University College Hospital

Comparing various Bariatric proceduresCentre for Weight Loss, Metabolic and Endocrine Surgery

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If you need a large print, audio or translated copy of the document, please contact us on 020 3447 9419. We will try our best to meet your needs.

ContentsPage

1. Introduction 5

2. Bowel Cancer Screening Programme. 5

3. Why choose University College London Hospitals? 5

4. Committing to bariatric surgery 6

5. Decision on who should undergo surgery 6

6. Alternative to surgery offered at UCLH 7

7. The bariatric multidisciplinary team (MDT) 8

8. Laparoscopic gastric bypass 11

9. Laparoscopic sleeve gastrectomy 12

10. Laparoscopic gastric band 13

11. Appointments and follow up 14

12. Self-assessment 15

13. Summary of care 17

14. The path to surgery 19

15. Patient support 20

16. Further information 20

17. Contact details 21

18. How to find us 22

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1. IntroductionThis booklet is designed to help you understand the different bariatric surgical options available at University College London Hospitals NHS Foundation Trust. We hope that after reading this booklet and speaking with the team you will have a better understanding of what bariatric surgery involves. You will also be well informed about the benefi ts and risks of bariatric surgery.

2. What is bariatric surgery?Bariatric surgery is also known as obesity surgery or weight loss surgery. Bariatric operations are designed fi rstly to improve your health and reduce the risks of future illness, and secondly to help you reduce your weight. The procedure works to regulate the amount of food your body can absorb by effectively reducing the amount of food that you can consume. Bariatric surgery is not the same as procedures that remove fat from the body such as liposuction or abdominoplasty.

3. Why choose University College London Hospitals?University College London Hospitals (UCLH) has invested in creating a truly multidisciplinary (MDT) bariatric team to provide a world-class service to patients seeking to undergo surgery. All members of the MDT have extensive experience in bariatric surgery. More than 350 bariatric procedures are performed in UCLH every year.

The MDT comprises surgeons, anaesthetists, specialist nurses, dietitians, psychologists and physicians; who all work together to ensure patients receive the highest standard of care before, during and after their surgery.

In October 2009 UCLH received an “Excellent” rating, respectively in quality of services and use of resources, by the Care Quality Commission (CQC).

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In March 2010 the CQC awarded UCLH registration without condition under their new, tougher healthcare monitoring system. In December 2006, in partnership with University College London (UCL), UCLH became one of the United Kingdom’s fi ve comprehensive biomedical research centres.

We are a member of University College London (UCL) Partners which brings together fi ve of the UK’s world-renowned medical research centres and hospitals. UCL Partners comprises of UCL; Great Ormond Street Hospital for Children NHS Trust; Moorfi elds Eye Hospital NHS Foundation Trust; the Royal Free Hampstead NHS Trust; and UCLH. UCL Partners was offi cially designated as one of the UK’s fi rst academic health science centres by the UK Department of Health in March 2009.

4. Committing to bariatric surgeryMaking a decision to undergo bariatric surgery is a serious step and it is important that you fully understand what it will involve and the changes that you will need to make to your lifestyle. Bariatric surgery is a tool for health improvement and weight loss but it is not a cure. Weight loss after surgery requires commitment and motivation on your part; it is not a quick fi x.

In order to achieve the best results from surgery and also to avoid side effects, you will have to commit to the recommended changes to your diet and lifestyle; you will have to maintain these changes for life. This is not always easy but as a team our aim is to help you make these changes.

5. Decision on who should undergo surgeryNot all patients who are referred to our service will eventually undergo bariatric surgery. Some patients will be found to be unsuitable for bariatric surgery within the National Institute for Health and Clinical Excellence (NICE) guidelines.

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The fi nal decision about proceeding to surgery is made at our multi-disciplinary team (MDT) meeting. The team meets once a week to discuss patients who have completed their bariatric assessment and to decide whether a patient is suitable for surgery based upon the risks and likely benefi ts of surgery to the patient. After the meeting the MDT will write to you and recommend which surgery would be the most suited for you based on your assessment and your preferences. The MDT might recommend a surgery different from one that you have indicated a preference for.

Not all patients will be accepted for surgery. Reasons for not proceeding with surgery may include: pre-existing medical conditions which would make the risk of surgery too high; or current and severe mental health diffi culties or eating disorders, where the team feel that treatment prior to surgery would be benefi cial. If this is the case, the clinical psychologists in the team will attempt to facilitate the appropriate treatment.

If you are turned down for surgery it does not necessarily mean that you will not be considered in the future. Sometimes we will recommend further treatment to help improve your medical or mental health, after which the MDT will review your case again in the future.

6. Alternative to surgery offered at UCLHIntensive Weight Control Programme (IWCP):This programme is for people who are obese and whose weight is affecting their health. It aims to help you lose weight through diet, exercise and lifestyle changes. You may also be prescribed drugs that have been licensed for treating overweight and obesity. The programme is based upon research that has been done over the past 20 years. It has been assessed for safety and for successful weight loss (on average 12% weight loss in patients who complete the 24-week programme). Some patients may be offered the IWCP as part of their preparation for surgery.

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Some patients decide to try the IWCP if they don’t feel ready for surgery at this stage. If you would like to know more about this specifi c pathway, please ask one of the team.

7. The bariatric multidisciplinary team (MDT)The bariatric multidisciplinary team (MDT) is a group of specialists whose main aim is to ensure you get the best treatment in order to lose weight safely and effectively.

Administration and management:A team of pathway assistants (PA) and managers will organise your appointments and admission to hospital. If you are not able to make an appointment on a given date please contact the PA as soon as possible (contact details at the end of the leafl et).

Anaesthetists:The anaesthetic team is made up of anaesthetists who have experience specifi cally in bariatric surgery. It might be necessary for you to meet an anaesthetist before your surgery at the pre-assessment appointment. Patients who are usually referred for anaesthetic assessment include those with complex medical histories. The majority of patients proceed to surgery without the need for anaesthetic assessment; so in most cases the fi rst time you will meet the anaesthetist will be on the day of surgery. He or she is responsible for the anaesthetic that will be administered during the operation and will ensure that any pain is well controlled afterwards.

Bariatric surgeons:There is a team of experienced Bariatric Surgeons within the MDT. You will meet a member of the surgical team at your fi rst pre-assessment appointment; however, this may not be the surgeon who will eventually perform your surgery. We will make every effort to accommodate your wishes if you prefer a specifi c surgeon; however, we cannot guarantee that you will be operated on by the surgeon of your choice.

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Bariatric Physicians:The MDT also has a team of endocrinology and obesity specialist physicians that will assess you medically if needed. For example, this may be done to improve or optimise your treatment if you have conditions related to obesity such as type 2 diabetes. Our physicians are also available to help with post-operative management, and to run the medical treatment aspect of the service.

Clinical Nurse Specialists (CNS):There are 2 full time bariatric nurse specialists within the MDT; their role is to help you prepare for surgery through assessment, education and information giving. You will meet them at your fi rst bariatric assessment and subsequently for your pre-assessment for surgery. You will also meet them at the fi rst follow up appointment after surgery. They are available to speak to on the telephone to provide advice and support throughout your bariatric journey.

Clinical Psychologist:Clinical psychologists working in our team understand that patients have a medical need for bariatric surgery. They aim to use their expertise to assist patients in preparing for surgery and to achieve the best outcome possible. Before surgery you may be invited to meet with the psychologist for an initial consultation, lasting approximately 50 minutes. At the end of this meeting a set of recommendations may be made and it is possible that you may be offered some additional individual sessions. Psychologists also meet with patients in the post-operative period for a variety of reasons, including providing support in adjusting to new eating habits and changes in body image. These appointments can be arranged at your routine follow up with the other members of the team.

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Dietitian:There are 2 full time Dietitians within the MDT. The dietitian’s goal is to help prepare you for the dietary and lifestyle changes that you will need to make in order to achieve the best outcome from surgery, and to support you with these changes after surgery. You will meet the dietitian at your fi rst bariatric assessment, at pre-assessment before surgery, and at 3 and 6 9 months post-surgery.

The type of support offered by the dietitian can involve the following:

• Helping you to prepare for the dietary changes you need to make for successful weight loss after surgery;

• Providing you with information and support for the pre-operative 2-week diet;

• Supporting you with eating and drinking after surgery;

• Helping you make changes to your eating behaviours to ensure long term weight loss;

• Helping you to maintain motivation with regard to changing eating behaviours after surgery.

Research:There is an active research team at University College London which is looking into a variety of subjects related to bariatric surgery. When you attend a clinic appointment you may be asked if you would like to take part in one of these studies. Participation is voluntary and will not affect the MDT’s decision about your surgery.

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8. Laparoscopic gastric bypass

How it works • Moderate restriction of portion sizes. • Alters blood levels of hormones that regulate

body weight• Most patients experience a loss of appetite. • Sometimes unable to eat sweet foods

(dumping syndrome)Surgical risks • Risk of death: <1:500

• Complications within 28 days of your procedure = 2 - 5%

Hospital stay • 1 or 2 nightsRecovery • 1 to 2 weeksExpected weight loss at 18 months

• 50–75% excess (30–40% absolute) weight loss, usually occurs within the fi rst 12 months

Long term effects • Type 2 diabetes is put into remission in 70% of patients.

• Appetite should remain less than before surgery.

• Healthy diet and lifestyle essential for success.Possible long term problems

• Nutritional defi ciency: lifelong supplements are needed to prevent this.

• Gall stones. • Weight regain.• Loose skin – this is a permanent problem, it

can only be resolved by surgery.• Hernia.

Dietary Supplements

• Calcium, iron and multivitamin tablets. • Vitamin B12 injections 3 monthly.

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9. Laparoscopic sleeve gastrectomy

How it works • Moderate restriction of portion sizes• Most patients experience a loss of appetite

Surgical risks • Risk of death:<1:500• Complications within 28 days of your

procedure = 2–5%Hospital stay • 1 or 2 nightsRecovery • 1 to 2 weeksExpected weight loss at 18 months

• 50–75% excess (30–40% absolute) weight loss, weight loss usually occurs within the fi rst 12 months.

Long term effects • Type 2 diabetes usually improves signifi cantly within the fi rst year.

• Five-year outcome data similar to bypass• Long-term results are not yet known as this

is a new procedure. • Healthy diet & lifestyle essential for success.

Possible long term problems

• Weight regain. • Gallstones. • Acid Refl ux. • Loose skin – this is a permanent problem

which can only be resolved by surgery.Dietary Supplements

• Calcium, iron and multivitamin tablets. • Vitamin B12 injections 3 monthly.• For fi rst year after surgery and then altered

according to blood test results

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10. Laparoscopic gastric band

How it works • Variable restriction of portion sizes• Little loss of appetite

Surgical risks • Risk of death: 1:2000• Complications:

- Within the fi rst 28 days: 1 in 100 - Within 5 years of surgery: 1 in 5 (20%)

Hospital stay • Less than 24 hoursRecovery • 1 to 2 weeksExpected weight loss at 18 months

• 50% excess (25% absolute) weight loss. • Weight loss slower than both sleeve and

bypass and can take up to 2 to 3 yearsLong term effects • Band adjustments in the bariatric clinic

necessary for weight loss.• Majority of weight lost over a period of 2-3 yrs. • Type 2 diabetes will hopefully improve with

band related weight loss. • Healthy diet and lifestyle essential for

success.Possible long term problems

• Band Failure: 1 in 20 • ‘Flipped port’: 1 in 50 • Slippage: 1 in 20 • Erosion: 1 in 50 • Band removal: 1 in 10 • Loose skin – this is a permanent problem

which can only be resolved by surgery.Dietary Supplements

• May need multivitamin/ iron/ calcium supplements.

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11. Appointments and follow upIt is extremely important that you attend all your appointments; non-attendance can result in you being discharged from our service according to Trust policy. These appointments are an important aspect of your treatment and will help you get the most out of your surgery. If you cannot commit to attending appointments you should not be considering bariatric surgery.

The one-stop clinic:The fi rst assessment is usually at the one-stop clinic (the visit will take around 4 hours) where you will be assessed by the dietitian, clinical nurse specialist and surgeon. You may also be seen by a physician at this visit. You will be asked a number of questions about your medical history, weight loss history and eating habits. You will also be provided with information to help you decide the operation which best suits your expectations, your lifestyle, eating habits, medical conditions and physical anatomy. Please bring a list of all your medications to this visit.

Note: The average time that it may take from your one-stop appointment to the day of surgery is 8 months; the minimum time that it may take is 3 months.

Assessments you may require following the one-stop clinic: 1.Sleep studies to screen for obstructive sleep apnoea;2.Psychology – some patients will see the psychologist on a one to one basis for more individualised support;3.Haematology – this is to assess your risk for blood clots and to provide advice on how best to prevent these;4.Physician – in the event that you require medical review.

After the initial appointment your case will be discussed at our multi-disciplinary team (MDT) meeting and you will be informed of the team decision regarding surgery after this meeting by letter.

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Pre-assessment: You will attend a presentation to help you prepare for surgery and will have an assessment by the nurse specialist. You will have a blood test, an ECG and a breathing test at the appointment. You may also be referred to the anaesthetist.

Follow up appointments after your procedure:• Contact by telephone on the Monday after the operation;• 4 weeks - appointment with nurse specialist;• 8 weeks –appointment with nurse specialist• 12 weeks - appointment with dietitian, blood test;• 6 months - appointment with nurse specialist, blood test if required;• 9 months appointment with dietitian and blood test if required• 12 months – appointment with CNS or surgeon or dietitian and

blood test.• Yearly appointment with member of the team and blood testFinally, you can request an appointment with one of our clinical psychologists at any point during the follow up period. This can be arranged via our administrator or at one of the above appointments.

12. Self-assessmentHaving health-related problems can affect many aspects of a person's life. The physical challenges are often the most obvious and are the focus of any treatment, you may have concerns or issues you want to discuss with us in addition to your diagnosis and treatment plan. This leafl et has been designed to help you do that. If you do not wish to complete the form, this is ok. If you do choose to complete it, please bring it to your appointment to discuss with the Bariatric team. If you have any questions about this process then please discuss with a member of the team at your appointment. Note: It can be helpful to think about the things that you would like to talk about during your appointment. Take some time to think about what these things might be. We may be able to answer your questions or direct you to additional advice and support.

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The boxes below may help you when thinking about this:

Practical issues Relationships Housing Financial Transport

Work/School/Study

With children With partner With family/friends

With other

Emotional concerns Spiritual concerns Anger/frustration Anxiety/nervousness Depression/sadness Worry about the future

 

Loss of faith Loss of meaning/purpose to life

Physical problems and symptoms Appearance Bathing/dressing Breathing problems

Changesin urination

Changesin bowel habit

Diffi culty sleeping Eyesight changes Eating/appetite

Fatigue/tiredness Feeling sick Feeling swollen Feverish/hot fl ushes

Getting around Hair loss Hearing problems Indigestion Itchy or dry skin Memory/concentration

 

Mouth sores/ulcers Nose dry/congested

Pain Sex Fertility Tingling Hands Weight gian/loss

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I would also like to ask about:1)

2)

3)

13. Summary of careHeaviest ever: Weight: __________ Height: __________Important medical conditionsCondition Present/Absent Date resolvedType 2 diabetes

Hypertension

Disturbed Lipids

Fatty liver disease

Sleep apnoea

Arthritis

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Events leading up to surgeryEvent Date Weight CommentFirst Appointment

Surgery Type

Events / Appointments after surgeryEvent Date Weight Comment

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One–two months

One–three months

One–twelve months depending on further investigation, anaesthetic review/waiting list

Average time to surgery from fi rst appointment: eight months

One Stop Assessment clinic

Referral received

Further investigations/

treatment/preparation workshops

recommended

Approved for surgery

Pre-assessment and surgical date

bookedReview with bariatric

anaesthetist

Discharged to care of GP

Turned down for surgery

Surgery

Multidisciplinary Team Meeting

No further discussion required

Other assessments e.g

sleep studies, blood pressure,

psychology

14. The path to surgery

15. Patient supportWe run voluntary monthly meeting for patients considering surgery or who have already had surgery. Please ask the clinical nurse specialists for details of these.

The support group is a good chance to meet other patients who have had surgery or are awaiting surgery. You are welcome to attend any of these sessions along with your family members. There will be a different topic or theme at each session; and there may also be guest speakers.

Support groups are also organised by British Obesity Surgery Patient Association (BOSPA) and Weight Loss Surgery Information.

16. Further informationBritish Obesity Surgery Patient Association:Website: www.bospa.org

Weight Loss Surgery Information & Support: Website: www.wlsonfo.org.uk

Association for the Study of Obesity: Website: www.aso.org.uk

National Obesity Forum:Website: www.nationalobesityforum.org.uk

British Obesity & Metabolic Surgery Society: Website: www.bomss.org.uk

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17. Contact detailsAddress: UCLH Centre for Weight loss, Metabolic and Endocrine Surgery University College London Hospitals Ground Floor West Wing 250 Euston Road London. NW1 2PG

Switchboard: 0845 155 5000Surgical PA Direct Line: 020 3447 9419 Medical PA Direct Line: 020 3447 4962Clinical Nurse Specialist: 07943 826 528 or 07852 221 166Dietician: 07904 912 441Ward: 020 3447 0900Fax: 020 3447 9217Email: Bariatric@uclh.nhs.ukWebsite: www.uclh.nhs.uk

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18. How to fi nd usWe are based at University College HospitalNo car parking is available at the hospital. Street parking is very limited and restricted to a maximum of two hours.

Please note the University College Hospital lies outside but very close to the Central London Congestion Charging Zone.

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Space for notes and questions:

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First published: July 2012Last review date: September 2014Next review date: September 2016Leafl et code: UCLH/S&C/GI/BAR/COMPARING/2© University College London Hospitals NHS Foundation TrustCreated by Medical Illustration RNTNEH 020 3456 5103 Unique Code: 28546