Gastric Bypass

Is Gastric Bypass Surgery Right for Me?

Gastric Bypass surgery is for patients who have not been successful in losing weight through dieting, exercise and medication. It is primarily used as an anti-reflux procedure, with weight loss benefit.

It is a suitable weight loss treatment for patients who are not eligible for other surgical procedures due to risk factors associated with a high BMI (>40) or lower BMI (>35) where other medical conditions coexist.

How Much Weight Will I Lose?

By following the post-operative recommendations patients can expect to lose approximately 1-1.5 kg per week until they reach a healthier weight.

Studies have shown that Gastric Bypass patients can lose up to 90% of their excess body weight. 75% of patients will lose 75-80% of their excess body weight after surgery.

How Gastric Bypass Works

The surgery uses a combination of restrictive and malabsorptive techniques to achieve a successful outcome.

The size of the patient's stomach is decreased using staples so that only small portions of food can be consumed and part of the intestines are bypassed to limit the nutrients and calories absorbed.

In addition, the rerouting of the food stream produces changes in gut hormones that promote satiety, suppress hunger, and reverse one of the primary mechanisms by which obesity induces type 2 diabetes.

Why Consider Gastric Bypass Surgery?

Gastric Bypass surgery has a number of advantages over other weight loss procedures. These are:

• Quick and dramatic weight loss
• Continued weight loss for 18-24 months post-surgery
• Often leads to conditions that increase energy expenditure
• Produces favourable changes in gut hormones that reduce appetite and enhance satiety
• Many patients maintain a weight loss of 60-70% of excess weight 10 years post-op
• Improved mobility and quality of life and self-esteem.

Many patients are able to stop taking medications for diabetes and hypertension as a result of the weight loss.

The disadvantages of Gastric Bypass Surgery are

• the normal risks associated with major surgery,
• malnourishment and anemia may occur without dietary supplements (vitamin B12, iron, calcium, and folate),
• increased risk of gallstones due to rapid weight loss and dumping syndrome
• The lifelong requirement is to take vitamin supplements and to maintain dietary adherence.

What Conditions Does the Gastric Bypass Help?

After weight loss has occurred patients report considerably improved health and the reduction or cure from the following conditions:

• Diabetes,
• Heart Disease
• High blood pressure,
• Arthritis,
• Non-alcoholic fatty liver disease
• Asthma and
• Sleep apnea.

What Tests are Needed Before Surgery?

At our practice, we like to make your surgery as safe and predictable as possible.

We routinely perform a blood test on all patients before surgery, this test includes

• a full blood count,
• blood group,
• cholesterol levels,
• kidney, liver and thyroid function, and
• a diabetes screening test.
• Vitamins and minerals base level

Depending on your medical history and as required we may also arrange:

• a chest X-ray, or
• an ECG.

Other Preoperative Consultations

Sometimes a referral to another specialist such as an

• endocrinologist,
• cardiologist, or
• a respiratory physician

maybe made. This will be determined at your Initial Consultation with Dr Blackham. If you already have other specialists involved in your care, we will also correspond with them.

Preparation Before the Gastric Bypass

Preparing for Gastric Bypass Surgery

Patients may need to lose weight, start exercise, or change their diet to prepare for the procedure. Our doctors will go over the specific instructions for pre-operative care, but generally, patients will need to:

• Go on a liquid diet two-three weeks before surgery.
• Avoid eating after midnight, and on the day before surgery.
• Ask a friend or family member to be at the hospital for support and comfort.

Other Preoperative Preparation

Patients may also want to arrange for the food, drink, and medications they will require after surgery before they go to the hospital.

What Should I Bring with Me to the Hospital?

A hospital representative will call you before your admission and advise you on everything you need to know.

Generally, only a few things are required. These include

• Bathroom items & personal toiletries
• Clothing for your stay that is easy to put on and take off including pyjamas, bathrobe, slippers
• Your regular medications
• Mobile phone, iPod, tablet, laptop, books, photographs, etc
• Do not wear jewellery
• If you have sleep apnea, bring your CPAP mask, tubing and machine.
• Don’t forget to bring any X-rays and other important medical documents that may be relevant to your surgery.

Day of the Gastric Bypass Surgery

Before Your Procedure

If you are diabetic or pre-diabetic, an accucheck will be done and women may have a urine pregnancy test. You will then be:

• Given an IV drip and start with an antibiotic as well as a blood thinner shot to reduce your chance of developing a blot clot in your leg veins during surgery
• Given compression stockings to be placed on your lower legs
• Asked to void before going back to the Operating Room
• Able to meet the anaesthetist who may give you a sedative, and
• Meeting Dr Blackham before you go into the theatre

Transfer to Theatre

You will be transferred to the Operating Room with large ceiling lights and many machines.

Then:

• Moved onto the operating table, lying flat on your back with your arms extended on arm boards and be covered with a blanket
• Heart monitors will be placed on your chest
• An oxygen monitor will be placed on your finger
• The anesthesiologist will place an oxygen mask on your face, then will give you your initial anesthetic drug through the IV and you will go to sleep

Once you are asleep, he will place a breathing tube in your trachea (windpipe) through which you will receive oxygen and anesthetic gas throughout the operation. You will not feel this.

What is Involved in Gastric Bypass Surgery?

The Gastric Bypass procedure involves two components where your surgeon.

• Making a series of small (keyhole) incisions on the upper abdominal wall (the umbilicus may also be used for one of these to minimise visible scars)
• Insert specialised surgical tools, including a camera, through the incisions.
• Firstly the upper portion of the stomach near the oesophagus is converted into a small pouch (30-50 millilitres in size) using staples
• The second step of the surgery involves the creation of a bypass for food to flow from the new stomach pouch. This involves the first portion of the small intestine is divided, and the bottom end of the divided small intestine is brought up and connected to the newly created small stomach pouch. This is referred to as the “roux limb”.
• The upper section of the small intestine which carries digestive juices from the remaining portion of the stomach is attached at the distal end of the roux limb.
• The roux limb enables food to bypass the lower stomach, duodenum, and a portion of the small intestine and the stomach acids and digestive enzymes from the bypassed stomach and first portion of the small intestine will eventually mix with the food.
• At the end of the procedure, the incisions are closed with sutures.
   

These incisions are deliberately placed within your natural skin lines to minimise any visible scarring. All skin wounds are closed with hidden absorbable sutures that do not need to be removed.

All you will see when the dressings are removed is a neat line.

No surgical drains, nasogastric tubes and urinary catheters are routinely used by Dr Blackham for Bariatric surgery.

How Long Does the Gastric Bypass Take?

The actual procedure takes less than two hours, but the pre-operative checks and postoperative observation and recovery will require two nights stay in the hospital.

After Weight Loss Surgery Will I Feel Pain?

Because weight loss surgery is performed using laparoscopic (keyhole) surgery, pain after surgery is greatly reduced.

Immediately after surgery, some patients report sensations of

• chest tightness, or
• a stitch feeling in the upper abdominal area (especially on the left side, up under the rib cage), or
• an ache in the left shoulder tip

These sensations usually resolve within 3-4 days.

This discomfort is generally not limiting and you will still be able to sit up comfortably and walk.

You will be provided with adequate analgesia, both in the hospital and after discharge, to make sure you are comfortable and be offered a variety of medication to make sure you are not in pain, majority of patients will not require any analgesics other than panadol after discharge from hospital.

Waking Up After Surgery

Although you will be awake in the recovery room, it is common to still feel a little drowsy. Our anaesthetists will ensure your comfort. Occasionally this may be a self-administered pain management system.

In addition, Dr Blackham routinely infiltrates all skin wounds with long-acting local anaesthetic prior to making the incisions (this technique is called ‘pre-emptive analgesia’ and works by blocking the nerves before they are stimulated).

Because your procedure is performed laparoscopically, any initial discomfort quickly passes, and virtually all patients feel completely awake, alert and able to have a normal conversation within an hour or two.

How Soon will I be Able to Walk?

As soon as you feel up to it. In fact, we encourage you to get up and walk about the ward within 24 hours of your procedure. This helps avoid problems like blood clots and chest infections.

On leaving the hospital, you should be able to care for all your personal needs but may need a little help with shopping, lifting and transport for the first few days.

Patients also need to commit to a healthy lifestyle as part of the recovery and weight loss process. This involves eating healthy foods and exercising regularly.

What Should I Expect After the Gastric Bypass?

How Long will the Hospital Stay be?

The vast majority of patients feel well enough to be discharged within 3 days of their procedure. This means staying overnight in the hospital for one or two nights.

Everyone heals at different rates and surgery can vary in its complexity depending on a patient’s past medical history. You will be allowed home when you feel ready. No-one is ever pushed out of the hospital.

How Long Will it Take to Recover After Surgery?

Patients having a Gastric Bypass recover quickly in the first few days after surgery, and by 2 weeks most patients feel they have adequately recovered and are back at work.

Gentle exercise such as walking can be restarted straight away, but you should wait four weeks before resuming swimming or more vigorous activities such as the gym or boot camp.

Will I have a Surgical Drain, Nasogastric Tube, or Urinary Catheter After the Surgery?

No surgical drains, nasogastric tubes and urinary catheters are routinely used by Dr Blackham for Gastric Bypass surgery.

An intravenous drip in your arm is usually the only thing that you will have when you wake up. This is removed as soon as you are drinking enough fluids.

What About Other Medications?

You will still be able to take prescribed medication. Large tablets may need to be broken in half or dissolved in water so they do not get stuck, however, most of the common tablets for high blood pressure, diabetes are fine.

Will I be Constipated?

Quite possibly. We recommend taking a soluble fibre supplement (such as Benefiber) in the liquid phase after surgery to help maintain normal bowel movements. Lactulose and Movicol can be of benefit.

If difficulties do arise, just let us know.

How Soon Can I Drive?

It is illegal to drive within 24 hours of a General Anaesthetic, therefore it is important that you arrange for someone to pick you up from the hospital.

Most patients feel ready to drive again after 7 days, however for your own safety; you should not drive until you have stopped taking any strong pain medications, and feel comfortable that you can break in a hurry.

Can I Have Visitors?

Spouses, significant others, parents or a friend are encouraged to help you in your hospital recovery, by encouraging you, walking with you and helping you to remember to drink your water and use your incentive spirometer.

One individual may be permitted to sleep in the hospital room with you.

Visitors are not permitted to bring food into the hospital room.

Do not bring family members or friends who are not supportive of your decision to have bariatric surgery. We do not encourage several or frequent visitors during your hospitalization. We want you to concentrate and participate in your recovery.

Eating After a Gastric Bypass

What can I Expect After the Surgery when I Eat?

You will only be able to eat a few ounces of food at a time. You will not be able to drink and eat at the same time as your new stomach will not be able to hold both.

Following surgery patients will need to be on a liquid diet for two to three weeks and eat a pureed diet for another two to three weeks, before progressing to soft foods for two to three weeks after that. Following these stepwise diet progress you will be able to eat normal food but in smaller portions.

You will also have to concentrate on eating slower and chewing your food thoroughly. You will also have to avoid certain sugary foods as these can lead to “dumping syndrome”.

What is Dumping Syndrome?

Dumping syndrome happens when the food you eat passes too quickly through your new GI tract causing diarrhea, shakes, sweats, and other unpleasant symptoms.

Dumping syndrome can be avoided by not eating sugary foods such as chocolate, juices, soft drinks, and other foods high in simple sugars.

Post Surgery Follow Up Appointments?

Our Care Plan has been carefully designed to allow you to get the most out of your bariatric surgery.

Your first visit after surgery will be scheduled within two to four weeks. After this you are required to visit our team regularly.

The follow schedule would typically be:

• Two to three months,
• six months and
• then annually.

At each follow-up visit, please keep your doctor informed of your recovery/progress and contact your doctor for any health concerns you have in between visits.

Please call the office to make appointments for your visits.

Dietary Changes

You will also be seeing our dieticians before you progress to the next phase of your diet. Usually at 2,4 and 6 week intervals.

During the first month patients must:

● Adhere to a strict liquid only diet for the first two to three weeks before progressing to puree.

● Drink plenty of fluids to avoid dehydration.

● You will require to see our dietician regularly.

Post-Operative Outcomes

Our aim is to both maximise weight loss and enjoy freedom from post-operative problems.

As you lose weight, the amount of fat around your stomach will shrink,

Once your goal weight has been reached (usually around 18 months after surgery) your follow-up appointments can then be scaled back to yearly once.

Regular check-ups are a normal and a very important part of bariatric follow-up.

Surplus Skin

The skin has an amazing ability to remodel and shrink, it just needs time. As a rule, plastic surgery should not be considered for at least a year after the operation, as your skin usually continues to contract long after you have reached your goal weight.

Most patients find that skin trimming surgery is not needed. Regular exercise and keeping well hydrated also helps remould your skin.

If excess skin does persist, we can discuss Body contouring surgeries with you or refer you to a plastic surgeon for an opinion.

Possible Risk or Complications of the Gastric Bypass Surgery

General Surgical Risks

In roughly 2.5% of cases patients can experience severe complications, such as:

• Blood clots.
• Heart attack.
• Leaking in the surgical connection between the intestines and the stomach.
• Serious infection or bleeding.

As with any surgery there are potential risks and complications involved. Complications associated with Gastric Bypass include:

• Problems associated with anaesthesia
• Bleeding
• Infection
• Bowel obstruction
• Leaks in your gastrointestinal tract
• Deep vein thrombosis (blood clot in the leg)
• Dumping syndrome leading to diarrhoea and nausea
• Internal Hernia - so if you have abdominal pain at any stage after a RYGB you should present to a doctor to be assessed for an internal hernia (a loop of small bowel caught in a space). Usually this requires a CT scan to diagnose.
• Gallstones
• Malnutrition
• Ulcers

How can I Minimise Post Operative Complications

Blood clots (DVT or PE) - All patients receive a number of treatment measures to reduce the risk of blood clots. These include being given injections of a blood thinner during and after surgery, special leg stockings (TEDS), and the sequential calf compression device (SCD) whilst on the operating table.

As a result of these measures, we have never had a patient develop a deep venous thrombosis.

Any patient who is at high risk of a blood clot (such as a history of blood clots or clotting disorders) may be asked to continue blood thinning medications for 10 days after the surgery in addition to the other measures.

This can be done at home, and we will show you how.