Information for patients

Laparoscopic gastric bandingoperation

Weight-loss surgery

4Department of Surgery

IntroductionThe laparoscopic gastric band is a very effective tool to helpoverweight patients to achieve a substantial and long termweight loss. The gastric band works by restricting your portionsizes. In order to understand your operation, it may help to havesome knowledge of the digestive system.

Understanding DigestionFood is taken into the mouth and passes through the gullet(oesophagus) into the stomach, where it is eventually brokendown into a semi-solid form.

After several hours this continues into the small bowel, which isa long, coiled tube-like organ where further digestion andabsorption of nutrients takes place.

What remains then continues into the large bowel andeventually will be passed from the body as faeces.

Normal stomach

The normal bowel (Digestive System)

Mouth

StomachLiver

Duodenum

Pancreas

Small bowel(ileum)

Large bowel(colon)

Back passage(rectum)

Back passageopening (anus)

Gullet (Oesophagus)

How is the band inflated?• There is a small button called a port, which is placed under

the skin. This is usually below the rib cage and is connected toyour band by a very small tube, which is tucked into the fatlayer.

• The band is inflated by putting a fine needle through the skinand into the port.

Is the gastric band for me?The gastric band works best for people where large portion sizes are contributing to their weight. The gastric band can be less successful for people who snack, as it gives little restriction to foods such as chocolate, crisps, biscuits, cake and ice-cream.

How does the laparoscopic gastric band work?The word 'laparoscopic' means that the procedure is donethrough 5-6 very small cuts instead of one large cut on yourabdomen. It is also called 'keyhole surgery'.

Sometimes the operation cannot be performed via keyhole, and a larger cut has to be made. If this happens you may have morediscomfort after the operation. You will need to stay in hospitallonger and it will be a longer period before you can return tonormal activities.

The gastric band is placed around the upper part of the stomachto create a small pouch (size of an egg cup). Once the band hasbeen fitted it can be adjusted without any further surgery. The adjustment will depend on dietary intake and the amount ofweight being lost. This will then restrict the amount and types offood that you will be able to eat.

Your band is not inflated at the time of surgery. You will need toattend the X-ray department about six weeks after youroperation, so that fluid can be injected into the band to tighten it.

• Fluid is then injected through the port and into the band,which will make it tighter and therefore restrict dietary intake.

Fluid can also be removed from the band in the same wayshould it require loosening at any time. The amount of fluidrequired for best possible weight loss varies from person toperson. Although the amount of fluid injected is carefullymonitored, it may not be correct for all people all of the time.

The procedure works well once an adequate level of restrictionhas been established. It is important to understand that this maytake several visits to the X-ray department over a period ofmonths. During this time you need to eat healthily and followthe instructions given to you by the dietitian.

How does this operation affect eating?The gastric band restricts the amount and types of food that youcan eat and makes you feel fuller for longer. To get the mostfrom your band it is important that you make life-long, dietaryand lifestyle changes. There is no point considering thisprocedure unless you are committed to making these changesand to following the advice provided. The gastric band diet islow in fat and sugar and therefore calories.

Stomach with laparoscopic gastric band

The band will allow high calorie liquids and foods to passthrough, which may affect weight loss if you do not follow theadvice given.

What diet will I have to follow once I have had the operation?After the operation your dietitian will give you a diet sheet. For up to the first four weeks after your operation, you will beadvised to follow a fluid only diet. You will then progress to apureed, then to a soft/crispy and finally a normal textured dietbefore your band is inflated at approximately week 6. How quickly you progress through these stages will varydepending upon how quickly the swelling around your bandreduces.

Once the band has been inflated at week 6, you will be advisedto follow a pureed diet, with portion sizes of 2-4 tablespoons.You will then progress to a soft/ crispy diet and finally to a morevaried textured diet. Once your band is adequately adjusted youshould be able to manage no more than a tea plate sized portionof fairly normal textured foods. In addition to the reduction inportion sizes, there will be some foods that you may not be ableto manage in the long term. These are foods that are moredifficult to get through the band and are more likely to make yousick.

These caution foods include:

• White bread

• Boiled rice

• Pasta

• Meat

• Steak

• Nuts

• Lettuce

• Pineapple

• Fibrous fruits and vegetables, such asoranges, pineapples, green beansand mushrooms

You may be sick if you:

• eat too much

• choose the incorrect texture of food

• take food and fluid too closely together or

• if you eat too quickly.

What are the benefits of having LaparoscopicGastric Banding?This operation helps you to achieve effective long-term weight loss.

It reduces health related problems:

• Type 2 Diabetes

• Osteoarthritis

• Hypertension (high blood pressure)

• Coronary heart disease.(CHD)

• High cholesterol level.

What are the risks, consequences and alternativesassociated with having Laparoscopic GastricBanding?Most people get through their operation with few problems.Sometimes however, there may be difficulties.

As with any operation there is a risk of heart attack, blood clot orextremely rarely there is a risk of not surviving due to problemsrelated to the operation.

Risks associated with the gastric band include:

• 4-5% chance of band slippage.

• 1% chance of the band eroding into the stomach

• Problems with the port site such as difficulty accessing it for band adjustments

• Port site infections

• Band leakage

The chance of these risks occurring is small but it is importantthat you are aware of them and that you have all the informationyou need before agreeing to proceed with the operation.

The laparoscopic band is a restrictive procedure. There are othertypes of operation available, which work in a slightly differentway, also detailed in this booklet.

There is always the option of not receiving treatment at all. The consequences of not receiving any treatment are:

• further weight gain

• shortened life span

• increase in obesity related diseases (as listed under the benefits above)

• low self esteem/depression.

If you would like more information please speak to yourconsultant or the dietitian/nurse looking after you. If you wouldlike more information on counselling or weight managementprogrammes please speak to your GP.

What happens before I come into hospital?You will be sent an appointment to attend a group informationsession run by the specialist nurse and dietitian. This is an chancefor you to receive lots of information about the operation, yourstay in hospital, lifestyle changes and what happens afterwards.The dietitian will also give you information about what youshould and shouldn't eat after your operation. This session is alsoa good opportunity to meet other people who are considering

weight loss surgery. If you decide that you wish to be consideredfor surgery, you will be sent an appointment to see the surgeonfor medical assessment. You will also be given a sleep studyquestionnaire to fill in, so the anaesthetist can assess your risk forthe surgery.

Pre-Operative Assessment AppointmentYou will be asked to attend the hospital for pre-operativeassessment. At this appointment we will ask you about yourmedical history, medication and any operations you may havehad in the past. You may need to undergo some routine tests egheart trace (ECG), X-ray, blood test. You will also be weighed.

10 Day Milk and Yoghurt DietTen days before your operation date, you will be advised tofollow a milk and yogurt diet. This will shrink your liver, whichbecomes fatty and enlarged in people who are overweight. It isvery important that this diet is strictly followed. A smaller liverwill make it easier for the surgeon to access your stomach atoperation and also reduce your anaesthetic risk. If you do notfollow this diet there is an increased chance of your surgery notbeing able to be undertaken.

It is very important that you are as healthy as possible before theoperation and that you do your best to lose weight. You shouldnot gain weight as this could prevent you from having thesurgery. You will have had an opportunity to discuss theoperation with the doctors in clinic and with the specialistdietitian and specialist nurse at the group session, and hopefullyany concerns you may have will have been explained.

Stop Smoking We advise you to stop smoking before your operation. Smoking increases your anaesthetic risk.

What happens on admission to hospital?The ward is separated into bays with 4 beds in each bay. Both male and female patients are admitted to this ward, thoughthere will only be patients of the same sex in individual bays.

On admission to the ward, the doctors and nurses will answerany questions that you may have. Once you have been given allthe appropriate information, you will be asked to sign a consentform, which gives written the surgeon permission to do theoperation.

A nurse will check your temperature, blood pressure and pulse.The nurse will also check that nothing has changed with yourhealth since you were at pre assessment clinic.

You will be asked to put on a disposable gown and pants, aswell as some white/black stockings which promote blood flowthrough the deep veins in your legs, and so reduce your risk ofdeveloping a blood clot. You will be asked to wear these for sixweeks following your operation.

Other health professionals may need to see you at some timebefore the operation, including the anaesthetist, pharmacist andphysiotherapist. You may be asked if medical students can beinvolved with your care, you do not have to agree to do this.If you use a CPAP machine at night, please bring it into hospitalwith you.

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 willvisit you before your operation and discuss the anaesthetic withyou.

What should I expect after the operation?After the operation you will return to the ward. Some patientsmay be need to spend some time in the High Dependency Unit(HDU). This is a unit which provides more intensive nursing.Patients with sleep apnoea and/or respiratory complications maygo the High Dependency Unit.

You will have your pulse, blood pressure, breathing and woundschecked regularly by a nurse. It is usual to feel drowsy forseveral hours. You will be given oxygen through a facemaskuntil you are more awake.

Anaesthetics can sometimes make people feel sick. It isimportant that you tell the nurse immediately if you feel sick.They may offer you an injection which will help to settle it.You will have a drip running into a vein in your arm/ hand togive you fluids overnight/ or until you are able to tolerate morefluid.

Within the first 24 hours of your operation you will start a fluiddiet and you will be given a dietary booklet and advice from thedietitian about how to increase your intake gradually. You willneed to follow a fluid diet for up to four weeks after youroperation. This allows any swelling around the area of yourband to reduce and ensures that the band stays in the correctposition. Taking solid food too early may result in vomiting andthis may cause the band to move.

Following your operation, the dietitian will help you adjust toyour new diet, particularly in the first few months. You will begiven a detailed diet and information sheet to help with this andyour diet and weight will be checked regularly, to make sure it isadequate.

Will I have stitches?Wounds are usually stapled with metal clips to keep themtogether while they heal. Clips will be removed after 10 days.You will have dressings/large plasters covering your wounds.

Will I be in pain?Most people having this operation will experience some pain.If you do have pain it is important to tell the nurses who cangive you drugs to help.

How soon can I get out of bed after myoperation?You will be encouraged by the nursing staff andphysiotherapists to get up and move around on the same day as your operation. It is important to move around as soon aspossible after an operation in order to reduce the risk of bloodclots and to prevent problems with your chest.

When will I be able to go home?You will be able to go home usually on the day after youroperation, although if you are feeling well you may be able togo home on the same day.

How will I feel when I get home?You are likely to feel tired and need to rest during part of theday but this will improve with time.

What do I need to look out for?Check the wound for signs of infection - redness, pain, andheat. If any of these occur, see your GP as you may need acourse of antibiotics.

Your abdominal area is likely to feel bloated and sore for a fewweeks. This is normal. Take either the painkillers you were givenfrom the hospital or a mild painkiller such as Paracetamol -(follow the manufacturers instructions and do not exceed thestated dose).

When will my stitches be removed?These will be removed 10 days after your operation by yourdistrict/practice nurse.

How long do I need to be off work?We advise that you have 2-3 weeks off work depending on thetype of job you do.

How soon can I return to normal activities?We would normally expect you to take about 2-3 weeks to getback to normal activities. You should avoid heavy lifting for 2-4weeks.

Can I drive my car?Do not drive until you can wear a seat belt comfortably and feelable to perform an emergency stop. Your insurance companymay refuse to meet a claim if they feel you have driven toosoon.

When will I be able to start exercising?As you start to feel better, it is important to introduce gentleexercise such as walking. As you start to lose more weight youwill find that you feel more energetic and are able to undertakemore vigorous exercise. This will also help you to lose weightand tone muscles.

Will I need any different medication?You will be sent home with a 10 day supply of a blood thinningdrug called Clexane, which will need to be given through asmall injection into the skin on your abdomen.

Some tablets are going to be too large to get through yourband, and cause you to vomit. Your GP may already havechanged these to chewable, dissolvable or syrup form. If not,the ward pharmacist will do this where possible. In some casesthe medication doses may also change or you may be advised tostop taking some of your medication.

If you are on medication for diabetes, you may need to haveregular checks with your GP or practice nurse in order tomonitor your diet and medication.

Vitamin and Mineral SupplementsYou will need to take a daily multivitamin and mineral tablet forthe rest of your life to ensure that you are receiving all theessential nutrients.

Initially chewable or dissolvable vitamin and mineral supplementswill be required to ensure that they can pass through the gastricband. There currently is no chewable or dissolvablevitamin/mineral supplement available on prescription.

Will I need to come back to hospital?Yes. You will be sent an appointment to attend the outpatientsdepartment approximately 4-6 weeks after your surgery, so thatthe team can assess your recovery. At this appointment, if yourwounds have healed well, you will be sent to the X-raydepartment to make arrangements for your first band fill.

Following this you will be seen by the dietitian/specialist nurse at3 months, 6 months, 12 months and 2 years.

After this time you will be discharged back to your GP forroutine annual follow-up.

How will this affect my life?As you start to lose weight you will feel much healthier but, youmust remember that these changes will affect your life in termsof going out for meals, going on holiday and buying clothes.The support of family and friends is very important, particularlyif you have to prepare larger meals for other family members.

Some patients have reported taste changes after the surgery andother patients have reported some slight hair loss. It is importantthat you are aware of the long term changes that will affectyour life style and relationships with others.

Is there any additional support?There is a weight management support group meeting, whichtakes place once a month and is open to all patients who havehad this surgery and those that are waiting for surgery. It is afriendly informal meeting when patients can get together todiscuss their experiences with health care professionals, as wellas other patients. The times and dates of these group meetingsare available in the outpatient clinic or from the specialistdietitian/nurse specialist.

How much weight will I lose?It is difficult to say how much weight loss will be achieved aseverybody is different and it will be dependent on your foodchoices, exercise and achieving the right band adjustment.Weight loss with the band is expected to be approximately 1- 2lbs per week. At 18-24 months after your surgery you couldhave lost up to 40-50% of your excess body weight.

You will still have to follow a low calorie, healthy eating dietand exercise regime to achieve a successful weight loss andmaintenance in the long term.

What will happen to the loose skin that I will be left with?Many patients who have lost a great deal of weight will haveloose skin, particularly at the tops of their arms and legs andround the stomach. Referral to a plastic surgeon to remove theskin from these areas can be arranged through your GP if youmeet the referral criteria. It is important to remember that thiswill only happen when enough weight loss has been achievedand is being maintained.

Will this operation affect any future pregnancies?We do not advise you to consider becoming pregnant until atleast 12 months after your operation, in order to allow yourbody an appropriate amount of time to adjust. The band may bedeflated during pregnancy to allow optimum nutrition for youand the baby.

If you are planning to become pregnant, it is important that thedoctors, dietitian and midwives looking after you are aware thatyou have had gastric band surgery, as they will be able tomonitor both you and the baby accordingly. It is important thatyour diet is nutritionally balanced, which will keep both you andyour baby healthy.

Who will be looking after me?

Consultant Surgeon: Mr Roger Ackroyd

Consultant Surgeon: Mr Kirt Patel

Specialist Dietitian: Mrs Nerissa Walker

Specialist Nurse: Miss Liz Govan

Consultant Radiologist: Dr Fred Lee & Dr Robert Peck

Radiographer: Chris Pridmore

Anaesthetists: Dr Paul Murray & Dr Nick Barron

Useful ContactsDella Oldham (secretary to Mr Ackroyd and Mr Patel)

Tel: 0114 305 2411

Liz Govan (Nurse Specialist) Tel: 0114 226 9083

Nerissa Walker (Specialist Dietitian) Tel: 0114 226 99083

Northern general Hospital Tel: 0114 2434343

NHS DirectNHS Direct is a 24 hour nurse-led, Tel: 0845 4647 or visit theconfidential service providing web site at:general health care advice www.nhsdirect.nhs.ukand information.

Useful websites for further information:

www.bospa.org (British Obesity Surgery Patients Association)

www.wlsinfo.org.uk (Weight Loss Surgery Information andSupport)

www.british-obesity-surgery.org(British Obesity and Metabolic Surgery Society)

PD3006-PIL1024v3Issue date: Jan 2011. Review date: Jan 2013

© Sheffield Teaching Hospitals NHS Foundation Trust 2011. Re-use of all or any part of this document is governed by copyright and the “Re-use of Public Sector Information Regulations2005” SI 2005 No.1515. Information on re-use can be obtained from the Information Governance Department, SheffieldTeaching Hospitals. Email infogov@sth.nhs.uk