Who can use it?
In Wales the Welsh Health Specialised Services Committee has produced a policy document which sets out the criteria that need to be fulfilled for an individual to qualify for consederation for Bariatric Surgery. This policy applies to all seven Health Boards in Wales.
The policy says that individuals must satisfy all elements of the access criteria for assessment and treatment to proceed.
The access criteria for specialised bariatric services are set out below:
- The individual is aged 18 years or over;
- The individual has a BMI of 40 or greater;
- Morbid/severe obesity has been present for at least five years;
- The individual has received, and complied with, an intensive weight management programme at a multi-disciplinary weight management clinic (level 2/3 of the All Wales Obesity Pathway) for at least 24 months duration, but has been unable to achieve and maintain a healthy weight; and
- The individual is approved for surgery by the bariatric MDT at the Welsh Institute of Metabolic and Obesity Surgery, Abertawe Bro Morgannwg University Health Board.
When weight loss surgery isn't suitable
Weight loss surgery may not be recommended if you have a serious illness that would not be improved after the operation, such as:
Weight loss surgery is also unlikely to be recommended if a mental health condition or other underlying factor means you'd be unable to commit to long-term follow-up and lifestyle changes.
Examples of these conditions and factors include:
- schizophrenia for which you are refusing to seek treatment
- actively abusing alcohol or drugs
- a previous history of not complying with medical recommendations about your care
- patients who are unable or unwilling to participate in prolonged medical follow-up.
- active/Unstable mental health illness
- severe depression, personality and eating disorders.
- active alcohol abuse and/or drug dependencies.
- a previous history of not complying with medical recommendations about your care
Children
Weight loss surgery would only be considered to treat obese children in exceptional circumstances, and only if the child is physically mature (around the age of 13 for girls and 15 for boys).
Most experts in obesity would only recommend surgery as a last resort treatment for children who are severely morbidly obese (a BMI of 50 of above), or who are morbidly obese (a BMI of 40 or above) and also have a serious health condition that would improve if they lost weight.
Read the NICE guidelines on managing overweight and obesity among children and young people.
How is it performed?
The three most widely used types of weight loss surgery are gastric banding and sleeve gastrectomy. These procedures moderate patients’ appetite and stimulate metabolism to cause substantial and sustained weight loss.
These operations are usually performed as a type of laparoscopic (keyhole) surgery, where a series of small incisions are made in the abdomen, rather than one large incision. The advantage of this type of surgery is it causes less pain afterwards and has a faster recovery time.
However, laparoscopic surgery may not always be possible in severely morbidly obese people, or those who have had other abdominal operations.
They are carried out under general anaesthetic, which means you'll be asleep during surgery and won't feel any pain.
The surgeon makes the incisions in your abdomen, then inserts an instrument known as a laparoscope through one of the cuts. A laparoscope is a thin, rigid tube containing a light source and a camera. The camera relays images of the inside of your abdomen to a television monitor.
Each type of surgery is discussed in more detail below.
Gastric banding
Other small instruments are placed through the cuts to place a gastric band around the top of your stomach, effectively dividing your stomach into two, leaving a small pouch at the top.
As it takes less food to fill the pouch, it takes less food to make you feel full.
The band is connected to an access port, which is placed under the skin. Saline (sterile salt water) can be injected into this port to inflate the band. This allows the band to be adjusted as required after surgery.
The surgery usually takes around an hour to complete.
Gastric bypass
Gastric bypass uses special surgical staplers to create a small pouch at the top of your stomach. This pouch is then connected directly to a section of your small intestine, bypassing the rest of the stomach and bowel.
This means it takes less food to make you feel full and you'll also absorb fewer calories from the food you eat.
Sleeve gastrectomy
During a sleeve gastrectomy, part of the stomach is removed. This restricts the amount of food that can be eaten and results in you feeling full sooner than normal when eating.
It can also moderate the appetite and stimulate metabolism to cause substantial and sustained weight loss.
Bypass, banding or sleeve?
All three types of surgery have advantages and disadvantages.
There's usually more weight loss after a gastric bypass and sleeve gastrectomy than after a gastric band.
Most people with a gastric band lose around half their excess body weight, whereas most people with a gastric bypass or sleeve gastrectomy lose around two-thirds of their excess body weight.
However, because it's more technically demanding, a gastric bypass carries a higher risk of complications, including death. Read about the risks of weight loss surgery.
A gastric band is reversible, so if you find it difficult to cope with the restrictions associated with life after surgery, you can have the band removed.
Although if the band is removed any restriction to your appetite is reduced and weight regain may occur.
A gastric bypass or a sleeve gastrectomy, on the other hand, can't be reversed. You'll also be required to take nutritional supplements for the rest of your life if you have a gastric bypass or a sleeve gastrectomy.
A gastric bypass often has a much greater impact on type 2 diabetes, in a shorter time, than either a gastric band or sleeve gastrectomy.
Discuss the advantages and disadvantages of both types of surgery with your surgical team.
Other types of bariatric surgery
Other types of weight loss surgery, which are less commonly used, are outlined below.
Bilo-pancreatic diversion
A bilo-pancreatic diversion is similar to a gastric bypass, except a much larger section of the small intestine is bypassed, meaning you'll absorb even fewer calories from the food you eat.
A bilo-pancreatic diversion can achieve a good level of weight loss (up to 80% of excess body weight) but it carries a high risk of complications and can cause unpleasant side effects, such as unpleasant-smelling diarrhoea.
Because of this, a bilo-pancreatic diversion is usually only recommended when it's felt that rapid weight loss is required to prevent a serious health condition, such as heart disease, from getting worse.
Intra-gastric balloon
An intra-gastric balloon is a soft silicone balloon that's surgically implanted into your stomach. The balloon is filled with air or saline solution (sterile salt water), and so takes up some of the space in your stomach. This means you don't need to eat as much before you feel full.
This procedure is only temporary, and the balloon is usually removed after six months. The procedure is useful if you don't meet the criteria for the other types of surgery – for example, because you're too obese.
An intra-gastric balloon procedure can usually be done without making an incision in your abdomen. Instead, the balloon can be passed through your mouth and down into your stomach using an endoscope (a thin, flexible tube that has a light and a camera on one end).
Read more information about a gastroscopy.
Recovery
After weight loss surgery, you will need a few days to recover. It may also be several weeks or months before you can resume normal activities, depending on the type of surgery you have.
Recovering from a gastric band operation
When you wake after surgery, you will probably have some pain at the site of the surgery. This is normal and should pass within a few days.
Blood clots are an uncommon but serious complication that can occur after banding, including:
To reduce the risk of blood clots, you may be given a blood-thinning medication, such as heparin, and compression stockings to wear.
Once you feel well enough, move around as much you can as this will further reduce your risk of blood clots.
For the first 24 hours, you will only be allowed to drink a small amount of liquid to prevent vomiting.
Gradually, small amounts of solid food will be introduced into your diet. For more information, see Weight loss surgery - recommendations.
Gastric band surgery may be carried out as a day case and most people are well enough to leave hospital within 24 hours of surgery. You can resume normal activities within two to three weeks.
Four to six weeks after surgery, your stomach should have healed enough that your band can be adjusted by inflating it with saline (sterile salt water).
This is done by inserting a needle via the access point through which the saline is pumped. The band will then inflate and constrict the upper pouch of your stomach. The whole process takes around 15 minutes. This is sometimes done after numbing your abdomen with a local anaesthetic, using an X-ray to locate the band.
Often, this process of adjustment is a fine balancing act. For example, if the band is too loose you may not lose weight, but if the band is too tight, you may vomit after eating.
Therefore, it can take a number of sessions before the ideal adjustment for your band is reached.
Recovering from a gastric bypass & Sleeve Gastrectomy
Once you wake after surgery, you will probably have a drip in your arm, to provide your body with liquids.
This will be removed when you are able to drink sufficient fluids by mouth.
Again, you may be given blood-thinning medication and compression stockings to wear to help prevent blood clots.
You will only be allowed a liquid diet immediately after surgery, and solids will be slowly introduced into your diet.
Most people are well enough to leave hospital one to four days after surgery and resume normal activities within four to six weeks.
Recovering from other types of weight loss surgery
The recovery time for other types of weight loss surgery are:
- sleeve gastrectomy - one to four days to leave hospital and two to three weeks to resume normal activities
- bilo-pancreatic diversion - one to four days to leave hospital and four to six weeks to resume normal activities
- gastric balloon - fitting a gastric balloon is a non-invasive procedure (does not involve making incisions in your body), so you should be able to leave hospital on the same day and resume normal activities almost immediately
You'll also only be allowed a liquid diet immediately after these types of surgery, and solids will be slowly introduced into your diet.
Risks
Complications of weight loss surgery
Possible complications of weight loss surgery
Weight loss surgery is a common and safe procedure. However, as with any operation there are risks. Your doctor will explain these to you.
Blood clots
Blood clots are possible after weight loss surgery because of how the blood flows and clots after surgery. Blood clots often start in the lower leg (deep vein thrombosis) or may sometimes dislodge and travel to the lungs (pulmonary embolism).
If you have a blood clot that causes pain or swelling, your doctor can give you anticoagulant medicines to help.
Stomach leak
In the days or weeks after a gastric bypass or sleeve gastrectomy, there's a small chance that food could leak out of your tummy (abdomen).
This can cause a serious infection inside your tummy that will need antibiotic treatment.
Gastric band slipping out of place
If you have gastric band surgery, there's a small risk that the band could move out of position.
This can cause:
- heartburn
- nausea (feeling sick)
- vomiting (being sick)
See a GP if you have these symptoms and they do not go away. If your band has moved, you'll need further surgery to put it back in place or remove it.
Wound infection
Wounds can become infected after surgery. Keeping a wound clean will reduce the risk of infection and encourage the healing process.
Blocked gut
The stomach or small intestine sometimes becomes narrower or blocked after weight loss surgery and food can get stuck.
This can be caused by scarring and reduced blood flow to the area.
Reduce the risk of a blockage by:
- cutting food into small chunks
- chewing thoroughly
- not drinking during meals
Gallstones
Gallstones are small stones, usually made of cholesterol, that form in the gallbladder. They can form if you lose weight quickly.
Excess skin
As you lose weight after surgery, you may be left with excess folds and rolls of skin, particularly around your breasts, tummy, hips and limbs.
Surgery, such as a tummy tuck, can be used to remove the excess skin. But it's usually considered cosmetic surgery so it's not always available on the NHS.
Ask a GP if surgery to remove excess skin after weight loss surgery is provided on the NHS where you live.
Call 999 or go to A&E if:
- you have difficulty breathing and pain and swelling in your leg
- you have chest pains and pain and swelling in your leg
- you have severe tummy pain
- you're bleeding non-stop from your bottom
- there's a lot of blood, for example, the toilet water turns red or you see large blood clots
- you're vomiting blood or poo, or your sick looks like coffee grounds or soil
Ask for an urgent GP appointment or get help from NHS 111 Wales if:
You've had weight loss surgery and you have:
- redness, tenderness, swelling or pain in your leg that is not getting better or gets worse
- a high temperature or you're feeling hot and shivery
- a fast heartbeat
- tummy pain
- fast breathing
- difficulty swallowing
- regular vomiting (being sick)
These symptoms could be a sign of a blood clot or a problem with your stomach.
You can call 111 or get help from 111 online.
See a GP if:
- you have pain in or around a wound
- you have red, hot and swollen skin
- pus is coming from a wound