FAQ

After significant weight loss it is common to find that the skin in parts of your body has become redundant and will hang down to various degrees causing discomfort and embarrassment. This most commonly occurs in the lower abdomen but also in the upper arms, breasts, buttocks and thighs. The amount of loose skin you have depends on the total weight loss you have had, your age and your general body habitus. 

Surgery is available to remove loose skin from these areas, although usually the trade-off is a permanent scar where the resection was done. Plastic surgeons and some weight loss surgeons perform these procedures but the amount your insurance company will cover will vary depending on the procedure. 

Massive weight loss is associated with prominence of loose skin folds.  These are particularly evident around the abdomen, thighs, upper arms and in women, the breasts may be affected.  Large redundant skin folds can be a source of infection, irritation and cosmetic concern. They may also interfere with toileting or sexual function.

Body contouring procedures are available for most areas of skin redundancy and are best performed when weight loss has plateaued, usually after 12 months for most bariatric procedures.

Abdominoplasty involves removing excess skin and fat from over the abdomen to prevent the "apron" hanging down.  In most cases, the abdominal muscles, which have been stretched by chronic obesity, can be tightened up at the same time.  Sometimes the belly button needs to be replaced and will be surrounded by a silvery scar for the rest of the patient's life.  A long scar the entire width of the abdomen will be present after the operation just above the pubic bone, in the same region as a Caesarean Section scar

Your nutritional state can be negatively affected with sleeve surgery.  In particular vitamin D, calcium and B12 absorption may be reduced.  Every sleeve patient should be on a multivitamin as recommended by a dietician and more supplements may be suggested depending on your blood profile.  Regular blood tests (every year for example) should be done to check up on things over time.  If supplementation is adhered to it is rare for any major nutritional issues to manifest.

In the first week or so you will be limited to liquid or soft foods.  Thereafter you should be able to take a normal diet for the remainder of balloon implantation as long as nausea or vomiting from the initial implantation has settled down.  Our dietician will discuss with you a diet which will allow healthy weight loss whilst the balloon is inside. 

As you get older, the long term metabolic benefits from weight loss are less clear.  In addition the risks of bariatric procedures may be higher.  Nevertheless, many studies have shown significant quality of life improvements for older patients.  Patients in their 60s may be suffer impaired mobility, back and joint pains and challenges to their independence.  As well as general health benefits, weight loss can improve these issues.  Patients over 65 should be considered on a case by case basis focusing primarily on quality of life improvements.

After two or three years it is extremely common for sleeve patients to regain a little weight.  You should expect it and accept that it is a pretty normal thing to occur.  A minority end up regaining quite a lot of weight which can be devastating after such good early results.  Maintaining a regular exercise programme and good dietary habits are, of course, critical to long term success.  Some patients will elect to undergo further surgery to get their weight loss back on track, such as re-sleeve, gastric bypass or other forms of surgery.

This is different for everyone but mostly people do not feel much pain with a band adjustment.  Sometimes there may be an uncomfortable feeling related to the sensation of the needle hitting parts of the port but usually this is very tolerable.  When ports are difficult to access (e.g. very deep) or placed under the muscle there may be a little more discomfort involved.  Generally it is not useful to use local anaesthetic to numb the skin as the anaesthetic itself causes a degree of pain and discomfort when infected.

My preference is to form a long, narrow pouch with a length around 6cm and volume around 60ml in most cases, about the size of a large egg.

The Endobarrier is another endoscopically implantable device to stimulate weight loss.  It consists of a sheath about 60cm long which is placed just beyond the stomach which must be removed at a maximum 12 months after placement.

The Endobarrier is thought to have anti-diabetic effects along with weight loss due to increased gut hormone release after implantation. 

Although the Endobarrier can be placed for more than 6 months, weight loss has mostly plateaued by 6-9 months with the device.  It is newer than the balloon and has much less published data available regarding its safety and efficacy.  In practice it probably has around a 10% complication rate mainly because of the anchoring device in the duodenum which can occasionally cause bleeding, perforation, migration, pancreatitis or liver abscess.  In this sense it could be argued that the balloon is a safer and better studied procedure than the Endobarrier with roughly comparable weight loss.

Mr Clough is trained in both Endobarrier implantation and removal as well as the intra-gastric balloon.

When the stomach is cut, fine staples seal off the remaining portion.  A small minority (2%) of patients will have a leak from the staple line which can make you very sick unless treated promptly.  It is unlikely a leak will occur after one week post op if you have had no adverse symptoms, therefore the healing is mostly complete.  However there is still swelling and tightness involved so we recommend avoiding normal textured solid food until one month post surgery.

Currently the intra gastric balloon is not covered by Medicare or private health insurance.   Therefore there is minimal rebate available for the procedure.

The costs are primarily made of up of hospital and theatre costs, professional fees and the cost of the balloon itself.

Total costs usually end up between $6,000 and $8,000.  This package does not include pathology bills or other miscellaneous unforeseen expenses which may arise. 

Around 80% or so of your stomach is removed.  In the collapsed state it doesn’t seem like much and can be extracted through one of the 12mm keyhole port sites (with some difficulty!).  The removed stomach is highly distensible however and when full or under pressure can expand up to 2 or 3 litres.

Gastric bypass is a powerful weight loss procedure which generally results in a loss of about 70% of your excess weight.   The excess weight is that part of your weight over and above what is generally considered your healthiest weight (at BMI 25).   If you are of average height and weight 130kg you may expect to lose between 40 and 50kg on average. 

Weight loss after sleeve gastrectomy depends on your starting weight and possible your age and exercise levels.  An average result after 12-18 months post surgery is between 60 and 70% of your excess weight.  The excess weight is that part of your weight over and above what is generally considered your healthiest weight (at BMI 25).   If you are of average height and weight 130kg you may expect to lose between 30 and 40kg on average.  However many patients will lose more than this and a few will lose less.

Weight loss success with the band is quite variable.  For some individuals the key seems to fit the lock and the weight comes off very easily.  Others have a constant struggle with food choices, food portions, eating style and suffer frequent vomiting.  It is not easy to predict who will succeed with the band and who will not.

Most studies suggest that the average excess weight loss with the band is about 50%.  This means that if you start out 120kg and your ideal weight is 70kg (if your BMI was 25) then you would expect to lose about 25kg all together.  Many people do manage to lose more than 50% of excess weight with the band, but many do not even lose this much.  Over a period of time, the chance of an individual losing 50% of their excess is itself about 50%.  This variability in outcomes with the band is key reason why some individuals prefer to look at gastric bypass or sleeve gastrectomy which tend to bestow a greater reliability of success. 

Weight loss with the band is a slow and steady process and can take up to 18 months to complete. 

Whether you can feel your access port depends on a number of factors including the surgeon’s choice of port position and how much fat you have between the skin and the muscle layers.  If you try hard enough you can almost always locate your port in the upper abdomen as a small firm lump deep underneath the skin. 

Occasionally ports cause discomfort during usual activities of life, such as at work, playing sport or even during sex.  If the sensation of the port is excessively uncomfortable, it is possible to place the port underneath the muscle of the abdominal wall which will make it much more difficult to feel or see.  The downside of this port position is that needle access to the port tends to be a little more difficult and painful. 

Anyone you talk to who has undergone a weight loss surgery journey will tell you that it’s not easy!  And it’s not the first journey they have undertake.  Weight loss surgery patients have all tried commercial diets and exercise programmes but have been unable to succeed other means.  Current evidence would suggest that weight loss surgery probably the only way for these patients to have a chance of success.  Weight loss surgery necessarily involves major lifestyle changes in terms of eating habits, nutritional monitoring and adopting an exercise programme.  It is a big step to take and one that patients should be proud of.

It is a common misconception with gastric banding surgery that one can lose the weight then have the band reversed (removed) and all will be well.  It is well understood that having the band removed leads to weight regain in almost every circumstance.  Those who have had success with the band are never interested in having the band removed!

The commonest places for redundant skin to appear after massive weight loss is the abdomen.  Other common areas include under the arms, thighs, breasts, sides and buttocks.  Unfortunately the loose skin will not resolve on its own even with significant toning in the gym.  How much redundant skin you may develop varies greatly from individual to individual and is influenced by factors such as age, skin tone, fat distribution and how much weight you lose.   Loose abdominal skin can be treated by abdominoplasty surgery, swapping the overhanging skin apron for a long scar with a scar around a new belly button.  Skin under the arms can be removed with brachioplasty surgery leaving a long scar down the arms which may be visible in certain positions.  Breasts, buttocks, thighs may be dealt with corresponding surgery, such as a breast lift and fill.

Arm reduction (brachioplasty) surgery involves removing redundant skin under the upper part of the arms (above the elbow).  The skin is replaced by a long scar which may be from just before the elbow up into the arm pit.  The scar will be seen in certain positions no matter how carefully it is placed.

It is possible that some of the weight you lose during balloon implantation could be regained after the balloon is removed.  This is more likely if your dietary and lifestyle habits remain unchanged over the period of implantation.  Further options at this point include re-implantation of the balloon (after a rest period of at least six weeks) or consideration of other weight loss interventions.

Up to 2% of patients will experience a leak after sleeve gastrectomy surgery.  A leak occurs when part of the sealed stomach breaks open and stomach acid and other contents spill into the surrounding spaces in the body.  This can make you very sick if not treated promptly.   It is your surgeon’s job during your hospital stay to pick up signs of a possible leak such as a fever or racing pulse.  In most cases a leak means a return to operating theatre to insert a drain to channel the noxious stomach contents away from the rest of the body and perhaps a feeding tube through the nose and stomach to provide nutrition as it is not advisable to eat or drink whilst a leak is present.  Sometimes other endoscopic treatments are used such as stents, clips or biological glue.  Most leaks will resolve with time (but could be many weeks!).  Occasionally a persistent leak may need major reconstructive surgery to resolve, which represents the worst case scenario.

A leak will generally (but not always) present during your hospital stay after the bypass operation. The risk of leak should be less than 2-3% if you have not had previous surgery on the stomach.  Leaks should be diagnosed and treated promptly for best results as delaying treatment can make you very sick.  At least one re-operation is normally required once a leak is diagnosed, to ensure that the leak is drained properly and infection is minimised.  Leaks will then generally heal by themselves over a few weeks as long as nutrition is maintained. Maintenance of nutrition is best done via a feeding tube during this time as you cannot eat and drink normally whilst the leak is healing. Procedures to encourage healing of the leak may include stent insertion to open up any narrowings or special devices such as clips or plugs.

The older guidelines for bariatric surgery did not include the range BMI 30 – 34.9.   However these guidelines were originally penned in 1991 when most surgery was performed open rather than keyhole and gastric bypass surgery was primarily used for outcome analysis.  These days we can perform most weight loss surgery laparoscopically and the safety and knowledge regarding these operations has improved. 

In 2010 a meeting of medical and surgical experts released a consensus statement after a conference in Rome, Italy.  This statement related to poorly controlled diabetics with BMI 30-34.9 and was supportive of a role for weight loss surgery in selected patients in this range. The FDA of America in 2011 approved the Lap Band system for use of in selected patients with BMI between 30 and 34.9.

In practice, if your BMI is less than 35, selection is individualized rather than guaranteed.  You will need to demonstrate a strong understanding of the pros and cons and basic rationale for surgery to be considered.  The responsibility for the decision for surgery is more in your hands as the overall metabolic benefits of weight loss in this group is likely to be less than those with BMI > 40 for instance. 

For many years, classic guidelines describing eligibility for bariatric surgery have indicated BMI > 40 or BMI > 35 with medical conditions such as diabetes or hypertension is necessary to qualify. This is because the risks of the surgery were not felt justified for the modest medical gains from those who are only mildly obese.  However in recent times, the safety of the procedures has improved and more information is available about potential benefits.  All the major bariatric procedures can now be performed with keyhole surgery.  Therefore in many cases patients with BMI between 30 and 35 may be assessed on an individual basis for surgery, particular if the patient has bad diabetes.

The band is placed around the top of the stomach and usually stitched into place.  In up to 5% of cases, the band will slip out of position and end up further down the stomach.  Usually the symptoms of this will be difficulties tolerating foods that were previously ok, increase in reflux symptoms and vomiting.  It can occur any time after the original band placement.

In the worst case scenario the pressure within the slipped band gets so high that the blood flow to the stomach is compromised.  In this situation it is impossible for the patient even to keep fluids down as the band is completely obstructed.  If there is a delay to surgery in this case it could lead to death of part of the stomach which is a very serious and even life-threatening condition. 

Key Point: If you are unable to tolerate fluids with the band you should seek urgent medical attention

In ordinary circumstances, however, band slips are not dangerous and can be fixed with further surgery.  Revision surgery may involve simply re-positioning the band back into the correct position, placing a new band in the correct position or removing the band altogether.  If the condition of the entrapped stomach is poor, temporary removal of the band may be the safest choice. 

“Mini” gastric bypass (or “Omega loop” gastric bypass) is really a misnomer as there is nothing “mini” about it.  The essential feature of the operation, creating a small stomach pouch, is exactly the same as the well established Roux en Y Bypass.  The only difference is that a loop of continuous bowel, rather than a separated segment of bowel is brought up to the pouch to maintain continuity, and a larger portion of small bowel is “bypassed”. 

Advocates of the procedure believe that because there is one less join to create in the procedure it is simpler and takes less time to do.  In practice the extra join required in Roux en Y bypass adds about 20 minutes to the operation.

The downsides of so-called “Mini” gastric bypass include a higher chance of acid or bile reflux from the loop of bowel hooked up to the stomach pouch.  This kind of reflux will not be easily controlled with anti-acid medication.  In addition,  malnutrition may be more likely due to the longer length of bypassed small bowel and there is also the fact that the procedure has not been studied for as long and in as great detail as Roux en Y bypass.  Occasionally cases of mini gastric bypass may need to be converted to Roux en Y bypass because of issues with reflux.

For these reasons I prefer to offer Roux en Y bypass rather than Mini bypass as the gold standard procedure until there is compelling evidence available to support newer variations.

More detailed information regarding the procedure can be found here:

http://www.bariatric-surgery-source.com/mini-gastric-bypass-surgery.html

A banded bypass involves placing a small silicone ring around the pouch to maintain restriction.  This ring is completely different to an adjustable gastric band or “lap band” and is much smaller and simpler.  The rationale behind the ring is to counter the long term possibility that either the pouch or the join to the bowel or even the bowel itself may expand with time, possibly allowing more food intake and hence weight regain.  Long term studies indicate excellent durability of weight loss with the banded approach.

A gastric balloon is a non-surgical and short-term (temporary) weight loss device. A smooth, soft saline-filled balloon (about the size of an grapefruit) is placed in your stomach, allowing you to control your portion sizes by filling space in your stomach. By following professional health and wellness advice, you can adopt good healthy eating habits and change your lifestyle so you can lose weight quickly and keep it off long term. Once in place, the gastric balloon is filled with saline to partially fill the stomach so that they may consume smaller portions of food. Most weight is lost in the first three months, but because the gastric balloon stays in for six months, you will learn the right amount of food to eat to maintain your new weight long term.

The remaining stomach stays in its usual place but out of circuit as far as food and drink goes.  It still makes stomach acid and substances such as intrinsic factor to aid Vitamin B12 absorption.  If you ever need the bypass reversed the stomach is sitting there waiting to be utilized again.

The balloon is implanted temporarily and allows for modest weight loss to occur.  Because it is relatively safe compared to the more conventional weight loss surgeries it is suitable for lower BMI individuals.  Your BMI should be more than 27 and you should have had no previous surgery on your stomach. 

Examples of situations where balloon implantation could be considered:

1. Failed many diets and considering weight loss intervention.  Want to try a safe, reversible procedure before considering more invasive options
2. BMI 27 – 35 and need a kick start for moderate weight loss
3. Unsuitable for conventional weight loss surgery for medical or other reasons but ok for an endoscopic solution
4. Need to lose weight quickly for either medical or social reasons.  Wedding, party, holiday for example.  Also those needing other kinds of surgery such as a knee replacement and needing to lose weight in advance of this

If your weight loss has slowed or stopped with the band, there are a number of possible reasons:

You may have reached your plateau weight.  The average weight loss with the band is 50% of your excess weight (your weight above BMI 25).  If you have reached around this point, it may be as far as you are going to go without making some further significant changes to your lifestyle.  If you and your dietician are happy with your eating choices and habits, increasing your exercise and activity levels may improve and maintain your weight loss at this point.

You may need a further fill of your band.  If your band is not restricting your portion size and inducing satiety it may be too loose.

You may be choosing high calorie foods and liquids which are not easily prevented by the band.  For example soft drinks, cordials, fruit juices, milkshakes, crackers, cheese, lollies, chocolate and so forth.  If you are having trouble avoiding these foods or are a frequent comfort eater you might consider consulting a psychologist for advice on behavioural intervention strategies. 

You may have a technical problem with the band.  If you have a band erosion or a leak from the system you will not be getting the restrictive effects that you need from the band.  Your surgeon can investigate for these problems if need be. 

The band may not be suitable for your weight loss needs.  Some people simply do not manage to lose the desired amount of weight despite prolonged attempts with the band.  

If banding does not appear to be giving you the results you need after prolonged attempts it may be worth considering converting to gastric bypass or sleeve gastrectomy surgery

For those suffering from severe obesity, significant weight loss through dietary programmes is challenging to achieve.  Obesity is not a choice but a disease process with a range of factors involved including genetics, physiology, behavioural programming, psychological factors and environmental factors.  Will power alone is often not sufficient to fight biology and most studies looking at dietary programmes for severe obesity show that initial gains are usually unsustainable for the long term.  You are fighting a complex disease process. 

The amount of fluid required to produce the correct degree of restriction and satiety is highly variable between individuals.  There are also differences between the types of band, for example, the Lap Band APS system has a maximum of 10ml, whereas the Lap Band APL has up to 14ml.  The old style Lap Band is smaller and only takes around 4ml altogether.  Differences in restriction from filling the band may also related to the size of your stomach or other anatomical factors.  Generally speaking it is best to get by on as little fluid as possible in the band to minimize vomiting and poor food choices. 

The balloon as a foreign body inside the stomach can irritate the stomach.  As well as an inflammatory reaction, erosions of the stomach lining can occur and ulcers.  The stomach wall can thicken abnormally in response.  The stomach will heal after then balloon is removed but to maintain safety it is recommended that the balloon is removed at a maximum of six months after insertion.  In addition, the material the balloon is made of will degrade due to the acid environment of the stomach leading to deflation of the balloon which may cause complications.

The main change you have to make with the band is not so much the kind of food you eat but rather how you eat it.  In theory there should be no particular food restrictions with the band, but foods need to be in smaller portions, chopped carefully and chewed well.  It is important to slow your rate of eating so that food does not accumulate in the oesophagus above the band during your meal.  This leads to vomiting and regurgitation.  You will need to learn to pause between each mouthful to allow the last quantity of food to start moving beyond the band.

Sometimes you will need to alter the textures of some of the foods that you like to eat.  For example, minced meat is usually easier than a standard cut of meat and casseroled dishes tend to be more easily tolerated.  Bread, rice and meat products tend to be the most difficult to eat but it is important to continue with these products in your diet – just reduce the quantities that you consume.

The sleeve is an operation which can promote reflux symptoms, however it is unpredictable who will experience them.  Most patients do not get significant reflux after sleeve and those who do are almost always well controlled with anti-acid medication.  Rarely a patient experiences reflux severe enough to warrant further revisional surgery, in this case to gastric bypass.

Dumping syndrome occasionally occurs in bypass patients, and also sometimes in sleeve patients. The most common manifestation of dumping in gastric bypass patients involves a feeling of nausea, cramping, sweatiness and fatigue within 15 minutes or so of a meal that is typically high in simple carbohydrates. The sensation will pass in a short while but can be quite unpleasant.  Dumping is usually not a prominent feature of gastric bypass experience and tends to be overstated as a post-operative problem. If it does occur it is often settles with time and is manageable with dietary modification.

A comprehensive description of Dumping Syndrome symptoms can be found here: http://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/dumping-syndrome/Pages/facts.aspx

Although a wide range of foods are tolerated with the bypass, the amounts consumed are much less and vitamin supplementation is essential for the rest of the patient’s life. In particular, vitamin D, iron and B12 must be carefully monitored at least yearly.  In most cases if supplement protocols are adhered to and monitored vitamin deficiencies should not be a problem.

The band is made of silicone and does not stimulate the body’s immune system, so there should be no concerns regarding rejection of the band.  The band may become infected (rarely) but this is a different problem.  Apart from mechanical and technical issues which may rise, such as band slippage, the band is a safe device which will co-exist harmlessly inside your body.

Type II diabetes usually responds very well to weight loss and particularly bariatric surgery.  Successful bariatric surgery will almost always result in reduced medications required for diabetes, lower blood sugars and improved blood tests.  Often, medications can be dispensed with altogether.  Early diabetes which has only recently been diagnosed responds particularly well.  Gastric bypass induces further hormonal changes which independently fight diabetes and is a particularly powerful anti-diabetic intervention.

Obstructive sleep apnoea usually has a relationship to your weight and weight loss will improve most cases of OSA.  Having said this, it may not completely reverse every case of OSA and it may still be necessary to use CPAP at night for long term medical health.  This decision needs to be made in consultation with your respiratory physician.

In the first week it is common for nausea and vomiting to occur.  This can be a difficult period however it will almost always pass as your body adjusts to the device.  After the initial adaptation period, episodes of prolonged vomiting should be unusual and reported to your surgeon.

The volume of the stomach often does tend to increase somewhat with time.  This is not necessarily the reason why some patients regain some weight down the track but it may contribute.  The powerful sensation of early satiety and fullness and reduced appetite will usually lessen somewhat with time in any case.  It is probably not the case that you can make the stomach stretch yourself by over eating.