More than 8,000 gastric band and bypass operations take place every year on the NHS, and many doctors consider them to be an effective solution to the growing problem of obesity. But what does bariatric surgery actually involve? And what are the risks? Andrea Childs reports.
There are three main types of bariatric surgery:
A gastric band is placed near the top of the stomach, reducing it to the size of a golf ball. Portion size and appetite reduce as a result – achieving around 47 per cent excess weight loss. The procedure is reversible.
A gastric bypass cuts the small intestine above the stomach and reconnects it below the stomach and duodenum, effectively bypassing the body’s main digestive organs (these stay in place but no longer function). So that the patient can absorb some food, a small gastric pouch with a volume of around 20ml is made from part of the stomach and connected to the bypass. This reduces food intake and appetite, and typically achieves a 66 per cent excess weight loss.
The gastric sleeve operation divides the stomach vertically, leaving a narrow, sleeve-shaped portion around 15 per cent of the original stomach size, thus reducing food intake and appetite. Weight loss measures between that of a band and a bypass. Both the bypass and sleeve operations are irreversible. All procedures, even corrective surgery, are generally carried out as keyhole surgery, says Shaw Somers, co-founder of leading bariatric practice Streamline Surgical.
Surgery is not the only option
The Endobarrier is a plastic sleeve that creates a barrier between the intestine and ingested food and works in a similar way to a gastric bypass. This is a temporary treatment for type 2 diabetes and is removed after 12 months. It is inserted via the mouth under anaesthetic.
Hypnosis can make you believe you have a ‘virtual gastric band’. Sam Alderwish, 36, a mother of two from Cheshire, lost 5½ stone and four dress sizes in three months after a 45-minute hypnotherapy session that tricked her mind into thinking she’d had a gastric band fitted.
A gastric balloon is a device inserted via the mouth and inflated inside the stomach, giving a feeling of fullness, so the patient eats less. It’s often used prior to weight-loss surgery to help reduce the patient’s weight and make the operation easier and safer to perform. Sheffield Children’s Hospital plans to fit ten teenagers weighing between 14 and 20 stone with gastric balloons. The trial aims to help morbidly obese 13- to 18-year-olds lose weight
The new buzz phrase is ‘metabolic surgery’
‘The term weight-loss surgery encourages the idea that these are cosmetic procedures with the sole aim of making larger people look better,’ says consultant Shaw Somers. ‘In fact, research shows that for anyone weighing more than 16 stone, metabolic (or bariatric) surgery is medically safer and healthier than staying big.’
The type of surgery you have depends on your health and eating habits
‘If someone’s main aim is to get rid of type 2 diabetes, I’ll recommend a gastric bypass,’ says Dr David Kerrigan, medical director of Gravitas, a nationwide partnership of leading bariatric surgeons. ‘It has an 80 to 90 per cent chance of providing a cure, while a gastric band has only a 30 per cent chance. Patients who have a sweet tooth and who tend to graze generally don’t lose as much weight with a gastric band. A band suits those who like to eat foods such as bread and chips, and have huge portions. A bypass works irrespective of someone’s eating pattern.’
THE POST-OP EATING PLAN
You have to follow a baby-food diet For two weeks before any kind of gastric surgery, patients drink only milk, or are put on a restricted diet, in order to shrink their liver and make it easier for the surgeon to reach the stomach. For a few weeks after surgery, it’s a liquid-only diet. The patient will then graduate to purées and soft food. Finally, they begin to eat small portions of normal foods.
The way you eat is important. ‘Patients need to work on their eating habits to limit problems and maximise success,’ says specialist bariatric dietitian Hala El-Shafie. ‘The ideal is to eat three small nutritious meals a day – the size of a side plate – plus two healthy snacks. It’s hard, as patients are often used to eating huge volumes quite erratically.’
A daily vitamin and mineral supplement is a must. Patients will be taking in a lower volume of food, which means a decrease in nutrients, so they’ll need to take vitamins D
and B12, plus calcium and iron for life, in order to prevent complications such as brittle bones and iron-deficiency anaemia. Patients need annual checkups to watch for any deficiencies in their diet.
Drinking with meals is a no-no. ‘Liquid takes up volume that is needed for nutrients from food. It also flushes food through the stomach, so patients don’t feel full, and can trigger dumping syndrome [see page 37] in gastric bypass patients,’ explains El-Shafie. ‘People should drink 30 minutes after their meal.’ And fizzy drinks are off the menu, as there’s a risk the gas will stretch the stomach pouch and cause bloating and discomfort.
The texture of food is as important as taste. ‘Bariatric patients can struggle to digest large lumps of food, such as meat. Bread is also a problem, as it swells in the stomach and causes discomfort,’ says El-Shafie. To obtain optimum nutrients, she advises people to eat protein such as minced meat, then vegetables and carbohydrates such as mashed potato or rice only if they have space at the end of the meal.
You can cheat a gastric band with liquid calories, but it’s not advisable. ‘Sugary drinks, ice cream, milkshakes and melted chocolate can slip easily through the band and sabotage weight loss,’ says El-Shafie. It’s harder to cheat a gastric bypass in this way as sugary foods can also cause dumping syndrome.
Mindful eating is essential. ‘I advise clients to chew their food well and spend20 minutes eating so their brain has time to register when their stomach is full,’ says El-Shafie. ‘It’s also useful for patients to keep a food and mood journal to identify whether they’re experiencing actual hunger or “head hunger”, when they want food as a comfort when stressed or angry.’
You can still enjoy food. ‘There are recipe books with post-bariatric meal ideas for dishes that are low in sugar, fat and bulky carbs or meat; you can order starter portions in restaurants; and you can savour dishes made from good-quality ingredients,’ saysEl-Shafie. ‘If you look after yourself, the surgery will look after you.’
Bariatric surgery cost the NHS £32.3 million in 2010. According to Professor Tony Leeds, an obesity specialist at London’s Central Middlesex and Whittington hospitals, if everyone who qualified for the procedure had it, the total cost would be £9.1 billion!
Around 800,000 people in England are morbidly obese, with a body mass index of 40 or above.
Bariatric surgery on the NHS is a postcode lottery. Nice guidelines say patients should have a body mass index (BMI) of 40 (or 35 plus a health complication such as diabetes) to be eligible. ‘But local Primary Care Trusts apply their own criteria, so someone may qualify in one trust area but not another,’ says Professor Leeds.
Expect to pay between £4,000 and £11,000 privately.
It costs around £6,000 for a gastric band operation. A gastric bypass costs £11,000, a gastric balloon £4,000, and a gastric sleeve £10,000. ‘Gastric surgery tourism’ to countries such as Spain, Belgium, Estonia and Cyprus, where prices are lower, is increasingly popular. However, UK surgeons warn of lower standards and a lack of follow-up care. When choosing a surgeon, ask how many of these procedures s/he actually does, says Shaw Somers. ‘If someone has done less than 50 a year, or offers only one type of procedure, you might want to choose a different surgeon.’
A gastric band is a ‘virtually risk-free operation’.‘It’s three times safer to have a gastric band fitted than to have your gall bladder removed,’ says Dr Kerrigan. ‘But five years on, there’s a 15 per cent risk of significant complications such as infection, erosion or slippage of the band, meaning more food can enter the stomach; and problems with the food access port that funnels food from the top half of the stomach, which is restricted by the band, to the lower part.’
There’s a one in 100 chance of a gastric bypass leaking.
Leakage happens when the small intestine is not rejoined properly. ‘But despite the scare stories of patients suffering from malnutrition [because leaking means they don’t absorb enough nutrients] there are few later complications with good aftercare,’ says Dr Kerrigan.
One patient in ten regains weight. ‘The main reason is inappropriate eating, which can stretch the stomach pouch and enable more food to be ingested,’ says Shaw Somers.
10 side effects:
1 PATIENTS ARE MORE PRONE TO FRACTURES. This is due to vitamin and mineral deficiency after surgery. A study from the Mayo Clinic College of Medicine in the US found that people who have had surgery to lose weight may be 2.8 times more likely to suffer bone fractures, particularly of the feet and hands. The risk is lower if patients were active before surgery.
2 A bypass can make you think like a thin person. New research at Imperial College London by consultant psychiatrist Dr Samantha Scholtz showed that a gastric bypass operation changed the way patients thought about food. MRI scans before gastric bypass surgery showed areas of the brain associated with reward were strongly activated in obese people when shown images of high-fat foods. After surgery their scans showed responses similar to non-obese people. ‘In effect, with bypass surgery we are changing someone’s brain,’ said Dr Scholtz (on the BBC’s Horizon programme).
3 You MAY need to budget to remove excess skin. According to Shaw Somers, this costs £5,000 to £10,000 to remove surgically. ‘I have loose skin on my breasts, belly and arms, and my bum is flat and wrinkly!’ says Andrea Brown, 40, from Stockport, who has lost six stone since undergoing gastric bypass surgery in March 2011. ‘I save £2 coins in my “skin tin” to pay for the corrective surgery I’ll need to remove it all.’
4 Weight-loss surgery can cure ‘diabesity’. Studies show that 80 per cent of diabetes is linked to obesity, but the disease can be reversed in 80 to 90 per cent of bariatric patients with the condition.
5 Beware ‘dumping syndrome’. Up to half of gastric bypass patients experience cramps, vomiting, diarrhoea, sweating and heart palpitations after eating fat-rich or high-sugar foods asstomach contents are transported to the small intestine abnormally quickly. Bariatric patients may also feel the effects of gastric flu orfood poisoning more severely.
6 Pregnancy is not advised in the first two years following surgery. The baby of a gastric bypass patient died of malnutrition because her mother didn’t know she was pregnant when she had surgery. Holly Emms, 25, weighed 18 stone when she had a gastric bypass operation last year; she had lost four stone by the time she gave birth, 25 weeks early. Her daughter Juli, who weighed just 1.9lb, died two days later. According to Imperial College Healthcare NHS Trust, delaying pregnancy after bariatric surgery reduces the risk of maternal malnutrition, miscarriage and premature or underweight birth.
7 IT’S NOT JUST WEIGHT YOU LOSE… ‘My hairdresser noticed that my hair was thinner, so now I take zinc tablets to help boost growth,’ says Andrea Brown. Generally, hair follicles become dormant for around six months after surgery, as calorie intake reduces and the body channels nutrients to vital organs. Hair growth should increase once the body has recovered from surgery and the patient is eating a nutrient-rich diet.
8 Alcohol goes to your head more quickly. ‘Alcohol is absorbed rapidly, meaning that a little goes a long way,’ says Shaw Somers. ‘Most bypass patients say they are a cheap date after surgery. Medication is not generally affected, although some slow-release treatments may be less effective. Your GP can advise.’
9 It reduces high blood pressure and high cholesterol. Cases of both conditions are halved a year after surgery, according to the first ever UK Bariatric Surgery Audit, from the National Bariatric Surgery Registry, which analysed data from patients at 86 hospitals. Cases of sleep apnoea dropped by more than half from 14.8 per cent to 6.1 per cent.
10 ‘COMFORT BREAKS’ ARE NEVER THE SAME AGAIN. The composition of urine changes after gastric-band surgery, so patients have an increased risk of kidney stones. A balanced diet can help minimise the risk. Patients also report only needing the loo once or twice a week or experiencing diarrhoea as their body adjusts to changes in diet and nutrient absorption.
You can be ruled out for surgery on psychological grounds. ‘We refuse surgery to three groups of people,’ says Dr Kerrigan. ‘The first are those with body dysmorphia. They might have a BMI of less than 40 but think they’re massive. The second group are those who have no idea about why they got so big; they offload the responsibility for their obesity and have less successful outcomes after surgery. The third group has vastly high expectations. Most people will have a BMI of between 29 and 31 after surgery, as weight loss plateaus after two years, although some patients may reach a BMI of 22 to 25. Anyone who wants a BMI of 20 will be unhappy with the result.’
Surgery can’t cure emotional eating.
‘When someone’s appetite returns after surgery, so can their issues around food,’ says Sylvie Collins, a clinical psychologist at Bradford Hospitals Trust.
An addiction to food may be transferred to gambling, drinking, shopping or sex.
‘Every patient should have counselling before and after surgery to help them find healthier ways to express their emotions,’ says Sylvie Collins. ‘I ask them to consider what they’ve been “using” food for; what they will do in situations that triggered them to eat in the past; how much support they can expect from the people around them, and how their role and identity will change once they lose weight and people respond to them differently.’
Patients have often suffered trauma. ‘Fifty per cent of my female gastric surgery patients have been sexually abused,’ says Shaw Somers. ‘And it’s likely that figure is representative of female patients nationwide. Food has replaced family structure for them, and they may also find unwanted attention difficult as they lose weight.’