Weight loss with or without a procedure requires long-term commitment and lifestyle change to achieve the best results. Although control over the demands of life to make time to plan diet and exercise are fundamentally important, many become frustrated when weight loss stalls or it creeps back on so they give up. Scientific evidence now reveals that this complex process is partly because our bodies become very efficient at holding onto weight we have gained when we try out new diets or engage in short bursts of exercise when motivated. Losing weight requires a sustained calorie “deficit” (reducing calories in your diet). Although the recommended daily intake for women is less than 2000 calories, weight loss would requires a daily reduction to around 1400 calories or less. Weight loss procedures can achieve calorie restriction through feeling fuller more quickly, a reduction in appetite-stimulating hormones and in some cases reduced absorption of energy from food and drink. Options include both temporary endoscopic balloon procedures and more permanent keyhole (laparoscopic) surgery operations.

I would always recommend meeting with your GP to exclude any medical or psychological factors that may have lead to your weight gain before moving on to these options. However I do offer free Mini-Consultations (01482 672414) for those wishing to know a little more before going further. Firm evidence that weight loss procedures are effective and safe is endorsed by the National Institute for Health and Care Excellence (NICE). Obesity is when somebody’s Body Mass Index (BMI) reaches 30 or more. Patients with obesity (BMI>30) who have not succeeded in losing weight or maintaining weight loss through diet alone are very likely to benefit from a weight loss procedure. When BMI reaches 35, you are carrying around 50% more weight than is healthy for your height. The NHS has an online calculator at: https://www.nhs.uk/live-well/healthy-weight/bmi-calculator Examples of where individuals may benefit include when: Their weight starts to reach a certain threshold that cause medical conditions to develop or deteriorate (diabetes, high blood pressure, arthritis and sleep apnoea) which can be potentially reversed in part or in full by these treatments. They are too heavy to have a safe planned elective operation for other conditions Where their self esteem, mood or activity levels are impacted upon by their weight The longer a patient is overweight the more chance there is of developing long-term health problems even if they are yet to be diagnosed. When non-surgical measures like diets, exercise programmes or medications have failed to achieve sustained weight loss it as this point operations become very effective tools in helping individuals regain control of their weight.

During your consultation, Mr Pellen will discuss the benefits, implications and risks of a range of interventions with you, not just one, particularly because different options are better suited to certain individuals’ circumstances, their goals and their weight loss history. Weight loss operations take between 60-90 minutes and are usually performed using keyhole (laparoscopic) surgery under a general anaesthetic. They achieve weight loss through a range of mechanisms such as “restricting” the amount of food you can eat to that which would fit on a small tea plate, reducing calorie absorption and hormone effects that can temporarily reduce appetite. You can expect to lose around one-third of your excess weight with a gastric balloon and more than two-thirds of your excess weight with the sleeve gastrectomy and gastric bypass. Most weight loss is achieved within the first year at which point your weight stabilises. The gastric band is an inflatable ring placed around the top of the stomach connected to an access port buried under the skin that requires adjustment injections of fluid to achieve the correct sensation of fullness. Mr Pellen does not recommend this procedure owing to significant long-term problems such as weight regain, band slippage and symptoms or complications that require the band to be removed in 1 in 3 patients.

These procedures reduce the amount of calories you will absorb leading to gradual weight loss. However they will also reduce other essential parts of your diet including daily vitamins, minerals and protein. Daily vitamin supplements are required life-long to avoid nutrition complications after any operation and for as long as a gastric balloon is in place. A dietitian consultation is always provided before and throughout your weight loss procedure pathway at Spire Hull and East Ridings Hospital. Weight loss surgery can lead to substantial reduction in medicines needed for or even reverse conditions such as type 2 diabetes and high blood pressure. Improvements in many other conditions such as sleep apnoea, reflux and joint pain can be seen and weight loss also improves eligibility and safety for many NHS procedures where weight restrictions apply. Weight loss surgery can have dramatic improvement in fertility. Contraception is an important consideration even if you are planning to start a family as pregnancy is not recommended within the first 18 months to ensure the baby develops healthily.

Excess weight loss is the amount of extra weight you are carrying than would be ideal for your height. The excess weight loss is the average amount of this you can expect to lose for each procedure. More can be lost with increased exercise and activity. Less might be lost if some lifestyle behaviour are not changed such as high intake of sugary drinks, alcohol or snacking.

Both the sleeve gastrectomy and gastric bypass are followed by a swallow test which ensures no narrowing or leaks at the seals and joins are present before a liquid diet is started. Dietitians guide you on what to eat and drink over the next few weeks. Both operations usually require 1 to 2 nights in hospital and patients often recover and return to work within 2 weeks for the sleeve gastrectomy or 2-4 weeks for the gastric bypass.

Many patients who struggle with their weight have a history of emotional or physical trauma and have developed a dependency on food to cope with low mood. An expert psychotherapist Marie Acton with whom Mr Pellen works closely can provide confidential private assessment and support sessions outside of the hospital environment.

The need to convert to an open operation is very uncommon, occurring in less than 1 in 100 procedures under Mr Pellen’s care. A return to the operation theatre or other procedures needed for complications occurs in less that 1 in 50 operations. Reasons can include, uncommon but serious complications such as leaks from the joins or seals where the bowel has been stapled or stitched together, or, obstruction (blockage) due to a narrowing from over healing. This may require further treatment with a balloon dilatation (stretch) endoscopy. Other risks include bleeding, thrombosis, wound infection and fall in vitamin levels needing replacement. Mr Pellen submits data on all of his weight loss interventions to the National Bariatric Surgery Registry.

To make an appointment to see Mr Michael Pellen, or for further information contact Spire Hull and East Riding Hospital on 01482 672 412

Hernias do not get better or heal by themselves. Occasionally some patients have no symptoms from their hernia and choose to leave them alone. If left alone, the bulge (contents) might increase in size but the opening/ weakness can remain the same size. Sometimes fat or bowel can get stuck in the narrow “neck” of this weak point. If not treated, hernias can result in complications of blockage of the bowel (obstruction) or strangulation (loss of the blood supply). There are various options for repair both in terms of technique and the type of anaesthetic used which can be tailored to those who may be higher risk for general anaesthetic. Devices such as a hernia-belt/truss ashould be considered carefully as these can compress and damage the contents of a hernia if not fitted correctly. Mr Pellen can discuss the balance of risks of “non-operation” (wait and see approach) against a planned operation. However, a wait and see approach may allow the hernia to become larger or risk complications. If complications occur emergency surgery may be required, which may be more invasive, such as bowel may need to be removed and risks are greater.

The historical repair of holes in the muscle wall with stitches alone is now largely reserved for very small hernias. Modern approaches usually incorporate a synthetic woven “gauze” mesh into the muscle layer to strengthen the weakened tissues. This happens because muscle heals to the mesh which then reinforces the weakened muscle by “growing” in to the tiny woven holes during the healing process making it far stronger than stitching alone and reducing the chance it will come back in the future.

In Mr Pellen’s practice laparoscopic groin hernia repairs are performed under a general anaesthetic and take around 30-45 minutes. While you are asleep the abdominal cavity is inflated with gas to create an internal working space and through 3 small incisions, thin telescopic instruments are used to bring the stretched hernia sac back out of the hernia defect in the muscle. If we use the analogy of “wallpaper” to represent the non-stick lining of your abdomen, this is peeled back and then a patch (the mesh) is rolled up, placed through keyhole access port, unrolled and placed in a pocket covering the hole – essentially like placing a birthday card into an envelope. The wallpaper is then sealed back up using internal hand-sewn dissolvable stitching. This seals the mesh in place.

These include weak points on the front or the sides of the abdomen and through scars of old operations which have given way. Keyhole techniques carefully separate the internal scar tissue from the hernia and a special mesh coated with a non-stick layer is secured over the hole with a “tacking” staple device to anchor its position while it heals. For larger hernias (where the hole or defect through which the sac is herniating is around 5cm diameter or more) the open technique carefully separates the muscles from the stretched sac and a mesh is stitched underneath the muscle. This occasionally needs temporary small drains to stop the space created by the previously stretched skin filling up with healing fluid (seroma).

If performed correctly by an experienced surgeon, mesh repair is without doubt the most effective technique available reducing long term risk of recurrence. Reports of mesh eroding into other organs such as the bladder and womb have been reported when such material has been used for other operations on the pelvic floor for incontinence and prolapse surgery and this is a different use and location to abdominal wall hernia surgery. Mesh can shrink over time and if there is infection, bleeding or disruption of anchoring stitches while the mesh heals in to place it can cause a scarring reaction or even recurrence of the hernia. Chronic pain reported after hernia repair, whilst very uncommon, has multiple possible other causes aside from including the original pain not being due to the hernia and persisting after repair, pain from stitches or tacks.

Most patients having repair of groin or umbilical hernias can go home the same day of surgery whereas larger or more complicated abdominal wall or incisional hernia repairs may need a day or two in hospital, sometimes needing a suction drain to reduce fluid collecting under the skin (seroma). This depends on the hernia’s location but in general regular pain relief tablets are taken for 3-7 days and heavy lifting is avoided for around 6 weeks. Most patients can drive when they can comfortably perform an emergency stop braking manoeuvre when stationary in their car (around 1 week after surgery).

Mr Pellen has specialist experience in both open and keyhole (laparoscopic) hernia repair. In general keyhole surgery offers advantages of smaller wounds, reduced postoperative pain and in the case of groin hernias the ability to simultaneously repair both sides of a “double” hernia with no extra incisions. Factors which may influence recommendation of an open rather than laparoscopic technique include location of the hernia, its size and the likelihood of internal scar tissue from previous surgery. However, Mr Pellen will discuss all options with you and their respective advantages and risks.

Hernia surgery is one of the commonest and safest operations but there are always small risks. These can include internal bleeding, old blood or healing fluid collections (seroma) in the sac and recurrence of the hernia. Bowel complications such as injury or blockage (obstruction) or exceptionally rare. Temporary difficulty passing urine requiring placement of a catheter can occasionally affect male patients undergoing groin hernia repair especially if there is a history or prostate enlargement.

Occasionally stones can find their way out of the gallbladder into the bile ducts causing complications like pancreatitis (inflammation of the pancreas gland), jaundice (blockage of bile draining from the liver causing the skin and eyes to turn yellow) and cholangitis (infection in the ducts of the liver). If your history or investigation results suggest this, Mr Pellen may organise other tests like an MRI scan (MRCP) or perform an “operative cholangiogram” during removal of the gallbladder. This is a special X-ray of the bile ducts, taken during the operation and performed by injecting a contrast liquid into the bile ducts during surgery and taking several X-ray pictures. If stones are found in the bile duct, other treatment may also be required. The commonest treatment approach for this is endoscopic removal. Endoscopic retrograde Cholangiopancreatography (ERCP) uses an endoscope under sedation and X-rays to view the bile ducts attached to the gallbladder (if present), pancreas and liver. This can identify and usually remove any trapped stones causing symptoms. Alternatively, Mr Pellen may attempt to remove bile duct stones during the operation (laparoscopic common bile duct exploration). If a bile duct exploration has been performed, a special soft drain is sometimes placed in the bile duct to relieve the pressure in the bile duct and help the bile duct to heal over several weeks. This drain is called a “T-tube” and its care will be discussed with you before you are discharged from hospital (often with this still in place). Treatment for bile duct stones is usually only performed in Castle Hill Hospital where Mr Pellen has access to the necessary equipment.

Gallstone symptoms can be controlled to an extent with a low fat diet. Only an operation guarantees a cure of symptoms caused by gallstones. If you choose not to have this procedure, symptoms related to your gallbladder/gallstones may continue, deteriorate or cause life-threatening complications. This includes pain, infection and inflammation, jaundice and pancreatitis.

The majority of patients will be discharged the same day (daycase surgery), or, the following morning. Whilst you should be mobile and self-caring almost immediately after surgery, recovery usually takes 2 weeks. The wounds will usually need no aftercare as they will be closed with dissolvable stitches and medical glue,

These are very uncommon, but gallstone disease can cause severe scarring and inflammation around the gallbladder. Although rare, this can mean risks of infected collections, bleeding or damage to surrounding structures like the bowel or liver. Conversion to a conventional open operation is very rare in Mr Pellen’s experience, occurring in less than 1 in 100 operations. Other complications that may require further treatment, re-admission to hospital or rarely a return to the operating theatre include - wound infection, bile leakage or injury to the bile duct, deep vein thrombosis or pulmonary embolism. Whilst an operation should remove all gallstones there is always a small chance small pieces of grit are silently within the remaining bile duct, which may cause symptoms many years later but this is very uncommon.

To make an appointment to see Mr Michael Pellen, or for further information contact Spire Hull and East Riding Hospital on 01482 672 412

The vast majority of patients with GORD or hiatus hernia do not require surgery but in some circumstances surgery is useful for those who have not completely responded to medical treatment and lifestyle adaptive changes. Fundoplication involves wrapping or folding the top part of the stomach around the lower part of the oesophagus to strengthen the valve. Types of procedure include the Nissen fundoplication which is a full 360 degree wrap or partial fundoplication which is occasionally used when the oesophagus function is found to be weak on pre-operative tests. If you also have a hiatus hernia (when part of the stomach slides through the diaphragm into your chest) Mr Pellen will bring the stomach back to the correct position under the diaphragm and stitch the muscle surrounding the opening (the crura) to stop it slipping back up. Often a special degradable tissue reinforcement material(BioA) is used to strengthen the muscle for this repair. The operation takes between 60 and 90 minutes and is usually performed laparoscopically (keyhole) with around 5 small incisions of up to 1cm in size. Very rarely a larger incision will be needed to safely perform your operation such as when there is internal scar tissue from previous surgery.

This operation reduces reflux of stomach contents but can also make it more difficult to belch making you feel bloated. If gas from the stomach cannot come up it may pass “downstream” causing increased passage of wind. The improved function of the valve can also cause a temporary feeling of difficulty swallowing though this usually improves for most patients over time. Certain foods can cause persistent trouble such as gassy carbonated drinks (which make bloating more likely) and large chunks of red meats and bread which may feel like they become stuck.

The majority of patients will be advised by their GP to modify their lifestyle by reducing weight, stopping smoking, reducing alcohol intake and eat smaller volume meals containing less fatty and spicy foods. Medications such as antacids, or acid suppression drugs (H2 antagonists and Proton Pump Inhibitors, PPIs) are often prescribed to neutralise or reduce the irritation of any acid reflux. However, these medications do not stop reflux they simply reduce symptoms from it. Some gastroenterologists elsewhere in the UK offer novel procedures that attempt to strengthen the valve without surgery. These endoscopic procedures include the Stretta procedure (radiofrequency wave delivered through a catheter probe). Mr Pellen does not offer this type of treatment.

Reflux over many years may lead to adaptive defensive changes in the cells of the oesophagus and rarely these can become pre-cancerous (Barrett’s oesophagus). Lifelong protective medication and regular endoscopic surveillance is recommended for this condition. A hiatus hernia can become larger over time or may even be detected on tests when it is so large much of the stomach has migrated into the chest or become twisted which can compromise its blood supply or its ability to empty properly.

It may not be possible to complete the operation using keyhole surgery and may require a larger incision. Very uncommon but serious risks include bleeding from nearby organs such as the spleen, injury or perforation of the stomach or gullet, deep vein thrombosis or pulmonary embolism. Unfortunately as many as 20% of patients do not fully respond to this treatment requiring additional medication, or, if the weakened tissues fail it can lead to a recurrent hiatus hernia where surgery may need to be repeated.

To make an appointment to see Mr Michael Pellen, or for further information contact Spire Hull and East Riding Hospital on 01482 672 412

You will be having a general anaesthetic, and will have a pre-operative screening appointment to assess your suitability for surgery, before you are given a date for your operation. At this appointment the nurse will take details of your: medical history and current medication home care arrangements after you have been discharged from hospital including relative/friend support and transport arrangements. Please use this opportunity to ask any questions about your surgery and aftercare. You will also be given instructions about preparing for your operation, which will include advice about: having a bath or shower before you come to the hospital eating and drinking pausing or taking your normal medication, if appropriate returning to work after surgery

You will need to have been fasted from midnight before your operation. If you wear contact lenses, you will need to remove them prior to your operation. Please bring your spectacles or an extra pair of contact lenses with you. On admission to the ward you will be greeted by a nurse who will check that your details are correct. The surgeon and the anaesthetist will talk to you and you will be invited to ask any questions you may have before signing your consent form. A member of staff will escort you to the operating theatre. After the operation, you will recover in a special recovery area near to theatre until you are fully awake before you return to the ward.

After the operation, you will recover in a special recovery area near to theatre until you are fully awake before you return to the ward. You will then be transferred to the ward area where nurses will continue to monitor your condition. Initially you may also have some neck and shoulder tip pain, this is due to the gas used (carbon dioxide) to enable a clear view inside your tummy, which can get trapped. It will disappear by itself after a couple of days. If you feel any discomfort, please inform the nurse looking after you, so that pain relief can be given. If you feel sick after the operation you will be given medication for this and remain nil by mouth until the nausea and sickness wears off. Your anti- reflux medication should stop at the time of the operation. After a few hours you may be allowed to take sips of fluids only. If you are able to tolerate sips you may then be able to build up to free fluids. On the first day after your surgery you can have a liquid diet. If the doctor feels you are sufficiently recovered you will be discharged home. Occasionally patients may go home on the same day as their operation although most patients stay in one night. It is important that you arrange some one to collect you at an appropriate time, if you have stayed overnight this will be before 11am. Due to the nature of the ward you may be expected to vacate your bed early and wait for your discharge transport in a discharge area. Before discharge you will receive a dietary advice leaflet. It is important to follow dietary advice to prevent a blockage, discomfort and vomiting. Your stomach may have reduced in size slightly; therefore you may feel full easily. We recommend you eat 'little and often'. It is advisable to avoid bread and fizzy drinks for the first 4-6 weeks. You will notice during the first few weeks that food tends to stick. It is important to eat slowly and to chew food thoroughly. It often helps if you drink fluids with your meal.

You will have some mild pain for up to a week after the operation.You will be prescribed painkillers to take home with you. Please take only as directed on the packaging. You will need to continue to wear the graduated compression stockings on your legs for 5 days (day and night). You should seek medical attention immediately if you develop: severe abdominal or chest pain vomiting and cannot keep fluids down Severe difficulty in swallowing where food becomes stuck You will be informed if the stitches in your wound are dissolvable or need to be removed. Some patients have Steristrips(small strips of adhesive tape) rather than stitches in their wounds. Even if you have dissolvable stitches, it is recommended that you have your wound checked by the Practice Nurse 4-5 days after your operation. You may shower on the day following your surgery. Any waterproof dressings over your wounds should remain in place for 5 days and then you may remove them. You should remain off work for approximately 2 weeks, or as directed by the surgeon. Your surgical team will provide initial sickness certificates and any required extension is provided by your GP. You will be followed up in clinic by your surgeon.

You may drive when you feel you can safely perform an emergency stop. This will not be for the first 48 hours following your surgery. Please check that your insurance policy does not prohibit you from driving for a longer period, following general anaesthetic or surgery. Based on Civil Aviation Authority guidance we recommend at least 48 hours before flying after keyhole surgery or 10 days after an open surgical operation.