ADVICE SHEET FOR WEIGHT LOSS PROGRAMME LAPAROSCOPIC GASTRIC BANDING Dr Mohd Faisal Jabar

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1 ADVICE SHEET FOR WEIGHT LOSS PROGRAMME LAPAROSCOPIC GASTRIC BANDING Dr Mohd Faisal Jabar Overview Surgical management of severe obesity is recognised as the main long term solution for severe obesity. While sustained dieting can be useful, the majority of people eventually put on the lost weight again over time chiefly by virtue of either lack of motivation and / or lack of discipline. While surgery has been demonstrated to significantly reduce weight and to reduce and in some cases cure obesity-related medical problems, it must be treated as a long-term permanent adjunct (or assistance) to a dedicated disciplined weight loss strategy by the person undergoing surgery. In other words, the decision to have surgery for obesity implies a change in your lifestyle and diet altogether, without which surgery would fail to reduce your obesity. Laparoscopic gastric banding (LAGB) is one of the commonest and simplest of these operations. It entails the placement of a flat silicone balloon band at the uppermost part of the stomach. The balloon is inserted through minimally invasive keyhole method ( laparoscopic ) and lightly secured to create a small gastric pouch approximately the size of a small egg. It can be filled with periodic injections of sterile water to adjust the tightness of the gastric opening now created by the positioning of this balloon band. The band is usually kept without additional inflation with water in the first four weeks following surgery to allow for your tissues to incorporate it in its place securely without risk of difficulty swallowing, friction injury to the stomach ( erosion ) or the migration of the band down the body of the stomach ( slippage ). It is thus a purely restrictive method of dieting without any resection or cuts to the stomach or any rerouting of the stomach or intestines ( bypass ). 1

2 Before the operation You need to consult a specialist centre with expertise in managing obesity surgery. The good centres have obesity surgery teams each comprising obesity surgery (or bariatric) surgeon or surgeons, a bariatric physician, a nutritionist or dietitian and a clinical psychologist. Your chosen surgeon is ultimately responsible for you in the hospital but this is essentially a team effort. You may be referred to other specialists in other medical disciplines if you have other significant medical problems. If surgery is contemplated, the minimum requirements are (iv) (v) (vi) (vi) (vii) that you have severe obesity, with or without associated diseases sufficient evidence of motivation sufficient evidence of attempts at weight reduction mentally and emotionally normal with a good grasp of issues discussed basic physical investigations to look at your general state of health. The operation necessarily requires general anaesthesia. There is a small risk of having to perform the operation by conversion to open surgery particularly if significant bleeding is encountered. The risk of this happening, however, is low. endoscopy of the stomach to rule out underlying conditions, as well as conditions whereby placement of the band is far from ideal with potential short- and long-term problems, when another modality of surgery should be offered. counseling by the dietitian regarding postoperative and long-term diet control to stop smoking if smokers These are usually performed in the office setting before hospital admission to facilitate the timing and logistics of surgery. 2

3 Admission for surgery Once the bariatric team and your surgeon is happy to proceed, you will be admitted. The gastroscopy may be performed in this same admission just prior to surgery. (iv) (v) (vi) (vii) The timing of admission may differ between different patients, largely determined by their degree of obesity and the degree of associated medical problems. Patients with moderate to severe cardiac and / or respiratory disease may need to come in much earlier perhaps 4-5 days before the operation. Another group who may require early admission are the super obese who get admitted for a preliminary weight loss diet regimen to make their operation easier. The majority of patients get admitted just one day before. Admission on the day of operation is not recommended. There will be a preliminary assessment by an experienced anaesthetist. You may be prescribed anti-anxiety premedication. You do not need to undergo bowel cleansing. You will be given preoperative chest physiotherapy and be taught breathing exercises to facilitate the recovery of your lungs after the operation. Any respiratory problems (fever, viral infection) must be informed early to your surgeon. The operation is elective and may be rescheduled if you have respiratory complaints which can potentially cause significant postoperative problems. You may be started on intravenous fluids the evening before morning surgery. You must be fasted for a minimum of 6 hours before surgery. Bariatric operations are usually scheduled early in the day hence keeping nil orally upon waking up on the day of surgery should suffice. This precaution is made to avoid you vomiting and choking on your own gastric contents when general anaesthesia is administered. The risk is higher in obese people. You may be given an injection to thin your blood sufficiently before or just after surgery to avoid the formation of clots in your veins ( deep vein thrombosis and pulmonary embolus ) Day of Surgery The operation is usually scheduled during the day. The actual operation takes about minutes, although this depends on the degree of obesity and if you have had prior abdominal surgery. Your general anaesthesia is normally straightforward bearing in mind co-existing related medical problems you may have. After the completion of surgery, you are placed in the Operating Theatre Recovery area and usually return to the ward. The whole process may take 4-5 hours altogether from your departure from until return to the ward. Intensive Care stay is rarely required and is usually anticipated for those with multiple medical problems. 3

4 Immediate postoperative period You may experience postoperative pain from the small laparoscopic wounds but this is usually moderate and can be taken care of with oral painkillers. Injection-type painkillers are not usually necessary. The pain is short-lived and lasts for 1-2 days only. You may get post-general anaesthesia side effects with nausea and occasionally vomiting. Again, this typically subsides and infrequently requires medication. You are encouraged to start moving around within your tolerance of the postoperative discomfort. Once your surgeon has seen you after the operation, you are usually encouraged to take sips of plain water on the same day and in the first postoperative day. You may take more pain water if the initial swallowing of water was easy to perform. You should be able to take free fluids including nourishing fluids by the first or second postoperative day. Your intravenous drip is usually discontinued once your doctor and the nursing staff are happy with your fluid intake. Postoperative diet As mentioned earlier, the laparoscopic gastric banding procedure will only work if you are motivated to have a complete change of lifestyle and diet and to stick to this plan. You can easily fool the band (and yourself) if you insist on taking in high calorie milkshakes and ice cream which will just as easily slip through the small gastric pouch. Your postoperative diet is split into two parts : the first four weeks after this four week period It is imperative that in the first four weeks postoperatively you do not overwork your stomach. It is important to let the recently placed band sit in its position to allow for scar tissue to set it in place. This avoids later problems of slippage and erosion. If you were to start on normal food as before, the movement of the stomach at digestion may cause discomfort and can potentially displace the band. 4

5 The general advice in the postoperative period is (iv) sips of water only after surgery on the day of surgery unlimited water only on the first postoperative day You are advised to slowly sip your water and not take it in big gulps nourishing fluids later on the first postoperative day, or on the second postoperative day If you are able to take this in easily, pureed food from the second or third postoperative day onwards (a) (b) (c) (d) (e) (f) (g) This should be in the form and consistency of smooth infant food at 3 months without significant solids. You must eat small amounts frequently (4-6 meals per day) The volume of pureed food per meal should only be about 100ml (about half a cupful or about 5 tablespoonfuls) You must not eat and drink at the same time. This will cause rapid filling of your gastric pouch and consequently cause you to cough, regurgitate food, vomit and may tamper with the placement of your gastric band internally in the first 4 weeks. Take a spoonful of your pureed food, swallow it completely and complete your meal. Drink water several minutes after you have finished or before you start your meal. You should stop eating as soon as you feel full. This early satiety is due to the small gastric pouch created and overall limits your calorie intake. You are encouraged to drink 2 litres of water daily. Please refrain from drinking too much sugary or high calorie nourishing fluids ( milkshakes / ice cream ) and soups for the sake of your weight loss. Carbonated drinks should not be taken. You may have difficulty belching. Furthermore these drinks are high in calories. Your dietitian shall calculate your recommended daily calorific requirement and the total volume of pureed food to be taken. This is based on your amount of excess weight, your calculated basal metabolic rate for your height and gender and your likely amount of daily activities. Remember that the general idea is for you to lose weight. Surprisingly, many people who have had gastric banding feel less hungry. Many of those with reflux oesophagitis ( heartburn ) also say their symptoms improve. You are then ready for hospital discharge. An appointment to see your dietitian is made (usually weekly) and to see your surgeon at about a month. 5

6 Diet at home You are advised to continue on your pureed diet for 4 weeks until your dietitian and surgeon are happy for you to progress to your new normal diet. Generally the same advice apply. (a) (b) (c) (d) (e) (f) (g) (h) You must chew your food thoroughly into a semi-pureed form before swallowing. You must eat small amounts frequently (4-6 meals per day) The amount of food per meal should only be about 100g (about half a cupful or about 5 tablespoonfuls) You must not eat and drink at the same time. This will cause rapid filling of your gastric pouch and consequently cause you to cough, regurgitate food, vomit and may tamper with the placement of your gastric band internally in the first 4 weeks. Take a spoonful of your pureed food, swallow it completely and complete your meal. Drink water several minutes after you have finished or before you start your meal. You should stop eating as soon as you feel full. This early satiety is due to the small gastric pouch created and overall limits your calorie intake. You are encouraged to drink 2 litres of water daily. Please refrain from drinking too much sugary or high calorie nourishing fluids ( milkshakes / ice cream ) and soups for the sake of your weight loss. Carbonated drinks should not be taken. You may have difficulty belching. Furthermore these drinks are high in calories. You are encouraged to perform regular exercise. What to look out for in the post-operative period (iv) Excessive vomiting Early : This may be due to early slippage of the band and may require re-exploration and adjustment. Late : Late slippage, which imply a possible balloon leak. Reexploration and either adjusted placement or complete removal may be required. Excessive pain Early : Operation-related problems Late : Band erosion into the stomach wall Other gastric or abdominal symptoms Persistent fever 6

7 Insufflation of the balloon band Your surgeon may decide to start to tighten the band after 4 weeks to further reduce your calorie intake. This is usually performed in little aliquots of 1-4ml of sterile water at a time on a periodic basis. Desufflation of the balloon band This occurs if : you are female and wants to become pregnant or have become pregnant. The balloon is usually kept deflated until you have finished with breastfeeding. upon your insistence. Please remember why you wanted to have the band inserted in the first place. if erosion or slippage is suspected Expected outcomes You have chosen the laparoscopic gastric banding as a means of weight control for morbid obesity. This can only be achieved if you remain motivated to lose weight and to maintain the weight loss. The rate of weight loss is greatest early on in the first few weeks while you are on the pureed diet and when you begin to appreciate the thoroughly chewed semi-pureed diet you have to take. We aim to get you down to your ideal weight at a BMI of 25. Weight loss shall be measured directly (as in how many kg lost), rate of weight loss (kg over time (week/months/quarter or 3- monthly) or as a function of excess weight loss (abbreviated to EWL, or your excess weight beyond a BMI of 25) On average, the EWL should be 25% at 3 months, 35% at 6 months, about 45% at 9 months and over 50% at 1 year is considered satisfactory. The weight loss rate is greatest initially (i.e. you have more to lose) and gets harder as time flies with you losing weight gradually. This is a typical pattern of any dieting regimen. The rate therefore differs and tends to slow down over time. Your goal total EWL is possible and has been done before. 7

8 Your example: Height: 5 foot 3 inches (1.61 m) Preoperative weight: 96 kg Preoperative BMI: 37.5 Ideal weight at BMI of 25: EW for you: EWL in first 3 months: Average weekly loss in kg: (at 4 weeks a month) 64.8 kg 31.2 kg 25% of 31.2 kg = 7.8 kg 7.8 kg over 12 weeks = 0.65 kg or 1.4 lb You tend to lose 1-2 lbs per week on average, but may be much more in the first few weeks postoperatively. MFJ /