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Patient info gastric band

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					   Gastric band surgery – preparing for
     surgery and the first six weeks.




                                The gastric band is
                                locked around the
                                top of your
                                stomach and
                                secured in place
                                with stitches.




Musgrove Park Hospital
Taunton
Bariatric Service
February 2010
1.        Pre-operative preparation

In the lead up to your surgery, you will have been seen by the multi-disciplinary team
(physician, surgeon, dietitian) who will ensure that all aspects of your obesity and
other medical conditions have been taken into account. Following funding approval,
surgery normally takes place within six months, and the hospital will contact you once
a bed and operating time have been booked for you. Although no-one likes to cause
any disruption to these arrangements, occasionally it is necessary to postpone this
type of operation (called ‘elective surgery’) if a patient with an urgent surgical
problem needs treatment ahead of you.

Anaesthetist – Your anaesthetist has been specially trained to treat obese people
and will look carefully at your medical history and tests that have been performed. If
you develop any sort of cough or cold or become unwell in the week prior to
your operation it is important to let the hospital know immediately so that your
operation can be postponed until you are better.
The most significant risk associated with this surgery is a blood clot in your lungs.
For this reason patients are mobilised as soon as practical after the operation and
drugs are given to prevent blood clots forming. If you are taking any preparations
containing oestrogen they must be stopped for at least 4 weeks prior to your
surgery, again to reduce the risk of developing a blood clot.

Cigarette Smoking – This surgery represents a turning point in your life so if you are
a smoker, now is an excellent time to give up. Smokers are much more prone to
experiencing problems with anaesthetics and recovery from surgery. Smokers, you
must stop for at least one month prior to your surgery. This really does make a
big difference to the anaesthetic.

Dietary Preparation – Just because you have been offered a surgical treatment for
your morbid obesity, this is not an excuse to sit back and eat as much food as you
can! You must continue to follow your weight management programme as any
weight you can lose through dieting before your surgery is an advantage – it will
make the surgery easier and will reduce the risks associated with it. It is vitally
important that for one week before your surgery you follow a very restricted
diet – one that is low in fat, sugar and carbohydrates. The reason is to shrink
your liver down to ensure that the operation can be done by the keyhole/laparoscopic
method. If your liver is too big you will have to have an open operation, the risks of
surgery will increase and your recovery will be delayed. By following a strict diet,
your body reduces its glycogen stores (glycogen is a form of sugar stored in the liver
and muscles for energy). With each ounce of glycogen, the body stores 3-4 ounces
of water, so when you follow a very strict diet, especially one that is low in starch and
sugar, your body loses its glycogen stores and some water. The liver shrinks as it
has less glycogen and water in it. This diet is only recommended for one week
before surgery and is not to be followed afterwards. You may find that you lose a lot
of weight that week, but it will be mainly be water loss. Please ensure you continue
to drink throughout the day.




Musgrove Park Hospital – Bariatric Service                                              2
Feb 2010
Here are some menu suggestions. If you are in doubt about a food then it is best to
avoid it. It is very important to avoid cakes, biscuits, chocolate, crisps and sugary
drinks.


Breakfast
      Small bowl of plain cereal (25g or the size of a small multi pack box)
      Or
      1 medium slice toast with scraping of margarine

Lunch
          1 slice bread or 2 crisp breads
          Salad (no dressings, unless just vinegar based no oil)
          Small portion of meat or fish (size of pack of playing cards) or cheese (size of
          a small matchbox), 2 eggs or 2 tablespoons of baked beans

Dinner
      1 small potato or 2 tablespoons of pasta or rice
      Vegetables- any vegetables but try to have mostly the green varieties.
      Small portion of meat or fish or cheese or eggs or quorn or tofu dish (portions
      as above)

Daily One third of pint of semi-skimmed or skimmed milk over the day for drinks and
      cereals
      Two portions of fruit (a portion is one apple, one pear, one small banana, an
      orange, or a handful of berries).
      Water, tea, coffee, low calorie squash, low calorie fizzy drinks allowed freely.
      (Limit fruit juice to one glass per day.)
      One low fat low sugar yoghurt or fromage frais per day.

If you think you will have difficulty following this diet, an alternative would be
to have a very low calorie liquid diet, eg 4 x Optifast or Slimfast sachets per
day, plus 1 – 2 litres calorie free fluids for 1 week. Please contact the Bariatric
Dietitian on 01823 34 3561 or 01823 34 3394 to discuss this further.

Medication – You will need to have liquid, soluble or crushable forms of your
normal medication for 6 weeks after the operation, or until you are back on solid food.
You will then be able to resume taking tablets, although you may want to break them
into smaller pieces at first. If you do not see your GP regularly, you should visit
him/her prior to your admission to hospital to discuss the medications you will need
after your discharge.

Emotional Support – for many patients a big question is “Who should I tell about the
surgery?” Your immediate family and close friends should know because they will
want to support you over the period of the operation and afterwards. There are
bound to be days when you feel more emotional about your decision. A diary of your
progress with your treatment will be a useful companion on your journey and it is
good to start out with some photographs of how big you are at the time of operation
(because in the future even you won’t believe the difference!). If you get a relative or
friend to take a photo of you, stand in a doorway – you will find the door frame a
useful reference point for the “after” photos you take later on.


Musgrove Park Hospital – Bariatric Service                                                   3
Feb 2010
Patient Support Group – This is a very important aspect of your care from the time
you make the decision to have this surgery, right through the years during which you
are losing weight. Talking to other patients who have been through the same
experience as you is the best way of finding out the most important details. They
know far better than any members of the multidisciplinary team what it is really like to
undertake this journey. Locally, the support group provides a “buddy” for each
individual patient. This person will stay in contact with you before and after the
operation and help to answer any questions that you or your family may have.
(www.bospa.org).


2.        Your hospital stay

Admission – You will be admitted to hospital either the day prior to, or on the
morning of your operation. The usual length of stay following your operation is one
night. Here is a suggested list of items to bring into hospital with you: sleepwear (one
set for each day of your stay); dressing gown, slippers, any medications, spectacles,
toiletries. Please do not bring any valuables in with you. When planning for your
clothing to go home again in, choose clothes which are not too tight around your
waist and flat shoes. Please make sure you have a bath or shower before
admission.

Prior to your operation any remaining or repeat tests that need to be done will be
completed. You will also be given a dose of Clexane (heparin) by injection. This will
decrease the risks of blood clots forming in your legs or lungs. If your operation is
scheduled for the morning, you will not be allowed to eat or drink anything from
midnight the night before your operation. If your operation is scheduled for the
afternoon, you will not be allowed to eat or drink anything more after breakfast. The
surgeon and anaesthetist will also visit you to answer any remaining questions that
you may have and to ask you to sign the consent form for the operation.

Going to theatre – you will be given a theatre gown to wear that opens at the back.
Jewellery, make up and nail varnish must be removed. Most patients walk to the
operating theatre (so make sure you take a dressing gown and slippers to hospital
with you) and you will be put to sleep on the operating table so that you do not have
to be moved once you are asleep. It will feel as though there are a number of people
buzzing around and busy doing things to you, but don’t worry, you are in excellent
hands. An intravenous drip will be inserted into your arm and various other items
including an oxygen mask, oxygen saturation monitor and blood pressure cuff put
into place.

Immediately after the operation – you will wake up either in the recovery room (part
of the operating theatre suite) or back on a ward. You will still be connected up to a
number of things including your drip, oxygen mask, oxygen saturation monitor and
blood pressure cuff. For the first few hours while you are still recovering from the
anaesthetic your blood pressure and pulse will be monitored frequently. You will
mostly want to sleep so it is a good idea to advise non-immediate family and friends
to leave you in peace. You will be sat up and you will find this the most comfortable
position to be in for a few days.




Musgrove Park Hospital – Bariatric Service                                             4
Feb 2010
Once you are awake you will be allowed to start taking sips of water and the staff will
encourage you to stand up and move around as soon as you are able. This is
important to prevent blood clots forming. Your intravenous drip is usually taken out
the following morning and you may be given a further dose of Clexane.

Pain relief – most patients find that the operation is not as painful as they had
expected. Initially pain relief is given by injection but once you are drinking, it can be
given in dissolvable tablet form. Once home, if you need to take anything for
discomfort or pain, soluble paracetamol tablets are recommended.

Discharge from hospital – When you are discharged, you will be taking Zoton, this
is a medicine called a proton pump inhibitor and works to reduce the amount of
stomach acid that you produce. The hospital will give you some for your first few
days, but then you need to get a prescription from your GP so that you can continue
it for one month after surgery – 15mg per day. Make sure the GP prescribes the
dissolvable form (Zoton fastabs). You should take one fastab first thing in the
morning, before food.

The five-six small wounds on your abdomen will be covered with waterproof
dressings after the operation. The dressings should be left in place for seven days
(only change if the wound is oozing or the dressing has lifted off and is no longer
waterproof). By that time, the wounds are usually healed enough to remain
uncovered. Any stitches used are dissolvable.


3.        The first six weeks after the operation

Eating and drinking- by the time you leave hospital you will be eating a pureed diet.
You will need to continue this for the first four weeks, while your stomach is settling
down again after the operation.

  Eating guidelines for the first six weeks:
     • Eat 4-5 small meals per day (about 1-2 tablespoons at each)
     • Eat pureed food for the first 4 weeks and then mashed for the next 2 weeks.
     • A pureed diet means your food should be the consistency of baby food or apple
         sauce – many people find a hand held blender most suited to pureeing small
         quantities of food.
     • Drink water between meals – you need extra fluids after the operation and may
         find you cannot drink a whole glassful at once so have several small drinks
         between each meal. Try to take a pint more water than you usually would in a
         day. Avoid fizzy drinks because they may cause wind to be trapped in your
         stomach which can be painful.
     • Eat slowly and stop as soon as you feel full.


Here are some sample menus to help you plan your eating in the first 6 weeks:

Breakfast (choose one from the list below)
   • 2-3 tablespoons porridge or Ready Brek (blended)
   • 1 Weetabix with skimmed milk
   • Yoghurt or fromage frais
   • 1 scrambled egg blended or finely mashed with a fork
Musgrove Park Hospital – Bariatric Service                                               5
Feb 2010
Lunch/snack meal (choose one from the list below):
  • Soup blended to a smooth consistency (100 – 150mls)
  • Milky pudding such as rice, sago or semolina
  • Fruit custard – eg stewed apple, mashed banana blended with custard or
     tinned fruit blended with custard
  • Yoghurt or fromage frais
  • 1-2 tablespoons pureed tinned fruit in juice

Dinner (choose one from the list below):
   • 5-6 tablespoons (100g) cottage pie, blended
   • 5-6 tablespoons (100g) bolognaise and mashed potato, blended
   • 5-6 tablespoons (100g) fisherman’s pie, blended
   • 5-6 tablespoons (100g) mashed potato with grated cheese
   • 5-6 tablespoons (100g) baked beans with mashed potato, blended

Some people find it easier to buy ready-made meals and blend them to a smooth
consistency. If you are making your own meals, you may need to make a sauce in
order to obtain the right texture when blended. Dried packet sauces can be made
with skimmed milk, tomato-based ‘Cook-In’ sauces are useful and gravy granules can
be made up with hot water. Pureed food can be very bland so add herbs and spices
if you yearn for some extra seasoning. After the first four weeks you will progress on
to more solid food (i.e. mashed, not pureed) for two weeks. The portion sizes will be
the same as those described above but you do not need to blend/liquidize the food.

At six weeks you should start re-introducing normal textured solid food.

Vitamin and mineral supplements – There is a risk of developing certain vitamin
and/or mineral deficiencies with this type of operation, so the following should be
taken for the rest of your life:-

1         A daily multivitamin with minerals. Examples are: Sanatogen Gold A-Z,
          Centrum Complete A-Z, or any equivalent A-Z multivitamin with minerals.
          These are available to purchase over the counter at supermarkets, chemists
          and health food stores. Forceval is another good option, but is available on
          prescription only. It comes as a large capsule which some people may find
          difficult to manage.

          For the first 6 weeks after the operation, it is recommended that your
          medication is crushable, and that if this is not possible you should have a
          liquid or chewable preparation. During this time, you may want to take a
          chewable multivitamin such as Bassett’s Active Health multivitamin with
          minerals for adults, or a liquid multivitamin such as Abidec. However, these
          are not complete and you should switch to a tablet multivitamin after the first 6
          weeks. If you find that you have trouble swallowing tablets, breaking the tablet
          into 2 or 3 pieces might help. Some people instead choose to crush their
          multivitamins and take them with drinks or food.

2         Extra calcium + vitamin D, for example Calcichew D3 Forte (available on
          prescription) – 1 three times per day with meals. Calcium + vitamin D can
          also be purchased over the counter. However, ensure that you take 1200-
          2000mg per day of calcium + 10-20ug per day of vitamin D.

Musgrove Park Hospital – Bariatric Service                                                6
Feb 2010
     3         There may be other supplements that your GP would prescribe, depending
               on the results of your blood tests.

Long-term dietary considerations - In the long-term after surgery, general healthy
eating recommendations apply. It is recommended to get into a routine of three
small healthy meals per day: for example, a meal should be about the size of a small
side plate. You may find that using smaller plates helps you get used to smaller
portions. It is okay to have healthy snacks between meals if needed, eg a piece of
fruit, a small pot of yoghurt. It is best to avoid “grazing” throughout the day as this
can lead to consuming more calories than you realise, and poor weight loss. The
Dietitians are available to support you in making changes to your eating habits and
activity levels – don’t hesitate to ask for help if you are struggling. We recognise that
it is difficult to change eating habits, and you will need support long-term.

Exercise – most people lose some weight quite quickly after the surgery and feel
more energetic quite soon after the operation. Start walking more as soon as you
feel able. With time you should gradually try to increase this until you are walking for
a total of 30 minutes per day. You should aim to walk at a speed that makes you
slightly short of breath and slightly sweaty. If you attend a gym or fitness club, you
should have a break of at least 4 weeks after your operation and then gradually get
back into it.

Sleeping – you will find it more comfortable to sleep propped up with several pillows
in a semi-sitting position.

Follow-up appointments – Your first post-op appointment with the surgeon will be
six weeks after your operation. Your band is usually put in at the operation in a
completely un-filled state and fluid will be injected into the access port which has
been positioned at the base of your breastbone. The procedure is only mildly
uncomfortable. To check that the band is not too tight, you will be given a glass of
water to drink immediately after the fill. You will continue to have further fills of your
band every few weeks until you reach the ‘sweet spot’ at which you are losing weight,
able to eat small solid meals and not feeling hungry. You will also be seen
periodically by the physicians and dietitian.

Returning to work – most patients are back at work by 2 weeks after their surgery.
If your job involves heavy lifting or stretching, check with your surgeon pre-
operatively about how long you should plan to take off.

Blood tests post-op for life – It is essential that you know that after having any type
of bariatric surgery, you must have regular blood tests at your GP Surgery to check
that you are not developing any nutrient deficiencies. The tests will be every 3
months in the first year after surgery and then at least annually for life. We will write
to your GP to tell him or her which tests are needed, but you will need to make the
appointment for them to be done at the intervals we recommend.

Driving – you should be able to drive again after 1 week, but always check with your
insurance company first.

Partying – being socially active is very important to positive emotional wellbeing but
be careful not to overdo it initially. Because you are eating only a small amount, you
may be more prone to the intoxicating effects of alcohol than you used to be!
Musgrove Park Hospital – Bariatric Service                                                  7
Feb 2010
Beware too of the fact that alcohol contains liquid calories and will bypass the effects
of your band.

Patient support group – Remember, the band is a tool and works best when you
think of it as 10% surgical handiwork and 90% your hard work. You will find the
patient group an invaluable resource for learning from other patients and your
success will, in turn, inspire other people considering surgery.


4.        Possible problems

Vomiting – Contrary to some things you may have read about banding, vomiting is
not common because the band is restricted very slowly to the point at which you are
losing weight and able to eat a healthy diet. Occasionally, you may regurgitate if you
eat too fast, eat too much, or the food is not soft or chewed enough. Remember, eat
slowly and stop eating the minute you feel full.

Constipation – Your body will take a little time to adjust to the smaller quantity of
food you are eating. To prevent or treat constipation, drink more water – about a pint
a day more than you used to.

Dry skin – Many patients report developing very dry skin when losing weight rapidly.
You can help prevent and combat this by drinking plenty of fluids, taking your multi-
vitamin and applying a good moisturising cream daily.

Note to NHS patients whose surgery is performed at the Nuffield Hospital
Taunton: If you experience any problems post-operatively that require your
return to hospital, please return to Musgrove Park Hospital and not the Nuffield
Hospital.




   If there is anything that you are concerned about, please don’t hesitate to
  call Yasmin Ferguson, the Bariatric Surgery Clinical Nurse Specialist on:
  01823 343561.




Musgrove Park Hospital – Bariatric Service                                             8
Feb 2010