normal to spend your first night after surgery on HDU.  You will be transferred to the ward and you will stay a further 1 – 2 days until you have a completed a normal swallow test and started your diet plan.

Post-operative swallow test

Shortly after your operation, on the first or second day usually, you will have a contrast swallow test, which is an X-ray test where you will be asked to swallow some colourless liquid (contrast), which then passes through your stomach and bowel and can be seen on X-ray.  It will show the doctors if there are any leaks or blockages.  Once this is confirmed to be normal, you will be able to start drinking and eventually start your diet plan.  Until this test is completed, you will often have IV fluids (drip), to make sure you have enough fluid in your body and therefore do not get dehydrated.

Can there be any complications or risks?

There are always risks of complications associated with surgery.  Specific information is detailed in the operation information leaflets on Sleeve Gastrectomy and Roux-en-Y Gastric Bypass.

How do I prepare for this type of surgery

Please read this information leaflet.  Share the information it contains with your partner and family (if you wish) so that they can be of help and support.  There may be information they need to know, especially if they are taking care of you following your surgery.  Before your surgery you will be given advice from your bariatric surgeon, dietitian and specialist nurse.

You will be asked to attend a local Bariatric Support Group.  The venue of this group will depend on where you live and you will be given details at your first appointment. We consider the visits to the group essential for all patients, as this will allow you to talk to other patients at different stages of the surgical process and then help you make an informed decision about your surgical choices.

You will also be given dietary advice from our specialist dietitian.  This will involve changes to your diet prior to surgery which will be necessary to help you after your operation.  A 2 weeks pre-operative liver shrinkage diet is essential to allow keyhole surgery to be performed safely and successfully this will be discussed with you at the pre assessment appointment and a diet planning sheet provided.

www.hey.nhs.uk/patient-leaflet/bariatric-surgery-pre-operative-diet/

If you have any illnesses which the surgeon feels require treatment prior to you having surgery, this will be organised and will help to minimise your risks of complications when having a weight loss operation.

Should you require further advice on the issues contained in this leaflet, please do not hesitate to contact the Bariatric Department On Tel no: 01482 624309.

For Dietetic advice contact (01482) 674133 or (01482) 875875 Extension: 3168

Important points about weight loss surgery

Pregnancy

Losing weight can result in increased fertility.  Female patients having weight loss surgery may wish to have children but must avoid falling pregnant ideally in the first 2 years after surgery, as the growing baby may be harmed by insufficient nutrition during this time.

Residual Excess Skin after Losing Weight

The bariatric service is not allowed to perform surgery for excess loose skin.  You should discuss this with your GP.  It is unusual for the NHS to fund such excess skin removal surgery and this is only by special agreement after an application by your GP.  Many patients are not unduly concerned by loose skin but for those who are, a private consultation with a plastic surgeon may be something you wish to consider.

Smoking

Smoking is a serious health risk and you must stop smoking if you wish to have weight loss surgery.  Smoking increases overall risk of complications and the specific risk of ulcer formation in the stomach, which can lead to long-term pain, vomiting and even internal leaks or perforation.

Eating and drinking after weight loss surgery

You will not have anything to eat or drink until after your X-ray swallow test and during this time you will receive fluids to hydrate you through a drip.  You may get very dry mouth; the nurses will offer you mouth washes and you will be able to gargle as long as you do not swallow anything.

When the results of your swallow test are known you will be able to start drinking, very slowly at first.  At meal times you will also be able to start to eat a soft diet.  You will not be discharged until you are managing to eat and drink successfully.

The specialist dietician may have already discussed the post-operative diet with you in detail and provided you with a written diet plan for the weeks after surgery. Alternatively they may see you on the ward. Your diet will gradually build up to more solid food.  You must avoid drinking fluids at the same time as food to avoid vomiting and side-effects of the changes in absorption.

Use the diet plan as a guide but it will be trial and error over what food you can manage at first and it takes time to get used to the earlier filling of your smaller stomach.  The first 3 months can be difficult and it is not uncommon to occasionally feel sick or regurgitate food but this should settle completely with time.

If you are unsure about your diet or fluids, ask to speak to the dietician before you are discharged from the ward, or ring up for advice if you are in-between outpatient appointments.  Do not struggle on unnecessarily; our specialist dietician/nurse will always be happy to advise you.

Discharge medication and advice

You must take the discharge medication below as outlined on your discharge letter:

  • Vitamin D and calcium (in a combined tablet) e.g. Calceos® or Calcichew® D3 Forte
  • A multivitamin A-Z complete with iron (e.g. Forceval® or other alternatives are available, please seek advice from your pharmacist)
  • An injection of vitamin B12 every 3 months at your GP practice
  • Lansoprazole 30mg (oro-dispersible) once daily for 4 weeks

Please note: ensure you leave a gap of 2 hours between taking the vitamin D and calcium combined tablet and the A-Z multivitamin.

  • 6 weeks following your surgery, your surgeon or specialist nurse may recommend that your GP commences vitamin B12 injections every 3 months, as your absorption of this vitamin is affected by weight loss surgery.
  • Ensure that you wear your compression stockings for 2 weeks after your surgery.
  • You can shower but not bathe for 1 week after your surgery.
  • Ensure that you keep your dressings clean and dry for 5 days and then remove the dressings. Most wounds are closed with absorbable stitches. If you have any bleeding, redness, swelling or excessive pain, please contact the discharging ward, Bariatric Specialist Nurse or your GP.
  • Your drain site may ooze for a couple of days after discharge but this should stop within 2 to 3 days. Additional dressings will be provided by the ward if needed.
  • Ensure that you have requested a ‘fit’ note from the ward doctor if you require one. You should expect to return to work after 2 to 4 weeks.
  • Regular blood tests will be required at intervals over the 2 year follow up period and occasionally, additional supplements will be needed if levels fall.
  • Ensure that you have your dietetic post-operative diet sheets before you are discharged.
  • Check your car insurance policy before driving. You can usually drive when you can safely perform an emergency stop and turn to look at your blind spot usually after 1 to 2 weeks providing you are not taking any medication that may affect your ability to drive.
  • Do not do any abdominal/heavy exercises for at least 6 weeks post- operative.
  • You may resume intimate activities when you are ready.
  • If you become constipated, ensure that you are drinking at least two litres of water over the course of a day in-between your meals.
  • Please speak to your doctor for advice if you intend to fly within the next few months. See also  http://www.caa.co.uk/Passengers/Before-you-fly/Am-I-fit-to-fly/Guidance-for-health-professionals/Surgical-conditions/

What must I do to ensure my operation will work long-term?

Any weight loss surgery can fail to help you lose weight if vital lifestyle changes are not made before and after surgery or end up with disappointing weight regain if these changes are not continued.  Only you can make these changes and this is why we prepare you for surgery over at least 6 months to ensure you are making the correct changes in diet and exercise to ensure it will succeed.  If we feel that you are not capable of making these changes (which is hard work) then you may not be offered surgery.

Examples of essential changes are:

  • A diet consisting of regular 3 meals per day that is low in sugar
  • Avoidance of drinking liquids with meals
  • Avoidance of snacks like crisps and sweets or sugary juices/drinks
  • Increased activity (see section on “Exercise Before and After Surgery” below)
  • Consider other ways to improve your mood or relax instead of relying on food

Exercise before and after surgery

You should try to increase your activity initially with something that is realistic and accessible.  There is no sense in joining a gym if you rarely go.  Getting out of the house for a walk for half an hour is an easy option for most people and quickly improves distance exercise tolerance.  Gardening, housework, swimming and dancing are all popular and effective ways to get your heart rate up and strength exercises such as squats (crouching down) and shoulder shrugs are simple ways to maintain posture and upper body strength.  Those with limited mobility should attempt chair-based exercises wherever possible.

General Advice and Consent

Most of your questions should have been answered by this leaflet, but remember that this is only a starting point for discussion with the healthcare team.

Consent to treatment

Before any doctor, nurse or therapist examines or treats you, they must seek your consent or permission. In order to make a decision, you need to have information from health professionals about the treatment or investigation which is being offered to you. You should always ask them more questions if you do not understand or if you want more information.

The information you receive should be about your condition, the alternatives available to you, and whether it carries risks as well as the benefits. What is important is that your consent is genuine or valid. That means:

  • you must be able to give your consent
  • you must be given enough information to enable you to make a decision
  • you must be acting under your own free will and not under the strong influence of another person

Information about you

We collect and use your information to provide you with care and treatment. As part of your care, information about you will be shared between members of a healthcare team, some of whom you may not meet. Your information may also be used to help train staff, to check the quality of our care, to manage and plan the health service, and to help with research. Wherever possible we use anonymous data.

We may pass on relevant information to other health organisations that provide you with care. All information is treated as strictly confidential and is not given to anyone who does not need it. If you have any concerns please ask your doctor, or the person caring for you.

Under the General Data Protection Regulation and the Data Protection Act 2018 we are responsible for maintaining the confidentiality of any information we hold about you. For further information visit the following page: Confidential Information about You.

If you or your carer needs information about your health and wellbeing and about your care and treatment in a different format, such as large print, braille or audio, due to disability, impairment or sensory loss, please advise a member of staff and this can be arranged.