The National Health Service (NHS) has strict criteria as to who should be considered for bariatric surgery. This is based mainly upon evidence from the National Institute for Health and Clinical Excellence (NICE) obesity clinical guideline (CG) 43.
The NHS will consider people for bariatric surgery if they have a BMI equal to or greater than 40kg/m2 or a BMI of 35kg/m2 or above with weight related health problems. People must have tried and exhausted all other weight loss methods before being considered.
The medical problems that are generally considered to be obesity related include:
Many patients with obesity suffer from depression and/or anxiety, or have problems in their past that mean they may need a little more support adjusting to surgery. Some people may be referred to see a psychologist before they have surgery. This is to make sure that they get the support required through their weight loss surgery journey and have safe, successful long term weight loss.
Most areas will require people to have attended a local community weight management programme before being referred for bariatric surgery. These programmes have doctors, dietitians, psychologists, nurses and exercise therapists to assess, advise and monitor people’s progress. These weight management programmes vary in length and can last for up to 2 years. It is usually the staff in these programmes or your GP that will decide if you are a suitable for consideration for bariatric surgery. Some areas have higher BMI referral criteria for bariatric surgery on the NHS, such as a BMI 45kg/m2 and above or BMI 50kg/m2 and above. You should check with your General Practitioner (GP) or community weight management programme what your local bariatric surgery NHS referral criteria and referral process is.
In the private health care sector people who pay for bariatric surgery themselves can be considered for bariatric surgery if they have a BMI equal to or greater than 40kg/m2 or a BMI of 35kg/m2 or above with weight related health problems as per NICE CG43 guidance. Some surgeons will consider performing bariatric surgery on people with BMI’s between 30kg/m2 and 35kg/m2. This will depend upon each individual’s circumstances and health.
People who wish to self fund their bariatric surgery will be assessed by the surgeon and dietitian/nurse. They should still have demonstrated that they have tried other weight loss methods.
However people who self fund their surgery do not have to have attended any community weight management programmes and therefore this can significantly reduce the length of time between being assessed by a surgeon and dietitian/nurse and having their bariatric operation.
People who are self funding their bariatric surgery, generally do not have to wait for long before having their surgery. They can also usually decide a operation date that is convenient to them.
There are a number of bariatric surgery packages available from many different companies. It is important to consider and choose the right company, surgeon and aftercare package that meets your needs.
See “How to choose a surgeon/ hospital” for more information.
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Before you have surgery, your surgeon and anaesthetist may want you to have a number of investigations, to make sure that you are healthy and to make sure there are no problems on the day of surgery.
There are a number of blood tests that may be taken before any operation. These are done to check how well your liver and kidneys are functioning, as surgery can occasionally put strain on them. They also check that you are not anaemic (lack of red blood cells). Red blood cells carry oxygen around the body, and this keeps your cells and organs working properly. If you are low in red blood cells, you may be given some iron (this helps the body produce more healthy cells) to take before your operation.
It is important before any weight loss operation to check that you are not lacking in any vitamins or minerals. Most of the weight loss operations mean that after surgery, your body does not absorb nutrients (vitamins and minerals) as easily as before surgery, so it is important to make sure your levers are normal BEFORE the operation. If you are lacking in any of these important vitamins or minerals, you may be given supplements before surgery.
Although not all surgeons require you to have one of these tests, you may be sent for a gastroscopy before your surgery. A gastroscopy involves putting a camera down your mouth and inspecting the inside of your oesophagus (food pipe), stomach and duodenum (first part of your small bowel). This is to make sure that you do not have a hiatus hernia or bacteria called H. Pylori living in your stomach.
A hiatus hernia is when the opening in your diaphragm (the sheet of muscle between your chest and abdomen) gets a little bigger than normal and part of the stomach can move up into your chest. This usually needs to be repaired if you have weight loss surgery.
H. Pylori is a type of bacteria that lives in the stomach. It is known to be associated with gastric reflux (heartburn) and has occasionally been known to cause stomach cancer in a very small number of patients. After bariatric surgery, it is thought that H. Pylori can increase the chances of getting a narrowing (known as a stricture) in the joins or staple lines in your stomach or bowel. If you are found to have H. Pylori, you will be given some antibiotics to kill it before you have surgery. There are other tests that can be done to look for H. Pylori, but a gastroscopy is the most reliable.
Many people with obesity suffer with sleep apnoea, a condition that causes interruption or your breathing during sleep. Many people do not know they have sleep apnoea, but it is important to diagnose because you will be asleep during your surgery. You may be given a questionnaire to assess your risk of sleep apnoea, and some patients may be asked to go for sleep studies before surgery.
If you are diagnosed with sleep apnoea, you may be given a machine (called a CPAP machine), which is connected to a mask that you wear at night. This machine pushes air into your lungs, keeping the small airways at the bottom of your lungs open, making sure you can breathe easily.
It is important to make sure that your heart is working properly before you have a weight loss operation. You will have your heart rate checked and blood pressure readings taken. If necessary, you may be given some medications to take to make sure these are as normal as possible.
You will probably asked for a urine sample to make sure you have no infection before surgery, and to make sure that you have no undiagnosed diabetes. You will also have to have MRSA swabs before coming into the hospital for your operation. MRSA is a type of bacteria that lives on the skin of 3 in 10 people. It usually doesn’t cause any problems, but if it gets into a wound, it can cause an infection. If you are found to have MRSA, you will be given treatment before your operation.
All of the above tests are routine: do not worry if you are sent for these tests, as most people having surgery need to have these done!
You may need support from your friends and family both before and after surgery to have safe, successful long term weight loss. Having weight loss surgery is a personal decision, but it helps to ensure that you have people who you can talk to, as surgery is life changing. Some people join local or internet based support groups or buddy up with people who had surgery at the same time as them.
Many people find that their life changes significantly after surgery, particularly from the health benefits they have felt from the weight loss they have achieved. People tend to be more socially active and want to go out and do the things that they felt they could not/unable to do before surgery.
This can sometimes put a strain on some relationships. It may be that you cannot eat the same foods as your friends and family want to eat or family members still want to give you larger portions of food. Talking to the people close to you, and making sure they understand how the surgery is likely to change your and their lives is important. Before surgery, you may want your partner, or a friend to attend your clinic appointments with you so that they understand what your weight loss journey may be. Sometimes, they will help by changing their lifestyle; this extra support can help make sure you follow your dietary and lifestyle advice.
Some people choose not to tell their friends or family about their plans for bariatric surgery. This decision is up to you and how you feel. However, you may find people asking you about your weight loss and possible changes in diet. It is a good idea to think about what you will tell them before you have your operation.
It may take a few weeks before you are ready to go back to work after surgery. The amount of time this takes depends on which operation you have, and how quickly you recover.
It is always a good idea to warn your employers that you will be taking time off work. This way, they can find people to cover your work during your absence. Most employers would prefer to be given advance notice of your absence, rather than finding out after you’ve had surgery.
In most cases, especially if you are having weight loss surgery to improve your health, employers will be supportive of your decision to have an operation, and will do what they can to make getting time off work as easy as possible. If you do not feel comfortable talking to your boss about your surgery, you could try your human resources department and ask for advice.
Honesty is usually the best policy!
Any doctor or nurse will always advise that you stop smoking or drinking alcohol before surgery. Smoking increases the risk of you having heart and lung problems during surgery, and increases the risk of most of the other complications (bleeding, blood clots, infections, poor healing, staple line leaks, strictures etc.). In some hospitals, the surgeons will not operate on you if you cannot prove (with a breathing test) that you have quit smoking.
Drinking large amounts of alcohol causes liver damage, and contributes to being obese as alcohol has a high calorie content. You are advised not to drink alcohol after surgery. The length of time you will be advised to avoid alcohol for varies by which procedure that you have had. Alcohol can also be rapidly absorbed after bariatric surgery and it can affect your liver function, particularly as you are expected to have significant weight loss.
In the first few weeks after surgery, you may find that some of your tablets are difficult to swallow, or you may fill up on your tablets and have no room for food. It is important to make sure that you are able to take all of your usual medications after surgery.
Your GP or local pharmacist can often advise you on alternative ways of taking your medications, i.e. whether your tablets can be crushed or dissolved. Some tablets cannot be crushed or dissolved (they lose their action if you do this) and therefore they will need to be changed to a liquid version.
In some cases, your GP may have to change your tablets, to other medications that you can take after surgery.
It is a good idea to speak to your GP or pharmacist about temporarily changing your medication to alternative forms before you go for surgery, as this means you are ready and prepared for when you leave the hospital.
There are a few pieces of equipment that you may wish to consider buying or borrowing before surgery. By preparing beforehand, it should make recovery from your operation a little easier, particularly if you have already have made preparations for food after your surgery, before you have your surgery.
Food Blender: Initially after surgery, you will be on a liquid and pureed diet, which involves blending all of your food (see out “After surgery: webpage). Using a blender is important to ensure that there are no lumps or bits in your food in the early stages after surgery. It is advised to blend and prepare food prior to your surgery, so that you have less food preparation and cooking whilst you are recovering from your surgery.
Ice cube trays: Many people after bariatric surgery find that freezing portions of blended food into ice cube trays is very helpful. Initially after surgery, you will only be able to manage 2-3 tablespoons of blended/pureed food. Ice cube containers generally provide the correct size to pop the frozen pureed food and reheat as required. This will help you prevent overestimating your portions sizes and reduce food wastage too.
During laparoscopic (keyhole) bariatric surgery, the surgeon has to operate on your stomach. The liver lies in the top part of your abdomen, alongside your stomach, and in many people who are overweight, the liver is so large that part of it lies on top of your stomach. This can make the surgery very difficult, and even dangerous.
The diet that you will be asked to follow before surgery, is especially designed to shrink the size of your liver. This is very important, because if your liver is too large, the surgeon may not be able to perform your surgery.
There are a number of different versions of the pre-op liver shrinkage diet. All the liver shrinkage pre operative diets are designed to reduce the carbohydrate and calorie intake over a period of days/weeks leading up to the date of the operation.
All the diets help reduce the carbohydrate (glycogen) stores in the liver, which leads to liver shrinkage and weight loss. The liver shrinkage diets range from using meal replacement drinks, milk and yoghurt and 800-1000kcal low carbohydrate food containing diets.
Each bariatric service and surgeon will choose their preferred option, which they feel gives the best results in achieving liver shrinkage. It is important to stick to the diet that your surgeon and dietitian have advised you- DO NOT choose any other diet or combine them. If you do not follow the diet fully there is a possibility that your liver may not have shrunk enough for the surgeon to undertake the operation.
Before you consider bariatric surgery, it is a good idea to undertake some research and look at some of the online forums, and websites like this. These websites often have links to clinics and hospitals, which recommended surgeons and bariatric surgery services.
In most cases, whether you seek surgery through a healthcare system such as the NHS, or decide to self fund your operation, it is a good idea to discuss this with your GP. They often know of good surgeons and services and can recommend someone with an excellent track record. They often know the local hospitals, and can help you decide where you should go for surgery. In most cases, your GP will have to write a referral letter to the hospital or consultant before you can see the bariatric team.
It is important to make sure your surgeon has the appropriate qualifications.
In the UK, the surgeon should be registered with the General Medical Council (GMC- you can check this on their website) and be a Fellow of one of the Royal Colleges of Surgeons (FRCS). They will need to hold a CCT (Certificate of Completion of Training) or CCST (Certificate of Completion of Specialist Training). They should have a specialise interest in bariatric surgery, meaning they perform at least 50-100 bariatric surgery operations per year.
In the US, ensure your surgeon is board certified and if he or she is a member of the American Society for Bariatric Surgery (ASBS). They should be working in a hospital that performs at least 125 bariatric surgery operations per year.
The hospital should have appropriate facilities, which include:
You can check with your local hospital, either on-line or by calling, what their complication and death rates are. In the UK, you can check www.drfosterhealth.co.uk
Do not be afraid to ask the surgeon when you see them, what their complication, success and death rates are. They should be honest- if they refuse to answer, you should consider seeking an alternative surgeon.
In the NHS, all patient have to be referred for surgery via a local community weight management programme. You can search online to find your local weight management programme, and in some cases, you can refer yourself. Otherwise, you can visit your GP and ask him or her to refer you.
In the local community weight management programmes, they will cover dietary and lifestyle changes, exercise, and other ways to make you more healthy. In most cases you will see a dietitian. You may get discounts to gyms, or take part in exercise programmes. If you suffer with depression or any other mental health problem, they can help you to see a counsellor of psychologist. This can be essential in helping you to lose as much weight as possible.
As long as you engage with the community weight management programme, and show that you are committed to losing weight, and fulfill the NICE CG43 or local BMI criteria they will then refer you to a bariatric surgery service. After this, you should be sent an appointment to see the surgeon and/or dietitian, nurse and psychologist at the hospital. Some hospitals ask that you attend an education seminar at the hospital before you see the surgeon- here they will discuss bariatric surgery in more detail and make sure that you wish to go ahead.
If you are considering having bariatric surgery privately, you should be able to book an appointment directly to see the surgeon and dietitian/nurse for an assessment and advice at a private hospital. Some surgeons may prefer to have a GP referral letter prior to seeing them. You should check with the hospital or private company when you are booking your consultation appointment. Once the surgeon has assessed you and discuss your bariatric surgery options they will then inform your GP that you are considering or are planning to have bariatric surgery.
If you have surgery on the NHS, you will not be expected to pay for either your operation of your aftercare. You will have to buy your own equipment to use at home such as a blender or weighing scales, but your hospital stay and follow up care will be fully funded.
Prices in the private sector depend on which operation you have, how much follow up you get, and which company you have surgery through.
It is very important that you find out exactly what you are getting for your money- this includes your hospital stay and how much after care you receive and other aspects such as the number of band adjustments included in the aftercare package. After care is probably the most important aspect of surgery to ensure that you have safe successful, long-term weight loss. Therefore you should opt for the package that gives you the support you feel that you will require after surgery.
Consider how you may access this aftercare, how often and whom it is with, such as the surgeon, dietitian or nurse. Are there clinic appointments that you can access, send emails to the bariatric team with queries, and have telephone contact? Check to ensure that the aftercare is accessible to you particularly if you do not live close to the hospital/service where you had your operation. Whilst this may not be the cheapest option, it may be the best option in the long run to ensure that you have the expected weight loss and health benefits.
Prices may vary considerably between hospitals and surgeons but, generally speaking, prices in the UK will be in the following ranges:
|-Sleeve gastrectomy (gastric sleeve)||£8000-11000|
|-Biliopancreatic diversion/ duodenal switch||£10000-13000|
|-Revisional surgery||£3000-15000 (depends on procedure)|