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Choosing the right surgical option

Which operation is right for me?

There is no straightforward answer to this question. It is likely that you will have an idea of the procedure you would prefer when you first attend the clinic. This may be based on your own research or from talking to other people who have had surgery. It is our job to provide you with the information based on our clinical experience to help you decide. It will be a joint decision between you, the surgeon and the rest of the team.

Some of the things to consider when deciding on the right choice of operation for you are:

1. How much weight do I need to lose?

You are likely to lose different amounts of weight depending on the type of surgery you choose. With a band you are likely to lose 50–60% of your excess weight, and with the bypass 65–75% of your excess weight. Your dietitian can work out for you what your expected amount of weight loss would be following each procedure.

It is important to remember that surgery will not necessarily get you back within the healthy weight range (BMI of 20–25 kg/m2), but will get you closer to it.

2. How quickly do you need to lose weight?

It is worth considering that the different types of surgery will make you lose weight over different time periods. With the bypass, the weight loss tends to be rapid with most of the weight lost over the first 6–12 months. After this it slows down and most people reach the expected target after 18 months. Following the band there is a more steady weight loss over 2–5 years.

3. What other health problems do you have?

If you have other health problems that are linked to your weight, such as diabetes, high blood pressure, high cholesterol or sleep apnoea, losing weight with surgery will help improve them. A bypass has a higher success rate than bands in curing diabetes so may be a better choice.

Certain health problems may place you at a greater risk when undergoing long anaesthetics. In this case, the band or sleeve gastrectomy may be better choices.

4. How do my eating patterns affect my choice of operation?

Your eating patterns are one of the most important factors to consider when choosing a surgery as they can affect the amount of weight you are likely to lose, and how easily you will be able to keep the weight off. Consider the following:

a) I eat lots of sweets and chocolates: If you tend to eat lots of sweets and chocolates and find it hard to change or control this, you may be more suited to the bypass. If you have a band and continue to eat these foods you are not likely to lose weight. Most people who have the bypass find that the unpleasant side effects that occur after eating sugary foods mean they start to avoid these foods altogether.

b) I eat lots of fatty, fried foods and/or I drink alcohol regularly: These foods are high in energy and make it hard to lose weight if eaten regularly. As with the sugary foods, fatty foods eaten after the bypass can give you diarrhoea which means you may end up avoiding these foods altogether. You will still be able to eat these foods following a band, and may therefore slow down your weight loss. Consider your ability to restrict these foods from your diet.

c) I eat irregularly and can go long periods between meals: With all procedures, you will tend to lose more weight if you can stick to a structured, regular eating pattern. It is particularly important to eat regularly following weight loss surgery because allowing yourself to become too hungry may result in eating too quickly and not chewing your food well. This can result in pain and vomiting if you overfill your pouch.

d) I hardly eat anything at all: If you already have a small intake, a purely restrictive procedure (eg gastric band) is unlikely to make much difference to your intake or result in significant weight loss. You may be better suited to the bypass.

e) I am vegetarian or lactose intolerant: This is important to consider if you are leaning towards the bypass or sleeve gastrectomy. Although this does not stop you from having any of the procedures, it is important that you are able to get enough protein in your diet to meet your requirements. Your dietitian will discuss with you alternative foods to ensure you are eating enough protein.

f) I don’t have any back teeth: Following the gastric band, it is important that you eat dry, crunchy foods. These foods fill up your pouch and keep you full for longer. If you need to eat liquid and sloppy meals, you may be better suited to the bypass.

g) I comfort eat or binge eat: Surgery does not stop binge eating or emotional eating or change the triggers for these. While binge eating will not necessarily prevent you from having surgery, we need to think carefully about whether it would be better to get some additional help to address this before having surgery. We can help you access this support.

A band may not be suitable if your binge eating continues after surgery. Trying to overeat with a band will cause you to be sick. Continued overeating and vomiting can lead to damage to the band or your oesophagus and may require further surgery or even removal of the band.

Other important considerations include the following:

5. I smoke

You will be advised to quit smoking. Generally we will not consider you for gastric bypass surgery if you are actively smoking because smoking is associated with higher risk of anastomotic leaks and ulceration after surgery. If you need support with this, we can refer you to the Stop Smoking Service at Chelsea and Westminster Hospital.

6. I am planning to become pregnant soon

We recommend that you do not fall pregnant while you are rapidly losing weight, for example following the bypass. During weight loss, your body may not be getting all the essential nutrients it needs for you and your baby to be healthy. We advise you wait 18 months to 2 years after surgery before falling pregnant. If you do fall pregnant, we advise you let us know so we can monitor you more closely.

It is important to remember that you are likely to become more fertile when you lose weight and so precautions need to be taken, even if you have been told you cannot have children.

7. I’m worried about the dangers of having surgery

Patients are often worried about the complications of major surgery such as the bypass. The most common risk following the bypass is a leak from one of the joins in the bowel. This can require a longer stay in hospital. If you are concerned about this, you may wish to opt for the band.

8. I’ve had previous abdominal surgery

Generally you will still be able to undergo surgery. If you have had many surgeries of your abdomen, you may need open rather than keyhole surgery. Your surgeon will discuss this with you.

9. Is the procedure reversible?

We do not consider any of the procedures reversible as reversing the procedure would result in weight regain. Reversal procedures also carry more risk than the initial procedure.

If you would still prefer a procedure that is reversible, the band may be the best choice for you as it is easier to reverse than the other procedures. However, you should not choose an operation with the intention to have it undone in the future—we will only remove the band if there is a complication because removal is likely to result in you regaining your weight.

10. I am unable to attend regular appointments

You will need to attend regular hospital appointments after your surgery to ensure everything is going well and you are losing weight safely. You will need to see the dietitian every 3 months in the first 1–2 years. This is to make sure you have adequate nutrition. You may also need regular blood tests. Following the band, you may need extra appointments for band fills.

If you cannot attend these appointments you will not be considered for surgery at Chelsea and Westminster Hospital.

11. I snore

This will not stop you from having surgery, however it is important to know that snoring can be a sign of obstructive sleep apnoea. If you have sleep apnoea, we may need to delay your surgery until your sleep apnoea is managed so that surgery can be conducted safely.

12. Will my eating patterns and lifestyle have to change after surgery?

Yes. Many people believe that surgery for weight loss will force you to follow healthy eating patterns but this is not true. Surgery can help you lose weight but the amount you lose and how healthy your diet is depends on your hard work and determination.

Surgery restricts how much you can take in at a time. This helps you to limit your food intake and therefore lose weight. However, the procedures do not physically stop you from eating your favourite foods. You are still ultimately responsible for what food you choose to eat. You will need to use willpower to stop eating energy dense foods such as crisps, chocolate, biscuits etc. Even small amounts of these foods can slow down your weight loss.

It may be necessary to continue with other methods that you have found successful for weight loss, such as attending regular Weight Watchers® meetings. Most people find that once they have had surgery and are losing weight, it becomes easier to stick to a healthy diet and exercise.

It is quite common to eat to provide comfort or to help cope with stressful or distressing situations. Realistically we cannot change the fact that you are likely to experience stressful or difficult things at some point in your life but it is very important to find alternative ways of coping with these.

If you continue comfort eating, you may find you don’t lose the amount of weight you want even following surgery. Food can no longer be your way of coping if you wish to lose weight and it is important to be aware that you will need to make many adjustments.

We recommend that people start making changes to their diet and behaviour before surgery because surgery alone will not change your eating habits.

You need to gradually prepare yourself for the changes ahead otherwise it can be daunting to make all the changes following surgery. We will work with you to set goals and make changes prior to surgery.

It is essential that you increase your activity levels. This will help prevent your losing muscle tissue while you lose weight. It will also help you to lose more weight, and prevent weight regain. We generally recommend people begin by incorporating daily walks into their lifestyle, or use a pedometer and aim to build to 10,000 steps per day.

We recommend caution with alcohol consumption after bypass surgery. The absorption of alcohol is unpredictable and one glass of wine may result in you becoming drunk. Alcohol should be avoided as it is high in calories and may slow your weight loss.

Remember, surgery is a tool; no matter what you think it is NOT the easy option.

13. Will I have loose, saggy skin after I lose weight?

Most people are left with some loose skin, especially around the abdomen, arms and thighs. You may feel you need surgery to remove some of this skin. You will need to ask your GP to arrange funding for this from your local Primary Care Trust.

They can then refer you to our plastic surgery team at Chelsea and Westminster Hospital. However, you must wait until you have lost all your weight and have been weight stable for 6 months before we can make a referral to our plastic surgery team. This is usually around 2 years after surgery.

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