Mirella Falcone

Good evening, everyone. I hope you're well and welcome to our webinar on weight loss surgery. My name is Mirella and I’ll be your host this evening. Our expert presenter is Consultant Surgeon Mr Hamouda, supported by Surgical Care Practitioner, Maria Duckworth.

The presentation will be followed by a Q&A session. If you'd like to ask a question during or after the presentation, please do so via the Q&A icon, which is on the bottom of your screen. This can be done with or without giving your name.

If you would like to book your consultation, we have Jane Andrews from the Private Patients team on hand to take phone calls after the webinar and we'll provide the phone number at the end of this session. Please note that this webinar is being recorded. I’ll hand over to Mr Hamouda and you'll hear from me again shortly.

Mr Ahmed Hamouda

Thank you very much everyone for joining us. I’m really pleased to be talking to you about weight loss surgery, having started this service at Benenden approximately five years ago - but having done weight loss surgery myself for about 12 years in total. There's myself and Maria; we're part of a bigger team, of course, that look after all patients that come through into our bariatric service and I’d just like to introduce them as we go along. At the moment I'm just going to check and make sure that this presentation is good to go, we've got, there we go, yeah, lovely.

So, we're moving on to the next slide. So, I have, as I was saying, I’ve been a member of BOMSS for as long as I’ve been a Bariatric Surgeon. I lead the team at Benenden Hospital as well as the MDT, which is the multi-disciplinary team looking after all individuals coming through and I'm supported in this role by Maria who has extensive experience, not only nursing experience but also in bariatric and weight loss surgery treatments. As part of our team, we have dietitians and nutritionists to support us and also a psychologist who forms part of the patient pathway and everybody that comes through to see us basically sees every member of the team to get the most out of their journey throughout, obviously, the one year that they're with us.

So, I’d like to talk to you a bit about bariatric surgery, about the options that we have and really the ethos of our service is to maintain a healthy lifestyle but also a healthy weight and we're trying very much to bring people into a more healthy range of BMI. The reason is because we know that obesity can have an impact on health and there are several conditions that have been linked to obesity as you can see there; things like type 2 diabetes, developing coronary heart disease, strokes, different types of cancer, sleep apnoea - of course - high blood pressure and then the weight that people carry can sometimes affect their joints, so back pain, hip pain, joint pain, the need for joint replacements as well as forming gallstones - amongst obviously other conditions that can happen.

So, weight loss surgery is a lifestyle choice. When you consider surgery, you really need to come and have a chat with us because we can talk to you about all the ins and outs, what to expect, what the risks may be of surgery and it's very important that you come and see the people that have been doing this, you know, almost on a daily basis for the past several years - who can give you the very close knowledge and experience of what to expect. But when you come and see someone like myself -  a weight loss surgeon - there are four interventions in the mainstream. There are variations of those interventions, but the main interventions are a bypass, a sleeve, a band and a balloon. They work in different ways. Some are permanent as you can see, there – a bypass and a sleeve - others are temporary, like the balloon which only lasts for a year. And then you have obviously flexible and reversible procedures like the gastric band. Flexible because you can fill it and defill it and reversible because at any point you can have it taken out.

So, talking about the gastric bypass - which for many individuals is considered the gold standard, depending of course on their dietary history - but also their BMI. So, with a BMI approaching the 50s, we talk about gastric bypass. We sometimes include sleeve, a band and balloon - maybe not as much. But, of course, they have a role that's very important. The gastric bypass is an operation where, with a general anaesthetic and keyhole surgery, I go in and I create a very small pouch of stomach. As you can see at the top of that diagram there, that pouch is actually the size of a thumb. So, it's quite a small pouch. And then I divide the bowel and create a diversion on the bowel by joining it to the very small pouch of stomach and then creating a further joint lower down between the two bits of bowel. Those two bits about the top of the diagram, people don't get any richness out of the food through there, so this operation is a double whammy. You're basically not able to eat as much because the stomach is much smaller, but also there isn't that much nourishment that comes through the food that one is eating and ingesting. It is definitely more powerful than a band or sleeve.

And when we talk about power. In terms of these operations, we're looking at the amount or the percentage of extra weight lost. Extra weight is a concept which is the amount of extra weight you're carrying, from an ideal BMI of around 25 to the BMI that we're at. So, if my BMI is 45, for example, and the ideal is 25, my extra weight is 20 BMI points - from 25 to 45. And if I'm looking at a bypass, I'm thinking of losing about 80 to 90 percent of the extra weight on average with this procedure. We talked about it restricting volume, reducing the absorption of food through those two diverted bits of bowel. It works well for people who are sweet toothed, because it creates or causes something called dumping and dumping is a condition where - if you've had something that's very rich or sweet after you've had a bypass - it travels very quickly into the intestine and creates a bit of swelling, but also a possible surge of insulin. So, people can become cold, faint, clammy and sweaty. And even though it's not a very nice sensation to have, it tends to stop people from having things that are quite sweet.

Because we are not absorbing as much from our nutrients in our food as we normally would have, we must have a multivitamin supplement every single day after the bypass for the rest of our lives. We also require blood tests to be done by your GP on a yearly basis. In the first year, sometimes it's on a three-monthly basis just to check and make sure that nutrients like calcium, iron, B12 aren't deficient and, if they are, then we need a top up. It is a moderately major operation, so it requires two nights’ stay in hospital, two weeks off work and driving and six weeks of no heavy lifting. Once the scars have healed, and we've seen you in clinic, then of course it's back to normal again.

Moving on to the next procedure in terms of power. So, with this one - which is a sleeve gastrectomy - we're looking at a power of approximately 70 percent on average of the excess weight being lost. Again, general anaesthetic using keyhole surgery and the principle here is to remove approximately 75 percent of the stomach. So, on the diagram there, on the right-hand side, you can see the bit that's shaded is the bit that gets taken away and taken out of the body. It doesn't remain inside the body; it gets taken away. And so, you have two effects with this operation; it’s that you only have a quarter of the volume that's left behind - therefore there is an effect of restriction – you cannot eat as much as you did before, but also the bit of stomach gets resected and decreases the amount of ghrelin and alters gut hormones, so that we hope that craving an appetite with this operation is reduced. It's a permanent procedure, very much like a bypass. Again, it requires one or two nights’ stay in hospital with two weeks off driving, six weeks no heavy lifting - and we tend to generally do blood tests once a year with this operation and advise also multivitamins on a daily basis - obviously important, but not as essential as a bypass.

And then going on to the gastric band, which is a reversible procedure but also very flexible. It is principally a silicon doughnut that is wrapped around the top of the stomach, which creates an hourglass effect. And you can see on the diagram, the portion of stomach above the band (above the adjustable band) is quite a small amount and the rest of the stomach's below. And again, just to sort of give you a visual of how big that is, it's again the size of an egg or a thumb. And the principle here is slightly different to the other two operations. This is just to slow down what we're eating so, if we have a large portion size and we tend to eat quicker than normal, then what happens is - with a band - you'll find that once you've had one or two mouthfuls, food sits in that pouch above the band, and it feels quite uncomfortable. It will take some time to mush up with saliva and juice and then it very slowly trickles down, through the band into the rest of the stomach. And that's when we can have another one or two mouthfuls. Of course, the effect is that over a period of time, what's happening is our portion size is being much reduced and we really are slowing down with our food intake. We need to take some time and spend some time to obviously eat a small meal.

The band itself - the donut - is attached to tubing and the tubing runs through the stomach and meets an access port which sits on the muscle just underneath the skin (usually underneath the rib cage) and that's where we can inject fluid into the band to alter the size of the band. So, in other words, make it tighter, make it looser. And that in itself is quite a good benefit of having the band, because it's flexible. We can almost try and alter the amount of weight that we're losing - but also, if there's too much restriction or too much reflux that's happening, we can release the band a bit to allow people to obviously not have those symptoms anymore. This procedure is reversible, so if one were to come back in five, six years and - for any reason, whether it's because they feel they've done it on their own or that they don't need the band to help them or guide them anymore, or whether it's just a bit of reflux that, you know, that irritates them - we can do another operation, take out the band and everything returns back to normal. So, in other words, we haven't cut any part of the body or altered any part of the body. It can be performed as day case, so either one night in hospital or in and out on the same day and, again, it's a general anaesthetic with keyhole surgery.

The gastric balloon, which is the last of our tools, and I always call them tools because I want people to understand that we cannot make a wave a magic wand. We're only able to give you a tool, explain how it works, give you all the support that's required during the period of year but - at the end of the day - it really is important that people take it on board, take responsibility for the tool and alter their dietary habits, alter their lifestyle - but also increase the amount of calorie burning that accompanies this lifestyle change.

The gastric balloon is temporary; it's only there for a year. We tend to favour the Orbera® balloon, which is endoscopic, so people come in as a day case, they have a sedative and throat spray, we go in with a camera, check that everything is absolutely fine: there's no ulcers, no hiatus hernia and if it is, then go in with the balloon and start inflating it with saline. It normally takes about 500, 600 ml of saline with some blue dye. The blue dye is really important because, if the balloon were to rupture, it would then colour your urine green and you would know that the balloon is ruptured, and you'd come back and see it straight away because otherwise the balloon can then go into the bowel and cause an obstruction of the bowel. It sits at the very top of the stomach in the area that we call the fundus of the stomach, and it occupies the space there, so it creates a sense of bloating, but also there's less space available for food, of course, that's coming down through the gullet. And therefore, that's the effect of it and that's how people lose weight. On average, we're looking at about 35 percent of the excess weight being lost with the balloon. It's only there for a year, it must come out after a year. There's one that is a six-month balloon but, of course, I tend to favour the one year one, because I believe that people need that period of time to enable them to change their dietary patterns, their lifestyle and to hopefully prevent weight regain which can happen once the balloon has come out.

It's not an operation, it is not an anaesthetic and therefore there is no scarring that comes with it, and it is quite a very minimally invasive procedure.

So, I'm going to hand over to my colleague Maria who's going to talk to you about our patient pathway.

Maria Duckworth

Thanks Ahmed. Good evening, everyone I'm going to talk about the patient pathway and how it starts, if you decide this is what you would like to do. To begin with, you have a consultation with Mr Hamouda and discuss all the options that he's discussed previously to see which one is suited to you and your needs. And then after that you have a two-week cooling-off period. And then, if you still want to proceed, then you make an appointment for your pre-assessment through the Private Patient's office and that's when you come to see everybody else in the team. Can I have the next slide please?

In preparation for surgery, you see the dietitians for the liver shrinkage, and they give you support. There's usually two types; it's either shakes all the way or there is an alternative where you have a meal and the shakes. You also see me, and we go through any questions or concerns you have. You also see me on the day of surgery, because I support Ahmed in surgery, and you see the psychologist and the anaesthetist. You have a full workup prior to surgery and - next slide.

What happens after weight loss surgery? The dietitians will advise you on the post-surgery diet and they give you a menus to follow which suits you. It's usually two weeks of liquid food then moving on to puree and soft foods over six weeks period. That’s for the gastric sleeve and bypass patients. Gastric band patients follow a transition to normal textured foods from liquid to puree to soft foods over a four-week period. These are just guidelines. Some people take a little bit longer on the liquid diet or a little bit longer on the puree, it's not set in stone. Gastric balloon patients follow a transition to a normal textured food over a two-week period and, again, that's not set in stone. So, each individual patient is different - can I have the next slide please.

Follow up. You can have a telephone follow up with myself at two weeks, you also have my contact details and my email address with any concerns you might have, and you have a two-week telephone follow-up with the dietitian and then appointments are arranged for you to come into clinic to see us again. It's very important that you maintain these appointments because the support's there for you for the year and we can help you on your journey and give you all the support with any struggles you might be having - next slide.

And with the dietitian you learn healthy eating habits, the psychologist identifies areas where you might be weakening or any temptations in your behaviour and they give you blood tests at six months and above on supplements, according to your needs. And some of the foods are best avoided after surgery; some people can eat pasta, some people can't, some people can eat rice, some people can't. It is trial and error - there isn't one cut that suit everyone. And we also provide practical advice on eating out, whether it be just having a starter. But there's lots of advice and support so you shouldn't impact on your social life at all - next slide please. And these are some of our patients. I’ve probably seen them on the internet! Jenny Eldridge, she had a gastric band; it's done fantastically well with us, and Sarah has done well with her gastric sleeve and so has Jessica. And then our famous couple - the roller coaster couple who wanted to lose weight to go on a roller coaster - the wife had the sleeve, and her husband had the balloon and they lost 13 stone between them.

Next slide please. And Ahmed, I’ll hand over to you now to discuss the risks.

Mr Ahmed Hamouda

Thank you, Maria. So yes, of course, with any type of surgery there's always going to be an element of risk. Just to put it into context, I just want to say that the risk with bariatric surgery - whether it's a bypass, a sleeve or a band - is now the same as or even less than having your gallbladder taken out. So, with the research that we've done and the accumulation of data over the years, we found that the risk is - as I said - similar or less than that. And, of course, within any family you will have either friends or relatives who've had gallstone surgery and have the gallbladder taken out - so it's quite relatable.

But generally, we think of complications in terms of two categories. There are general complications, which can happen with any type of surgery, and there are specific complications that will happen with certain procedures. So general complications are things like bleeding, infection, clots on the leg veins going up to the lungs, risk of injury to internal organs with keyhole surgery. And the risk of conversion to an open operation from keyhole is generally in the order of about two percent. With a band, for example, and because a band is a foreign body - it's not part of our body - there is always a risk that, over the years, it can move out of position. That's called slippage erosion. It can internalise through an ulcer in the stomach that can become infected, or it could leak. With a sleeve, because we're using staples to cut away the stomach, there's always a risk of leakage from where the staples are left behind, but the risk is really very small - less than one percent, and that's the national average. It is also a risk that is only carried for approximately two or three weeks until the body heals up. And then, with the bypass, that risk is the same because there's two joins, but it is probably about - I would say - two percent.

With any of these operations we must be absolutely sure that, if we don't follow the rules, we won't lose the weight. If we think it's just going to work on its own then failing to lose weight is a possibility, but also any of these operations can be stretched. So, we always advise people not to have fizzy drinks, for example, after they've had these bariatric procedures and to avoid overeating beyond the level of comfort because, of course, weight regain is a possibility. So really the principle here is that when we go for bariatric surgery and when we feel very keen that we want something done to help us out, then we are actually changing our lifestyle. We are changing the way that we're going to eat, and we are committed to that in the long run - and that's how it works.

I hope that we've both been quite useful in offering the information that we have, and I’ll hand back to Mirella.

Mirella Falcone

Thank you, Mr Hamouda and Maria. So, we'll take some questions that we've received. So, the first one is: I have an INR level of three, I take six milligrams of Warfarin daily, as I have had three DVTs. Will I be able to have any of the surgeries? If so, which one?

Mr Ahmed Hamouda

Yes, so a lot of our patients come through and they need to be on anticoagulants for any reason. It could be because of heart rhythm (AF), it could be because of stroke risk and it's quite standard that in surgery generally we tend to operate by changing the Warfarin, so stopping the Warfarin five days before surgery and changing it onto an anticoagulant that only lasts in the system for 12 hours. And, of course, what we do is we plan to give the dose of the anticoagulant the night before surgery so that when they come in to have the surgery in the morning, the anticoagulant has sort of disappeared out of the system. We operate and then we start the anticoagulant again later that night and we carry on taking it for, I would say, five to seven days before we start warfarinising again.

So, we have a standard protocol for doing this type of thing and, yes, it does not at all preclude people from having surgery and any of those operations would be available, so whether it's a bypass or a sleeve or a band.

Mirella Falcone

Thank you. The next one is I work full time and have two children so I can't really take any more than two weeks off work to recover from surgery. What are the long-term recovery times? Will I need to book any more days off?

Mr Ahmed Hamouda

I’ll give that one to Maria if that's okay.

Maria Duckworth

It's usually two weeks but, as we say, every patient's an individual - so we can't give you a definitive “It will be two weeks”. But it is usually two weeks. I hope that answers the question.

Mirella Falcone

Thank you. I am a middle-aged man who has a high BMI of 39. At what point would you reject someone from qualifying for surgery? Does this change dependent on the type of procedure? I'm looking to have the gastric sleeve.

Mr Ahmed Hamouda

Yes. So, thank you very much for the question. And it's really a question that I should have covered in my initial talk. So, we follow guidelines and the NICE guidelines for bariatric surgery in the UK is that anyone between the age of 18 to 70 is eligible to have surgery. The guidelines as well for when we should be operating is if the BMI is 35 to 40 with any co-morbidities or any obesity-related conditions (you could say that back pain, joint pain is one of those) and above 40 you can have surgery straight away without actually needing to qualify through the obesity-related conditions. So middle-aged at 39 - definitely eligible for surgery. Definitely eligible again for any of the procedures. I think sleeve is a really good choice because it tends to work really well from BMI 35 all the way up to very big BMIs at 60.

The bypass tends to work from 45 and above. When I say tends to work, I would rather say it's a good procedure for BMIs 45 and above. And bands can start at BMI below 35; sometimes we, you know, you can qualify for a band at a BMI of 30 and above. So, I think sleeve is a good choice and I think, yes, the age and the BMI at 39 is absolutely fine.

Mirella Falcone

Thank you. Our next one is I’ve heard that there can be complications with the gastric band. What are the success rates from the band?

Mr Ahmed Hamouda

So again, going back to the presentation, two things to say. Success rates in bariatric surgery are measured by the amount of excess weight lost, and when we look at the band, on average we're losing about 35 to 55 percent of our excess weight. It is really very individual, like Maria was saying. Some people have had a band with us who've lost about 70 to 80 percent of their excess weight and one lady in particular I remember two years ago lost a hundred percent of her excess weight, so - in other words - returned to a BMI of 25, which is ideal with a band. It really is a tool, and you have to think of it as a tool. You can do whatever you want with the tool, so that's really important. The other part of the question, Mirella, if you just remind me again or go through the question again…

Mirella Falcone

So it was: what are the success rates? Oh sorry, so the complications, yes sorry.

Mr Ahmed Hamouda

This is a band, we went through it before and just basically looking at it it's a foreign body, it's not part of the body - but so are other things like hip replacements and knee replacements and, therefore, over a period of time the body can reject this object and it can lead to slippage, moving out of position, erosion - which is when an ulcer internalises into the stomach, the whole system can become infected or it can leak. And if any of those things were to happen, then two options really. The whole band needs to come out or - if it can be salvaged - then the band (a component of it) can be changed and then we work with a band again, maintaining the band system in place.

Mirella Falcone

Thank you. I suffer from diverticular disease which can flare up when I eat certain foods. Will I be able to have weight loss surgery and will the dietitian work with me to manage my condition?

Mr Ahmed Hamouda

Yes, very good question and thank you. Yes, diverticular disease is very common. We have operated on many individuals who have diverticular disease. Bariatric surgery is performed at the upper part of the gut so it really has no relationship to the colon at all and the only thing that obviously changes is diet so the dietitian would definitely need to take that into consideration, work with yourself, make sure that you still have a high fibre diet with plenty of hydration, and I don't see it as a contraindication to having this type of surgery.

Mirella Falcone

Thank you, next question. I know a dietitian/nutritionist is included in the weight loss package, but I'm concerned about the effects that my changing body will have on my mental health. Would you suggest counselling therapy alongside the procedure?

Mr Ahmed Hamouda

Yes, I think – again, Maria do you want to elaborate on that one?

Maria Duckworth

As part of the package, we do have a psychologist who does support the patient through this, because there is that element of when you lose weight, that you see the weight loss and it can be a difficult transition and she does help you through that.

Mirella Falcone

Thank you, next question. I will be 70 at the end of March and I'm interested in weight loss surgery. Have I left it too late and are certain procedures unavailable to older people?

Mr Ahmed Hamouda

So that's a difficult question to answer because, of course, I earlier talked about the guidelines and the fact that the guidelines were 18 to 70. So, when we have people come in, you know, either on the cusp of their 70th birthday and they want to consider something then we go through a very individualised risk assessment and that includes medical history, includes medication, includes how fit and active they are. And obviously we then say ‘Well, you know what, we have to tell you what the risks are versus the benefits’ and we have a risk/benefit ratio discussion and, if it's felt that the benefit is slightly more than the risk in this particular individual's case, then obviously with a good consent (which means that you agree to have surgery or you agree to all the risks that come with surgery) then a case can be made for an operation to be done.

We tend to generally advise the lower range of the procedure, so balloon or maybe band - perhaps a sleeve - at that sort of age range. But of course, as I said it's individualised, so I would very much recommend that you get in touch with us before your 70th birthday.

Mirella Falcone

Thank you. I hope that helps. I suffer from acid reflux, but I think that the balloon procedure is best suited to me. Can I have this fitted or would you recommend another?

Mr Ahmed Hamouda

Acid reflux is a very common condition, again, and that's part of the reason we go through a medical history with our patients and individuals is because some of our operations can actually exacerbate reflux and make it worse, and that is generally the restrictive procedures - so we are looking at the band and the sleeve. The balloon is known to cause a bit of reflux, but what we always do with the balloon is we ask people to go on an acid medication for the duration that they have the balloon. And that is one of the musts that we ask for.

So, I would very much say to you again it is something that we would have to consider in our medical history taking. We would then tailor the approach that we are taking and, if it's the balloon, I would be quite confident that Omeprazole or a similar antacid would help decrease those symptoms of reflux for the duration that you have the balloon, which is the one year. The only operation that we actually do that treats or helps treat reflux is the bypass, but I know for some people that may be too major a procedure to consider.

Mirella Falcone

Thank you. Next question. I don't overeat but I still struggle to lose weight and maintain it. What is the percentage of unsuccessful procedures especially for someone that doesn't overeat but still struggles to lose weight?

Mr Ahmed Hamouda

That is a difficult one to answer and the difficulty here is, where we talked about these tools being individual, and it depends on what people do with the tools. I’ll be very honest with you: there are obviously instances where somebody's had weight loss surgery and they haven't lost the weight that they expected to lose. It's difficult to tell you why but, of course, there is that possibility.

What I definitely know is that the satisfaction rate for these operations increases with the more powerful procedures, so sleeve and bypass tend to be quite effective, powerful procedures where patient satisfaction in terms of weight loss is quite high. We look at band and balloon and the satisfaction rate is less, because they're not as powerful and people might find ways - especially with a band, perhaps - to slide food through the band, to soften their food up, to put more sauces etc, creams, on it - which then will obviously make them put some weight on. So, the answer to the question is that it's individual, it's a tool and perhaps the more effective procedures are the more permanent ones.

Mirella Falcone

Thank you. Next question. Is there a risk of the balloon increasing the size of the stomach so, when it's removed, I’ll be wanting to eat more than before?

Mr Ahmed Hamouda

Well, you know what? I think the fact that the size of the stomach is increased or decreased is something about the anatomy of the body. Actually, we think of the stomach as a collapsible organ so - in other words - if you put a lot of food into it, it becomes quite huge. If it goes empty, then it shrinks and becomes quite small - very similar to the womb, for example. The womb with the baby is obviously very large and, without a baby, it shrinks and becomes very small. So, there isn't anything that you can put in the stomach that increases the size on a permanent basis because, once that balloon has been taken out of the stomach, it will then return to its normal size. It will actually shrink and only increases in size if you put food into it.

Mirella Falcone

Okay thank you. Next question. I had a fundoplication for acid reflux ten years ago. Does this mean I can't have the surgery?

Mr Ahmed Hamouda

A fundoplication does alter the way the stomach sits internally and, of course, for any of these procedures - because we operate at the very top part of the stomach where the fundoplication is and the fundoplication generally (for people who don't know what that means) is a wrap. It's a wrap of the floppy bit of the stomach around the lower end of the gullet to create a valve-like stoppage of acid from going up into the gullet. So, we would have to then first of all consider undoing the wrap – the fundoplication - and offering an operation like a bypass, because any other operation would cause reflux, which is obviously a problem. And that's the reason you had the fundoplication in the first place.

So, I wouldn't say ‘no’ to surgery, but I would say that it would become a bit more complex, in that you would need the fundoplication undone and then potentially a bypass as a procedure to follow.

Mirella Falcone

Thank you. Apologies in advance that I may not be able to pronounce this next one. I'm allergic to Clexane. Is it possible to avoid this post-surgery?

Mr Ahmed Hamouda

Yes, Clexane is only one of several anti-coagulant drugs or blood thinners that we can use. So, there's others that we can use. The question is really whether the person is allergic to all of the blood thinners or just this specific one. And if it's this specific one then obviously there wouldn't be a problem. We would probably want to try and test maybe one of the others and delve a bit more into it, rather than wait for the day of surgery and then give something else where we don't know whether or not there will be an allergy developing. But yes, again, not insurmountable and it can be looked into.

Mirella Falcone

Thank you and next question. I have type 2 diabetes. What impact would these procedures have on my sugar levels?

Mr Ahmed Hamouda

Very interesting that type 2 diabetes is one of the conditions that bariatric weight loss surgery hopes to treat, and when I say treat, I mean in the short term. We don't know what the long-term effect is, but we know from the data from the National Bariatric Surgery Register that about 60-65 percent of people who are diabetic, who have this type of surgery, go into remission two years after surgery. So, remission just means that they stop being diabetic. In other words, their blood is returned to normal. So, this procedure is actually one of the ones that are recommended.

Bariatric procedures are recommended for diabetics, that's one of the reasons why we do the type of surgery that we do. The second thing that's really important to mention is that, in preparation for surgery, we will probably reduce your dose of oral hypoglycaemics prior to the surgery, when you go on the liver shrinking diet. And we also go for an approximately 50 percent dose reduction of your diabetic medication straight after surgery, because it's amazing - as soon as the surgery is done - blood sugars tend to drop quite significantly. And therefore, I think the answer to your question is this is exactly why we do this type of surgery, to help diabetics. And we always take into consideration dose reduction in and around the time of surgery.

Mirella Falcone

Thank you, next question. You said that a balloon lasts for one year. What happens to the balloon after that time? Is there a limit on how many times balloons can be inserted?

Mr Ahmed Hamouda

So, the balloon manufacturer has given us very strict criteria for the usage of the balloons. So, one year is really their criteria. They say, ‘We don't know what's going to happen after a year’, so rupture is a possibility, hyperinflation where the balloon fills up with gas and then again ruptures is a possibility. And, of course, we don't really tend to contemplate leaving it beyond that. Once the balloon has been taken out, yes it is possible to have further balloons put in. I always try to stop people from doing that because I would then recommend, if you're going to go down that route, I would recommend something that's a bit more permanent. So perhaps looking at a band as an option or looking at a sleeve as an option.

If there are circumstances where you cannot have either a band or a sleeve then yes, of course, people can have a balloon. But it's just remembering that, you know, the balloon is considered an option for people who want to adjust their lifestyle, want to adjust their eating behaviours and they really want to do it on their own. So, looking at it as something that I can repeat over and over again is perhaps not the way that we tend to encourage people to look at it.

Mirella Falcone

Thank you. I have battled with my weight for over 20 years and have tried pretty much everything to minimal success, which is very demotivating. Is considering surgery a reasonable step as my GP seems very dismissive and pretty much implies ‘Just eat less’?

Mr Ahmed Hamouda

Yes, I think you've asked a very good question there and I think that most people who are with us today will realise that obesity is associated with a lot of prejudice in society and, of course, where we come from - myself, Maria and the team - is a completely different approach. We realise that this is a condition. It is something that won't go away on its own. It is something that, if people have a lot of ego around it and they tend to think well, actually - you know what - I can do it on my own, it tends to lead to a cycle of frustration and anger and disappointment. Because, at the end of the day, the most important thing is health. If we can get down to a range of BMI that is healthy for our bodies, then there shouldn't be anything stopping us from doing it.

Either our GP, who perhaps may not be very - sort of, you know – enlightened, I would have to say, open to consider this type of surgery as a procedure that helps people, helps them lose the weight. Or - others in the community, whether it's friends or relatives - who tend to say to you “Well actually, you know what, you got yourself in this situation, you get yourself out of it”. It isn't that easy. We know it isn't, because we have research showing that - no matter what diets and what exercise people go on - there's always a yo-yo pattern of weight regain and, for as long as you keep follow-up going with a diet, you could do it for a year, you could do it for 18 months but once the follow-up is gone, with a diet people tend to put the weight back on again - with a bit of extra weight.

So yes, don't let ego get in your way. Don't let others tell you what to do. I think that this is, you know, important for your health.

Mirella Falcone

Thank you. Having had a bypass, would I be able to have this re-looked at to help me get back to my appetite being significantly reduced, as it was the first two to three years post-op?

Mr Ahmed Hamouda

Yes. So, I said in my earlier presentation that weight regain is possible with any of these procedures and, of course, with a bypass procedure, what happens is the stomach pouch that you saw in the diagram stretches a bit. And what also stretches is the outlet, the join between that stomach pouch and the bowel, so you get quite a lot of capacity developing internally for food to go in - and we lose the effect of restriction. When somebody's had a bypass and the weight regained, they come and see me and we do some tests to look at the internal anatomy, the configuration, what it looks like, if there has been a stretch to the pouch or a stretch to the outlet. And what most people would recommend now is banding a bypass.

So, in other words, putting a band on top of that gastric pouch to regain the sense of restriction. And, because it's flexible, because we can fill the band, adjust it, put more liquid into it, it becomes quite a good tool. I’ve had a lady who had a bypass 12 years before she came to see me; we put a band on and with the band she tells me that she lost more weight than she ever did with the bypass. So, it's, again, regaining that sense of restriction and, yes, it is possible to consider another procedure to help.

Mirella Falcone

A few more questions. Can you tell us a bit more about the pre-op liver shrinkage diet?

Mr Ahmed Hamouda

Maria, I think that one can go to you.

Maria Duckworth

Liver shrinkage, it's two weeks. It's vitally important that you shrink your liver down before surgery, otherwise we're not able to do the surgery and we are very strict about it. But it's usually Slimfast twice a day with a meal in the evening, because people usually find it quite boring just having milkshakes all day. And so, the dietitian has a special plan and so that entitles you to a meal in the evening. And she also has alternatives, if you're lactose intolerant etc. for that as well. So, it's all completely covered and individually tailored for each person's needs.

Mirella Falcone

Thank you. Could the balloon be used with what is left from my bypass? I'm an absolute advocate of bariatric surgery!

Mr Ahmed Hamouda

So unfortunately no. The answer to that is no. When you think of the bypass, we've created a pouch of stomach that is really the size of a thumb. If you try and put a balloon into there, you're stretching it to become the size of a melon. So, first of all, that's not really what we want to do, because you'd put lots of weight on as soon as that balloon came out. And the second thing is, it would disrupt and rupture the join that's been created between that pouch and the bowel below it. So, it is unsafe, it's probably going to lead to a perforation and it's not something that we would consider ever doing.

Mirella Falcone

Thank you. Can these foreign bodies cause excess bleeding if you're taking blood thinner and preclude you from any of the tools?

Mr Ahmed Hamouda

No. I mean the only one that really is a foreign body is probably the band. The balloon sits on the inside of the stomach, so it doesn't really create much of a reaction. It's really not, it's very inert, so it doesn't create any chemical interference with the blood or the body, as such. It does create a bit of scar tissue around that area, so it's not contraindicated with any blood thinner at all, and people who are on blood thinners can have a band. There is no issue with that at all.

Mirella Falcone

Thank you. We have a couple more questions in the chat. I’ll just take some from there. So how can I notice, as a patient, that there is a leakage at the staple?

Mr Ahmed Hamouda

So, a leakage is not a nice condition. It is a condition that will lead to the escape of stomach juice into the tummy cavity, of the abdominal cavity, we call it in surgical talk peritonitis. You may have heard of the word before and it leads to sepsis, which is an infection running in the bloodstream. It certainly is a condition that is quite severe and grave, and you would know straight away. It would be accompanied with intense abdominal pain, with fever, shaky, being quite cold clammy and sweaty and possibly even fainting. So it would be, sort of, the condition where you would call the ambulance straight away and the ambulance would take you into A&E.

But, having said that, I don't want people to linger too much on leakage. We talked about it being quite a small risk - less than one percent -  in our experience it has been less than 0.5 percent and it certainly is a very transient sort of risk, that you only carry for a couple of weeks after surgery until the body heals. But what I also do during surgery is I put blue dye down into the sleeve or the bypass and check and make sure it doesn't leak out. But also put an extra line of sutures on top of the staples as a belt and braces approach. So yeah, it's fully covered.

Mirella Falcone

Thank you. Is there a weight limit?

Mr Ahmed Hamouda

Good question and, of course, where we do the surgery, we tend to be guided by the anaesthetic team as well. They tend to look at weight limits from their perspective because they have requirements in terms of ventilation; how much pressure they can, you know, put into the lungs during the course of an anaesthetic. So, we tend to - at the moment - work on a limit of about, I would say, around 60. But, as I said before, I'm more than happy to see people and talk to them and get them down with the use of medication or perhaps talk to them about a balloon to where their weight is acceptable for a general anaesthetic.

So, it is never a ‘no’. It is ‘Come and have a chat’. We'll have a look at the condition, we'll have a look at the situation, and we can probably help by reducing weight over a period of six months and then consider doing the surgery afterwards. But yeah, generally around the 60s or so mark.

Mirella Falcone

I have an underactive thyroid and take thyroxine. Is that an issue, as well as being on HRT?

Mr Ahmed Hamouda

No, not at all. We have a lot of people come through who are on regular medication. The medication can range from blood pressure tablets to oral hypoglycaemics for diabetes to lots of painkillers for arthritis of the knees and joints and hips to obviously things for reflux, so medication for reflux. Thyroxine, all the medications that you are on, will be taken into consideration. The ones that we feel are going to be an increased risk for surgery, we tend to advise to stop before the blood thinners. We tend to change to anticoagulants that are injectable, like I said before, 12 hourly injectable blood thinners. So, we have protocols that we go through to look at everything and to adjust what we're doing during the course of surgery in terms of your medication.

Mirella Falcone

Thank you. How many surgeries do you do each day?

Mr Ahmed Hamouda

So that's a difficult one because I work at different places, so I tend to be operating maybe three or four times a week and I’d normally - on a typical day - I’d normally do about five to six operations. And so that's my that's my output. Another thing to say is that Benenden, when we started about five years ago, we were projecting to do about 50 cases per year. We did more than that and, at the moment, we are averaging about (at the Benenden) only about 150 cases a year.

Mirella Falcone

Thank you. Next question. Unpleasant, but is the act of vomiting the same post-op?

Mr Ahmed Hamouda

Yes, vomiting is something that becomes quite common after these procedures and the reason being that there's a learning curve. So, where we used to have a much bigger pouch, a much bigger stomach, we now are much more restricted in terms of the volume that we have. So, our mind doesn't catch up as quickly and we tend to try and put more food into those very small pouches than we can accommodate. And the side effect, unfortunately, is nausea, wretching and - on occasion – vomiting. So the act of vomiting will obviously be there.

It's possible to - in the first six months perhaps - maybe vomit once or twice a week, but hopefully less than that as we go along. And yes, it's really a learning curve. Some people vomit just once and then they never do it again, because they don't like the effect of it. So they try to limit that effect by eating much less.

Mirella Falcone

Thank you. If the band slips down, what symptoms should I experience?

Mr Ahmed Hamouda

So, band slippage is, again, one of those interesting ones. It can be very subtle - where people put weight on, where their weight was quite stable before - or they start losing too much weight. It can be pain in the left side, underneath the ribcage on occasion discomfort there. It could be vomit, perhaps, with a bit of blood tinge in the vomit and it can be quite severe where, again, you go into a state of shock and sepsis because it slipped down, and it's strangulated. So, in other words, torqued off a bit of the stomach and caused it to become unhealthy.

So, it can be very subtle, it can be quite severe, but generally you probably need to come and see someone like ourselves to advise you on what tests need to be done to figure out whether it's slipped or not.

Mirella Falcone

Thank you, just a few more. I suffer from RA and pernicious anaemia. Would I still qualify for surgery? I have a BMI of 58.

Mr Ahmed Hamouda

Yes, rheumatoid arthritis and pernicious anaemia. Again, two conditions that do not preclude you from having surgery. A BMI of 58 is just under our cut off, which I mentioned earlier is around the 60 mark. And so that doesn't, in any way, preclude you from having surgery.

What we would need to do is go through a full medical history, including all the medications that one is on for rheumatoid arthritis. People can sometimes need to go on immunomodulators, so drugs to depress their immunity, and - what we sometimes tend to do is - we try and stop those medications prior to surgery because it decreases the healing power, and what we need after surgery is for the body to heal really well to prevent any complications from arising.

So again, I don't see anything there that stops us from discussing and talking about surgery - and it would just need to be individualised.

Mirella Falcone

Thank you. Next question. Threatened by diabetes last year, I put myself in a very strict diet and lost 17 kilos but I'm now static and - despite being very food aware - I'm terrified I will regain weight. Would bariatric surgery help me maintain my weight loss for the long term?

Mr Ahmed Hamouda

So, one of the benefits to bariatric surgery is that it gets rid of the yo-yo pattern of weight regain and - we may have alluded to this earlier - about diets and exercise and the fact that, no matter how good the diet is, no matter how good the person is going on the diet then the longevity of it is really the big issue. The research shows that, after a period of time, there will tend to be a yo-yo pattern of what you regain with the surgery. What we're hoping to do is a more permanent, more effective solution over the longer term. And we've had success with people who've been, you know, 10 years after bariatric surgery and they've maintained their weight.

But likewise, we've also had people 10 years down the line from bariatric surgery who have regained their weight. It still goes back to this being a tool. To the fact that it needs to initiate a lifestyle change, a dietary change and that everybody needs to take this as a new beginning. And that it's something that they will, you know, work well with in the future to prevent weight regain.

Mirella Falcone

Thank you. I’m going to take the last two questions. What is the minimal weight allowed for surgery?

Mr Ahmed Hamouda

So, we work on BMI, not weight, because weight is - it's a number that doesn't really mean anything unless you take it in consideration to a person's height. So, if you work out the BMI, which is the ratio of height to weight -  and it's quite a simple equation, you divide the weight in kilograms by the height in meters squared - and if you can work out what your BMI is at. A BMI of 27, you're eligible for a balloon. At a BMI of 30 you're eligible for a band. At a BMI of 35 and above you're eligible for either a sleeve or a bypass.

Mirella Falcone

Okay, last question. Does menopause impact weight loss when you're post-op from a bypass from six years ago?

Mr Ahmed Hamouda

So I think the question is, you've had a bypass six years ago and you're now perimenopausal or gone into menopause and does weight regain happen as a result? We know that the period around menopause there will be hormonal changes and we are not 100 percent sure of what exactly happens to women's bodies at that point in time in terms of weight.

But yes, of course, metabolism slows down a bit as we grow older - that's an effect that we've seen in a lot of people. And whether the menopause has a similar effect in terms of weight gain, it could possibly do. So I think that if you are weight regaining, you've had a bypass six years ago, whether or not you're going through the menopause it's probably something that you would need to consider another intervention for or – perhaps - maybe have a chat with us and see if there's anything else that can be offered to try and keep your weight stable during that period of hormonal change.

Mirella Falcone

Thank you very much Mr Hamouda and Maria for answering all those questions and for everyone that's asked those questions this evening. I'm sorry we didn't get to answer all your questions, but we will do so after the event.

If you would like to book your consultation, please contact the number on your screen. The lines are open until 8 o'clock this evening, where Jane will be on hand to answer your questions. Alternatively, the lines will be open 9am-5pm Monday to Friday. You'll receive a short survey and I’d be grateful if you could spend a few moments to let me have your feedback on today's webinar.

Our next webinar is on the 23rd of February with Consultant Orthopaedic Surgeon, Mr Alex Chipperfield and Associate Specialist Surgeon, Mr Kumar Reddy who will be discussing treatments for hip and knee surgery.

So, on behalf of Mr Ahmed Hamouda, Maria, myself and the team at Benenden Hospital, I’d like to say thank you very much for joining us this evening and we look forward to you joining us again for another webinar very soon. Thank you.