What is Obesity Surgery?
What is obesity?
Overweight and obesity are defined as abnormal or excessive fat accumulation that presents a risk to health. A body mass index (BMI) over 25 is considered overweight, and over 30 is obese. The issue has grown to epidemic proportions, with over 4 million people dying each year as a result of being overweight or obese in 2017 according to the global burden of disease.
Rates of overweight and obesity continue to grow in adults and children. From 1975 to 2016, the prevalence of overweight or obese children and adolescents aged 5–19 years increased more than four-fold from 4% to 18% globally.
Why should obesity be treated?
It’s very important to take steps to tackle obesity because, as well as causing obvious physical changes, it can lead to a number of serious and potentially life-threatening conditions, such as:
- Type 2 diabetes,
- Coronary heart disease,
- Some types of cancer, such as breast cancer and bowel cancer,
Obesity can also affect your quality of life and lead to psychological problems, such as depression and low self-esteem (see below for more information about the health problems associated with obesity).
Other obesity-related problems
Obesity can cause a number of further problems, including difficulties with daily activities and serious health conditions.
Day-to-day problems related to obesity include:
- Increased sweating,
- Difficulty doing physical activity,
- Often feeling very tired,
- Joint and back pain,
- Low confidence and self-esteem,
- Feeling isolated.
The psychological problems associated with being obese can also affect your relationships with family and friends, and may lead to depression.
Serious health conditions
Being obese can also increase your risk of developing many potentially serious health conditions, including:
- Type 2 diabetes – a condition that causes a person's blood sugar level to become too high,
- High blood pressure,
- High cholesterol and atherosclerosis (where fatty deposits narrow your arteries), which can lead to coronary heart disease and stroke,
- Metabolic syndrome – a combination of diabetes, high blood pressure and obesity,
- Several types of cancer, including bowel cancer, breast cancer and womb cancer,
- Gastro-oesophageal reflux disease (GORD) – where stomach acid leaks out of the stomach and into the oesophagus (gullet),
- Gallstones – small stones, usually made of cholesterol, that form in the gallbladder,
- Reduced fertility,
- Osteoarthritis – a condition involving pain and stiffness in your joints,
- Sleep apnoea – a condition that causes interrupted breathing during sleep, which can lead to daytime sleepiness with an increased risk of road traffic accidents, as well as a greater risk of diabetes, high blood pressure and heart disease,
- Liver disease and kidney disease,
- Pregnancy complications, such as gestational diabetes or pre-eclampsia (when a woman experiences a potentially dangerous rise in blood pressure during pregnancy).
Obesity reduces life expectancy by an average of 3 to 10 years, depending on how severe it is. It's estimated that obesity and being overweight contribute to at least 1 in every 13 deaths in Europe.
What is sleeve gastrectomy?
Sleeve gastrectomy, also called gastric tube surgery, aims to reduce volume of stomach (approximately 60-100 cc) in order to make patients feel full with minimal food intake. A certain part of the stomach is surgically removed and a tube-like stomach is left behind (very similar to banana in size). Moreover, the part of stomach which releases the hunger hormone is also removed. This operation limits only volume of food intake; since nutrients are absorbed in usual way, patients do not need vitamin or mineral supplements.
How do we eat after gastric sleeve surgery?
After your gastric sleeve operation your body will need nutrients to heal your wounds and help you recover fully.
You will pass through five phases of eating that include: clear liquid, full liquid, pureed, soft food, and finally an ongoing protein-rich nourishing diet. You can expect to spend around one week in each phase. You should not skip phases.
Week 1 – Clear Liquids
During the first week after your gastric sleeve surgery you will continue with the clear liquid diet you started a couple of days before your operation. This will give your body time to heal and help avoid post-op complications such as diarrhoea, constipation, and dehydration.
You may think it will be hard to stick to a clear liquid diet but often people feel little or no hunger immediately after their gastric sleeve surgery.
You should start with sips of clear liquid to avoid becoming nauseated. You can gradually increase the amount you take in one go. You must make sure you drink plenty of clear liquid to avoid becoming dehydrated. You should aim to drink a minimum of 2.5 litres over the course of each day. Drink from the time you get up in the morning and throughout the day until you go to bed.
For the first two weeks after surgery, you will be recommended to take vitamin supplements in a chewable or soluble form. Your surgeon will give you further advice on vitamin supplements.
Clear liquids can include:
- De-caffeinated coffee or tea including herbal, fruit, and green.
- Clear broth such as chicken, beef or vegetable.
- Marmite or Bovril drinks.
- Diluted fruit juice such as apple, grape or cranberry.
- Diluted sugar-free squash.
- Sugar free drinks, flavoured water and popsicles.
What you should avoid:
- Caffeine – may contribute to acid reflux and dehydration.
- Sugary drinks – may result in nausea, fatigue, diarrhoea, and even vomiting. Sugar is also full of empty calories.
- Carbonated drinks – may contribute to gas and bloating.
Week 2 – Full Liquids
During the second week after your sleeve surgery, you will continue to drink plenty of clear fluids whilst also incorporating into your diet fuller liquids that are rich in protein. Your appetite may increase but your digestive system is not yet ready to handle solids. You should fill up on a variety of nutritional liquids.
Full liquid choices in addition to your clear liquids include:
- Low fat milk, semi - skimmed or skimmed. Milk can be flavoured with a low-calorie hot chocolate,
- Homemade smoothies,
- Slimming drinks and shakes,
- Yogurt drinks,
- Smooth soups such as cream of tomato, chicken, or oxtail,
- Sugar-free, non-fat plain Greek yogurt, frozen yogurt,
- Fat free, no added sugar ice cream,
- You should still avoid caffeine, sugary drinks and carbonated drinks.
Additional foods to avoid include:
- Sugary foods.
- High-fat foods such as whole-milk yogurt.
- Food that has any lumps.
Week 3 – Pureed Foods
As you reach the end of week two and move into week three you can start to add some “real” but pureed food to your diet. You need to ensure you eat 60 grams of protein each day so include protein in each meal. You can try adding milk when you blend your foods, ensuring that it is free of lumps and a yoghurt like texture.
You may find it tough at this time. Try to eat small portions slowly. Re-introduce new foods slowly, giving your body time to react to each new food so that you can identify any foods that are disagreeable and cause gas, stomach upset, or diarrhoea.
Once you can tolerate pureed foods you can choose a complete A-Z vitamin and mineral supplement in a tablet form, to help prevent nutritional deficiencies such as iron, folate, vitamin D, and calcium deficiencies.
Pureed foods can include:
- Soggy Weetabix or Ready Brek,
- Mashed fruit - bananas, avocados, and canned fruit. Be careful of their sugar content,
- Blended steamed fish in a low-fat sauce,
- Canned tuna and salmon - try adding low fat mayonnaise,
- Mashed sweet potato,
- Low-fat cottage cheese and soft cheeses,
- Liquidised meat or fish stew,
- Liquidised steamed or boiled vegetables,
- Thick blended soups,
- Scrambled eggs,
- Ground chicken or beef.
Additional foods to avoid include:
- Food high in starch such as pasta, rice and bread,
- Tough, raw vegetables such as broccoli, asparagus, celery, and leafy greens,
- Skin and seeds from vegetables and fruits,
- Fatty foods including oils and butter,
- Spicy food.
Week 4– Soft Foods
At week four you can start to add soft foods and lumps to your diet. You can also re-introduce caffeinated drinks, in moderation, at this time.
Soft food ideas to add to your diet include:
- Well-cooked chicken and turkey,
- Soft fish,
- Lean mince meats,
- Well-cooked vegetables,
- Low-fat cauliflower cheese,
- Eggs, including scrambled, poached, or hard-boiled,
- Soups with lumps,
- Canned or soft fruit,
- Sweet potatoes,
- Low-fat cheese,
- Low-sugar cereal.
Additional foods to avoid include:
- Hard-to-digest foods such as steak, tough vegetables, and nuts.
- White potatoes.
Week 5 Onwards – Healthy Diet
By week five you can eat solid food safely. You can use your new eating plan as a template of healthy eating for life.
Your new diet needs to be low in fat, low calorie, and portion controlled. Your bariatric team will offer advice and support for your new diet.
Keep introducing new foods and monitoring any reaction to them. Avoid empty calorie foods that do not have any nutritional value. Try to keep to three small meals a day and minimal snacks. Don’t forget to keep yourself hydrated.
Healthy diet foods include:
- Lean meat, poultry, and fish.
- Low-fat dairy products.
- Steamed or raw vegetables and fruits.
- Good starches and whole grains.
- Fats in small quantities.
Additional foods to avoid include:
- High calorie foods and drinks,
- Sugary sweets and soda,
- Long term diet tips following gastric sleeve surgery,
- You will need to continue eating a healthy, high protein, low fat, calorie-controlled diet for the rest of your life to achieve and maintain your weight goals.
Some top tips include:
- Keep to three small meals a day,
- Have protein in each meal and eat it first,
- Introduce new foods one by one,
- Take a tablet form daily vitamin and mineral supplement as directed by your bariatric team. You will also require vitamin B12 injections (1mg) once every three months,
- Eat slowly and chew your food thoroughly. The more you chew, the easier your food is to swallow and digest,
- Plan your meals so you are not tempted by off-diet foods,
- Drink plenty of water and always have some water to hand,
- If you feel hungry between meals try taking a drink first as your body may be mistaking hunger with thirst. If you are still hungry then have a small snack such as a piece of fruit or a low-fat yoghurt,
- Ask for half portions at restaurants – it may be discounted and it will prevent you from being tempted to overeat.
Foods to avoid:
- Food with empty calories – make wise diet choices and avoid foods with little or no nutritional value.
- Alcohol - is high in calories and your alcohol absorption will dramatically increase after surgery.
- Fizzy drinks - as they cause bloating and can increase your small stomach size.
- High fat foods – they may make you feel nauseous and will not help you to lose weight.
- Tough meats - are hard to chew and hard to digest.
Things to avoid:
- Avoid eating and drinking together - wait at least thirty minutes between eating and drinking. Drinking fluids with meals may lead to an overfull stomach and vomiting. It can also stretch your stomach and “wash” your food through too quickly so that you don’t sense the early signs of fullness and may lead to over eating.
- Avoid overeating - stop eating when you feel satisfied. Overeating will stretch your stomach pouch and may make you vomit.
- Avoid grazing - this often adds extra calories to your controlled diet. It also interferes with your body’s ability to burn fat as insulin levels will be consistently raised.
What is gastric mini bypass surgery?
In Gastric Bypass, a large portion of stomach is bypassed and a small volume of stomach (approximately 30 to 50 cc) is prepped and anastomosed to small intestines. As it is also the case with other obesity surgery procedures, this type of surgery aims that some part of nutrients is discharged without being absorbed by decreasing volume of stomach and inactivating a part of small intestines. Hence, patients feel satisfied with less amount of food and a part of digested nutrients is absorbed.
What is gastric balloon procedure?
Intragastric balloon placement is a weight-loss procedure that involves placing a saline-filled silicone balloon in patient’s stomach. This helps to lose weight by limiting how much he/she can eat and making the person feel fuller faster. Body mass index (BMI) is above 25. Willing to commit to healthy lifestyle changes, get regular medical follow-up and participate in behavioral therapy. Have not had any previous stomach or esophageal surgery.
How does gastric balloon applied?
The intragastric balloon procedure is done in the endoscopy unit as an outpatient procedure. You’ll be sedated for the procedure.
During the procedure, the doctor advances a thin tube (catheter) loaded with the intragastric balloon down patient’s throat into his/her stomach. Next, the doctor advances an endoscope, flexible tube with a camera attached, down his/her throat into stomach. The camera allows doctor to see the balloon as he or she fills it with saline.
The procedure takes about a half-hour. Patient can normally go home one to two hours after the procedure is finished.
What type of balloons are available?
There are two types of balloons which stay in stomach for 6 or 12 months. The decision of it made by patient and doctor. Short term balloon is generally advised for patients who has digestive problems. In both types of balloon procedure, patients may be given drugs that reduce stomach acid and prevent nausea. 12-month balloons can be adjusted in size if needed.
What happens after the gastric balloon procedure?
Pain and nausea affect about one-third of people soon after insertion of an intragastric balloon. However, these symptoms usually only last for a few days after balloon placement. These symptoms can usually be managed with oral medications at home.
What to eat after the operation?
Patient can have small amounts of clear liquids starting about six hours after the procedure. The liquid diet generally continues until the start of the second week, when you can start eating soft foods. You’ll probably be able to start eating regular food around three weeks after the procedure.
Safe foods patients can consume are fish, chicken, meat, egg, limited fruit, tea and linden. Forbidden foods are chocolate, pastry, pies, acidic beverages and fried foods.
How does it work?
An intragastric balloon can make the patient feel more full faster than he/she normally would, which often means he/she eat less. One reason is that the intragastric balloon slows down the time it takes to empty the stomach. Another reason is that the balloon seems to change levels of hormones that control appetite.
The amount of weight person lose depends on how much you can change your lifestyle habits including diet and exercise. Based on a summary of currently available treatments, loss of about 7% to 15% of body weight is typical during the six months after the placement. Total excess weight loss ranges from 30% to 47%.
Permanent healthy changes in your diet, along with regular physical activity and exercise, are necessary to avoid regaining weight.
Who are the experts of an Intra Gastric Balloon?
This procedure is performed by a general surgeon who are specialized in the area of obesity. Having an expert team and equipment is important for patient’s safety.
Why the doctor and hospital where you will be operated are important?
As in all surgical operations, the team and hospital that will perform the operation are very important in bariatric surgery. In order to avoid possible complications in the post-operative period, it should be asked how often the surgical team performs these operations. We offers high-tech devices, experienced doctors at reasonable prices.
Drug Use After Bariatric Surgery
A great majority of patients who are candidates for bariatric surgery suffer from many comorbidities such as diabetes, high blood pressure, high cholesterol and heart diseases. Significant improvements or even complete recovery are observed in such diseases of patients, who have undergone a successful bariatric surgery and have lost weight successfully. They can immediately stop taking all the drugs, in accordance with the recommendations of their bariatric surgeons and relevant physicians. Vitamin drugs needed to be taken after malabsorptive surgical procedures are the vitamin supplements having no harmful effects on the body. In other words, they are drugs added with intent to increase the dosage of vitamins, which are normally taken from foods. Therefore, it is not possible to compare them with compulsory medications used due to preoperative health problems.
How do the drugs that I use be affected by bariatric surgery?
The absorption of some medicines may change, depending on the type of surgery. In addition, the use of large-size tablets and capsules is not recommended in the early postoperative period. They may sometimes cause snagging. Therefore, your surgeon will recommend mouth-soluble and injectable forms of certain medicines, or you will need to take some medicines after mashing them. Some extended-release enteric coated drugs cannot be taken in the mashed form. On the other hand, it may be better to take some drugs after they are mashed and mixed with foods. Surgical procedures such as gastric band surgery and sleeve gastrectomy have a slight or no effect on drug absorption. However, bypass and duodenal switch procedures significantly affect absorption. Some drugs such as antidepressants may need to be taken in considerably higher doses to produce the same effect. This matter needs to be discussed with the relevant specialist.
Will my medicines be changed after bariatric surgery?
Yes, probably. As obesity-related diseases get healed, it may be possible to take certain medicines in lower doses or stop taking them. Patients with diabetes may need less insulin or may even stop taking insulin completely, depending on the type of surgery. Blood pressure and cholesterol drugs also require considerable dose changes in the first postoperative month, and their use may even be stopped. Such decisions should be taken by your physician. Do not attempt to adjust their dosages by yourself or stop their use completely.
What are the drugs that should be avoided after bariatric surgery?
Your consultation with our team about this issue is important. Since antirheumatic analgesics from NSAIDs (Nonsteroidal anti-inflammatory drugs) may lead to gastric ulceration and irritation; they should be avoided after surgical procedures that involve bypass. Bleeding or puncture (both of which are serious complications) may occur as a result of marginal ulcers developing on the anastomosis line. They do not lead to death by can sometimes cause uncomfortable conditions that may last months, and may even require secondary operations and revisions of bypass. Sometimes some surgeons do not recommend the use of NSAIDs after sleeve gastrectomy and gastric band operations. The absorption of some long-acting, extended-release or enteric-coated drugs may be impaired due to bariatric surgery. The best thing to do is enable us to contact your relevant specialist physician, for ascertaining what medication will be affected. In addition, some medicines have an effect on weight gain. In such a case, the balance between the benefit of the medicine and the risk of weight regain should be investigated. Preferring alternative medicines with fewer side effects may be a solution in this regard.
Will I need to use additional medicines after bariatric surgery?
You will have to use two medicines after surgery, regardless of whether you have used medicines before surgery. One of these is PPI, i.e. acid-reducing drug, for a period of 3 to 4 months. The other is Ursofalk preferred by some surgeons, which is intended for preventing the formation of gallbladder stones, and is recommended in the period of rapid weight loss.
Physical Activity After Bariatric Surgery
Physical activity is of great importance for long-term weight control. Each patient may have different needs and abilities. As you progress in your fitness program, your body will tolerate the same activity more effectively and easily. This means that you will burn less calories with each passing day. As your weight loss increases, the calories burned during the exercise performed at the same inevitably decrease. Therefore, you should also increase the duration and intensity of your fitness activity in the course of time. We recommend you to get advice from an exercise consultant about this issue.
How much do I need to exercise?
Current guidelines recommend at least 150 minutes per week of moderate exercise. These can be brisk walking, jogging, Zumba, swimming or the use of exercise equipment. Please note that the threshold for safe toleration of exercise may vary from person to person. It is very important to determine these amounts and durations on the basis of your specific condition.
How long after surgery can I exercise?
This depends on the type of exercise to be performed. You can start walking in the evening of the day of surgery. You can increase the duration and intensity of the exercise as you get better. You can start swimming from the 20th postoperative day, and light gym exercises from the 1st postoperative month.
What kind of exercises should I do?
Combining the aerobics (cardio), resistance, and flexibility exercises will give the best result. You can find the best one for you by trying different exercise programs. What is important is to make an enjoyable program that you can routinely implement at a place close to your home if possible Warm-water exercise programs are perfect for patients with joint problems. If you cannot go to a center, exercises done carefully at home under the guidance of exercise videos will also work.
When can I return to work after obesity surgery? How many days will I stay in the hospital?
Our patients stay in the hospital for an average of 3 days after surgery. You can return to work after the first week after surgery.
Will the surgery prevent me from getting pregnant? Can i get pregnant after surgery?
We do not recommend pregnancy in the first year after bariatric surgery. You can get pregnant after 1 year.
Why do people get loose skin after bariatric surgery?
It’s a typical byproduct of rapid weight loss. Just as your skin stretches as you gain weight (and results in stretch marks), your skin also tightens after you lose weight. However, the speed at which your skin can tighten is limited. This is generally determined by genetics, as some people have more elastic skin than others. When losing weight rapidly, fat cells are shrinking much faster than the skin can tighten. Thus, loose skin.
Not everyone is equally susceptible to loose skin after bariatric surgery. Factors include age, amount of weight lost, and natural tendency to elastic skin.
Are drains and urinary catheters inserted during and after the surgery?
We do not insert drains and urinary catheters during and after the surgery.
How long does bariatric surgery take?
Our surgeries take an average of 1 hour.
I will come from abroad for surgery. How many days will I have to stay in Istanbul?
It will be sufficient to stay in Istanbul for 3-4 days in total for the pre-operative preparation, surgery and post-operative period. Normally this period is 2 days for our domestic patients, but we extend this period to 3-4 days for our patients from abroad so that you do not need to stay at the hotel. We guarantee that you will receive service in the comfort of a 5-star hotel while you are in our hospital.
Will I experience nausea and vomiting after the surgery?
Rarely, our patients experience nausea and vomiting on the first day after surgery, but this is a temporary situation. It will be sufficient to inform our experienced nurses in case of possible nausea or vomiting. You will feel comfortable with the medicines they give you.
Is it possible to safely incorporate alcohol into a healthy diet and lifestyle after surgery?
The short answer is “yes,” but gradually and with modifications. Although it is inconvenient for you to drink alcohol for the first 6 months after sleeve gastrectomy surgery, there is no harm if it is infrequent afterwards. Remember that after sleeve gastrectomy alcohol enter the bloodstream much earlier and causes intoxication much more quickly.
Can i drink coffee after surgery?
Drinking coffee should be avoided for the first few months after sleeve gastrectomy surgery to help the stomach heal properly.
Assoc. Prof. Mustafa ATABEY, M.D.
Obesity and Metabolic Surgery Specialist