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Surgical Procedures

Sleeve gastrectomy, gastric band and gastric bypass are the common forms of bariatric surgery. All of these procedures are very safe and extremely effective in helping weight loss and most importantly maintenance of weight loss.

Virtual Clinic

When you see the doctor in the outpatients’ clinic you may well forget some of the answers that he gave to your questions. We have therefore taken the commonly asked questions by patients from each of the procedures and added the doctors answers.

All of these procedures have an extremely good safety record. All are highly effective in resetting your weight to a much lower and healthier level long term.

Gastric Bypass

What does the surgery involve?

“Gastric bypass involves stapling the stomach to produce a much smaller stomach, which will reduce the size of the stomach from that of a Galia melon to the size of an egg. The second part of the operation involves bypassing the digestive secretions that are normally involved in absorption of foods. A loop of the small bowel is bought up to the new small stomach and connected to this. This new configuration bypasses the digestive secretions for half of the bowel length. Eventually food and secretions will remix half way down the bowel.


Diagram showing the rout that food takes following gastric bypass.

A small meal will initially fill the stomach pouch before entering the bypassed part of the small bowel. This stimulates release of hormones that cause a pleasant feeling of satiety and fullness.

The gastric bypass therefore works in three distinct ways:

  • The amount of food that can be consumed is reduced.
  • There is a degree of malabsorption of some of the calories and nutrition in the food that is eaten (this malabsorption readapts after one year).
  • The reconfiguration of the bowel produces a profound decrease in the patient’s appetite, and a change in the patient’s food preferences away from sweet or fatty foods and towards healthier foods.”

How long does the procedure take?

“The procedure is under general anaesthetic and takes on average one and a half hours.”

What scars will I have?


Drawing showing the position of the 5 small scars after bypass surgery

“The procedure is laparoscopic or keyhole surgery, therefore there is no big scar. The procedure involves making five small cuts ranging from 5 mm to 12 mm long in the upper abdomen just below the rib cage.”

How will I feel following surgery?

“The morning after surgery you should be able to walk around your private room, use the bathroom and shower. You should be able to sit comfortably and drink tea, smoothies or milk. Your pain should be well controlled with soluble painkillers. ”

How long will I need to stay in hospital?

“Some patients will be keen to go home the day after surgery but most will prefer to stay and relax in the hospital and return home after the second night.”

How long will I need off work?

“One or two weeks.”

How long until I can exercise?

“You will be able to walk around within hours of surgery. The morning after surgery I would expect a patient to be able to walk around relatively comfortably. On discharge from hospital I would recommend increasing activity levels on a daily basis including longer and longer walks. More active exercise such as at the gym can be introduced one week after surgery, with a gentle reintroduction to aerobic exercise such as light jogging, cycling or swimming. Any exercise involving heavy lifting should be avoided for one month.”

How soon can I reintroduce solid foods?

“The dietician will give you a detailed description of your pre and postoperative dietary instructions. Following surgery a liquid diet should be maintained for one week. This should be followed by a diet of pureed consistency food for one week. The third week should consist of mashed consistency foods and a slow introduction of well chewed solid food should be introduced thereafter. I advise patients to be particularly careful with bread and dried meat, such as chicken, for the first two months after surgery as these are the foods most likely to cause discomfort if not chewed properly.”

What will my eating be like long term?

“Following a gastric bypass after the initial month where solid food is reintroduced, eating becomes much easier. Within two or three months you will be able to contemplate eating out. Clearly the amount of food will be much less and a starter portion will usually suffice, however patients report that the quality of life, as far as eating is concerned following a gastric bypass, is back to normal within a few months of surgery.”

Will my appetite change?

“Following gastric bypass patients report profound changes in their appetite. The gastric bypass produces a reconfiguration of the digestive system, which tricks the brain into thinking that a person has eaten much more than they actually have. For this reason, after eating a small amount of food a patient will feel full and have a pleasant satiated feeling for many hours thereafter. Food is generally not an issue following gastric bypass and many patients will have to remind themselves to have lunch by setting a reminder alarm. The changes of appetite tend to last for at least twelve to eighteen months and in many cases for a longer term. In addition to this, most patients report that they develop an aversion to sweet foods and also to foods in high fat content. Sometimes this can be due to a syndrome called dumping which occurs after eating high fat or sugar foods. This causes a feeling of faintness, weakness and sweatiness and leads to the development of quite a rapid aversion to these types of foods, making weight loss much easier.”

How much weight can I expect to lose?

“Following gastric bypass patients will lose about 80% of their excess weight. If a person weighs 20 stone but their ideal weight is 10 stone, then the excess weight they are carrying is 10 stone.

Following gastric bypass if they lose 80% of this excess weight, that will equal 8 stone of weight loss.

Therefore following gastric bypass this persons weight will decrease from 20 stone to the 12 stone level within nine to twelve months of surgery and remain at this level long term.”

What do I need to do to ensure long term weight loss?

“The gastric bypass is extremely effective in producing excellent weight loss in the first year and changing the patient’s appetites and food preferences to help maintain this long term weight loss. However it is vital that after surgery a patient changes their lifestyle significantly to help maintain this weight loss for the years to come. This would include changes in their eating pattern to ensure that they have a regular healthy breakfast, lunch and dinner. The stopping or cutting down of unhealthy high calorie foods and finally the introduction of a more active lifestyle. These changes should ensure that weight loss is maintained long term.”

Do I need to take vitamins after surgery?

“Following gastric bypass there is a malabsorptive component to the surgery and therefore we advise that people take a vitamin and a mineral supplement long term following surgery. We also advise that vitamin B12 levels are measured regularly and that supplements are given to prevent any deficiency arising in the future.”

What health improvements can I expect?

“Following surgery there are dramatic improvements in most of the conditions that are associated with obesity.

Type 2 diabetes, if diagnosed within the preceding five years, will have a 90% chance of going into complete remission. If type 2 diabetes has been present for longer than five years then it is more likely that it will be improved dramatically by surgery with a significant decrease in the amount of medication required and an improvement in the sugar control.

High blood pressure will be improved dramatically within a few months of surgery and usually will resolve completely.

Sleep apnoea in 80-90% of cases will resolve with patients not requiring a sleeping mask, and being able to sleep and rest easier and feel much more revitalised the next day.

Joint pain and osteoarthritis: degenerative joint problems secondary to long term weight problems are not reversible, however once a person has lost a considerable amount of weight, the pressure on the joints is decreased and invariably a person will report a considerable decrease in the amount of painkillers they need to take.

Following surgery the person’s quality of life dramatically improves. Patients generally feel fitter, healthier, revitalised and generally stronger after surgery.”

What are the risks of surgery?

“Within the first day or two after surgery there is a 2% chance of complications occurring. These include leakage from where the stomach and the bowel are joined together, or bleeding from where the stomach is stapled. In these unlikely circumstances either a blood transfusion or a further laparoscopic operation is required and a patient may require a longer stay in hospital. There are also small risks of leg thrombosis and embolisms. These risks are minimised by blood thinning injections, compression stockings, the short operation time and the early ambulation after surgery.

The long term risks of gastric bypass are also uncommon. They include vitamin or mineral deficiency if supplements are not regularly taken. Other rare long term complications include a small hernia developing at the site of instrument insertion in the abdominal wall, or an internal herniation or twist in the bowel, which can cause colicky abdominal pain and need investigation. In patients taking anti-inflammatory painkillers such as Aspirin or Brufen for medical conditions, such as arthritis, we recommend that an acid blocking tablet is also taken to prevent the development of a stomach ulcer at the site of the join between the stomach pouch and the small bowel. Long term risks after surgery are in the region of approximately 2% and therefore very rare.”

Sleeve Gastrectomy

What does the surgery involve?

“The sleeve gastrectomy works by reducing the size of the stomach. The stomach size is reduced from the volume of a Galia melon to the volume of a peeled banana. After the stomach has been divided, the excess stomach tissue is removed. ”


Diagram showing the new tubular shape of the stomach following sleeve gastrectomy. The main part of the stomach, shown on the right, is removed. This part contains an appetite secreting area, explaining the reduction in appetite that is commonly reported following this procedure.

How long does the procedure take?

“The sleeve gastrectomy is performed laparoscopically by keyhole surgery and takes generally less than one hour to perform.”

What scars will I have?


Drawing showing the position of the 5 small scars after sleeve surgery

“The procedure is laparoscopic or keyhole surgery, therefore there is no big scar. The procedure involves making five small cuts ranging from 5 mm to 12 mm long in the upper abdomen just below the rib cage.”

How will I feel following surgery?

“The morning after surgery you should be able to walk around your private room, use the bathroom and shower. You should be able to sit comfortably and drink tea, smoothies or milk. Your pain should be well controlled with soluble painkillers. ”

How long will I need to stay in hospital?

“One or two nights.”

How long will I need off work?

“One or two weeks.”

How long until I can exercise?

“You will be able to walk around within hours of surgery. The morning after surgery I would expect a patient to be able to walk around relatively comfortably. On discharge from hospital I would recommend increasing activity levels on a daily basis including longer and longer walks. More active exercise such as at the gym can be introduced one week after surgery, with a gentle reintroduction to aerobic exercise such as light jogging, cycling or swimming. Any exercise involving heavy lifting should be avoided for one month.”

How soon can I reintroduce solid foods?

“The dietician will give you a detailed description of your pre and postoperative dietary instructions. Following surgery a liquid diet should be maintained for one week. This should be followed by a diet of pureed consistency food for one week. The third week should consist of mashed consistency foods and a slow introduction of well chewed solid food should be introduced thereafter. I advise patients to be particularly careful with bread and dried meat, such as chicken, for the first two months after surgery as these are the foods most likely to cause discomfort if not chewed properly.”

What will my eating be like long term?

“Following sleeve gastrectomy food has to be chewed very well and eaten quite slowly at least for six to twelve months after surgery. After this time most patients report that the amount of food that they can eat increases slightly and the ease of eating also improves. Within a year of surgery a patient’s weight will have settled and they will report that they are comfortable eating a small starter plate of food before they feel full.”

Will my appetite change?

“Following sleeve gastrectomy most patients report that their appetite decreases significantly. This is usually in terms of a decrease in hunger feeling. When the stomach is removed an appetite hormone (called ghrelin) that is present in this part of the stomach is also removed. This causes a profound decrease in the amount of this appetite hormone that is secreted in times between meals. Appetite tends to return after approximately one year. It however will not be the voracious type of appetite that can occur following intensive dieting, and will be a more normal healthy hunger feeling.”


Comparison of hunger feeling before and 6 and 12 weeks after sleeve gastrectomy. Time on x-axis represents time after a meal.

How much weight can I expect to lose?

“Following a sleeve gastrectomy, patients will lose approximately 70% of their excess weight on average. However a proportion of patients do very well following sleeve gastrectomy and will lose almost all of their excess weight. An example will be in a patient who weighs 20 stone but whose ideal weight is 10 stone, their excess weight would be calculated as 10 stone. Following a sleeve gastrectomy their weight would decrease by 7 stone to a level of 13 stone within nine to twelve months of surgery. With lifestyle changes this weight loss should be easily maintained long term.”

What do I need to do to ensure long term weight loss?

“The sleeve gastrectomy is extremely effective in producing excellent weight loss in the first year and changing the patient’s appetites and food preferences to help maintain this long term weight loss. However it is vital that after surgery a patient changes their lifestyle around significantly to help maintain this weight loss for the years to come. This would include changes in the eating pattern to ensure that they have a regular breakfast, lunch and dinner. The stopping or cutting down of unhealthy high calorie foods and finally the introduction of a more active lifestyle. These changes should ensure that weight loss is maintained long term.”

Do I need to take vitamins after surgery?

“We now recommend that following sleeve gastrectomy a patient take a multivitamin and calcium tablet for the first year after surgery whilst they are losing weight. As the sleeve gastrectomy does not involve any malabsorption of food, long term vitamin supplementation should not be necessary if a healthy diet is being taken.”

What health improvements can I expect?

“Following sleeve gastrectomy there are dramatic improvements in all of the medical conditions that are caused by being obese. Approximately 80% of diabetic patients will have a complete remission of this condition or a dramatic improvement in the control of their sugar levels following surgery. Most patients who have high blood pressure will not require medications following their weight loss. High cholesterol is generally normalised. Sleep apnoea is almost always cured following weight loss and a patient will not require further sleeping mask therapy.”

“In patients who did not have any medical conditions before surgery, they will notice a dramatic improvement in not only their underlying healthy but also their feeling of contentment and improved quality of life.”

What are the risks of surgery?

“In the short term there is an approximately 2% chance of serious complications. These include bleeding from the staple line or leakage from the top of the staple line. These complications require either a blood transfusion or a further operation in the form of a laparoscopy to drain any leakage or stop bleeding. In the unlikely event of a leak then a patient can expect a longer stay in hospital.”

“Occasionally patients can have difficulty with swallowing solid food and occasionally liquids in the early period after surgery. This generally settles down in time.”

“Long term complications following sleeve gastrectomy are very rare but may include the sleeve gastrectomy tube re-dilating up, meaning a person can consume a greater volume of food and therefore increasing the possibility of weight regain.”

Gastric Band

What does the surgery involve?

“Laparoscopic gastric band placement is technically a low risk procedure. The gastric band is introduced around the top of the stomach and locked. The band is connected to an inflation port via a connection tube. The inflation port is placed underneath the rib cage on the left hand side of the abdomen.”

How does the gastric band work to produce weight loss?

“The gastric band sits at a level just below the junction of the oesophagus and the stomach. Once the gastric band has been inflated it will produce a separate, much smaller, stomach cavity above the main part of the stomach. The volume, or capacity, of the new stomach pouch is approximately the same as one mouthful of food. Once the band is working, it will force the patient to chew food very well and take time between swallowing mouthfuls of food. Once a mouthful of food has trickled from the new stomach pouch through the band, a further mouthful of food can be swallowed. If food is not chewed well it will not slip through the band very easily. If mouthfuls of food are swallowed too quickly then the food will be backed up in the oesophagus and the patient will experience quite unpleasant griping pains and occasionally will have to regurgitate the food. The video animation of the band demonstrates its mechanism of action well.”

“Therefore the gastric band works by only one simple mechanism. It works by forcing a person to eat slowly by making them chew their food very well and making them take time between mouthfuls of food. In this way a small side plate volume of food should take 20-30 minutes to eat.”

“My experience is that the band does not significantly change appetite in the majority of patients, however if a patient eats slightly too fast they will get the unpleasant too full feeling that occurs when food is stuck in the oesophagus. Some patients perceive this to be the feeling of decreased appetite.”

How long does the procedure take?

“The gastric band is performed laparoscopically and takes less than one hour duration.”

What scars will I have?

“The procedure is laparoscopic or keyhole surgery, therefore there is no big scar. The procedure involves making four small cuts ranging from 5 mm to 12 mm long in the upper abdomen just below the rib cage.”

How will I feel following surgery?

“You will feel slightly bruised but be able to walk around within hours of surgery and be quite comfortable the next morning. Usually the area where the port or inflation valve is placed, below the margin of the left rib cage, is slightly more painful than the other wounds. This is normal and is usually well controlled with painkillers. ”

How long will I need to stay in hospital?

“Patients can go home either the day of surgery or the morning after surgery.”

How long will I need off work?

“One week.”

How long until I can exercise?

“You will be able to walk around within hours of surgery. The morning after surgery I would expect a patient to be able to walk around relatively comfortably. On discharge from hospital I would recommend increasing activity levels on a daily basis including longer and longer walks. More active exercise such as at the gym can be introduced one week after surgery, with a gentle reintroduction to aerobic exercise such as light jogging, cycling or swimming. Any exercise involving heavy lifting should be avoided for one month.”

How soon can I reintroduce solid foods?

“Following gastric banding the restriction in the speed of eating is variable. The band is empty at the time of surgery and is adjusted about four weeks after surgery. Sometimes several band adjustments are needed in clinic before the perfect restriction is produced. We advise that patients take in liquids for one week after surgery, then introduce a puree consistency diet, followed by mashed food and then well chewed food. Following the band adjustments or tightenings, patients are requested to be careful with solid foods, particularly bread and dry meat such as chicken for several days until they know how tight the band is.”

How will I know when the band is at the optimum tightness?

“The band should work by forcing a patient to eat slowly and methodically.”

“The band is at the right tightness when a person can eat a whole range of foods and rarely has to avoid any type of food. A small side plate of food should be able to be consumed but will take twenty to thirty minutes. Occasionally a patient may regurgitate once or twice a month if they eat too fast. This would be the appropriate band tightness.”

“If the band is too loose a small side plate of food can be eaten in five to ten minutes and the patient will never regurgitate. If the band is too tight the patient will avoid a wide range of solid foods and will notice food sticking and regurgitation of food most days.”

What will my eating be like long term?

“The gastric band is designed to be a long term solution to weight loss and maintenance of weight loss. The appropriate tightness of the band would mean that even long term a person would have to chew their food very well and be methodical in their eating. Please see Golden Rules of Eating for advice on long term eating pattern.”

Will my appetite change following gastric banding?

“There is conflicting evidence in the scientific literature as to whether appetite really changes following gastric banding. Most of the scientific evidence which suggest that the appetite does change has an element of bias because it tends to be sponsored by the companies that market gastric bands. My own experience of patients that have had gastric banding is that appetite rarely changes. Occasionally a patient will confuse the feeling of food getting partially stuck in the lower oesophagus with a change in the appetite. This is because a patient will feel too full and slightly sick after eating too fast.”

How much weight can I expect to lose following gastric banding?

“Following gastric banding a person can expect to lose about 50% of their excess weight. Therefore if they weighed 20 stone before surgery and their ideal weight should be 10 stone, they will lose half of their excess weight and their weight would therefore go down from 20 stone to 15 stone within about a year of surgery. Patients that can change their eating habits to completely avoid foods high in fat and sugar will lose more weight, and those that cannot avoid these foods will lose less weight”

What do I need to do to ensure long term weight loss?

“The gastric band requires more effort than the sleeve gastrectomy or gastric bypass in the long term to ensure weight loss is maintained. Because there are no major hormonal changes in appetite or food preferences maintenance of weight loss following a gastric band requires much more self control.”

“Patients that do very well following gastric bands are those that tended to eat too fast and eat too much food in one sitting before the band was placed.”

“If a patient consumes too many foods or drinks of high calorie content that will slip through a gastric band, such as chocolate, ice cream or sweet drinks, they will be particularly disappointed with the amount of weight loss that they have achieved.”

Do I need to take vitamins after surgery?

“No.”

What health improvements can I expect?

“Following weight loss there will be significant improvements in diabetes, blood pressure, cholesterol, sleep apnoea and joint pains. In addition, quality of life after weight loss tends to be much better.”

What are the risks of surgery?

“Following gastric band placement the short term risks during the operative periods are extremely low with only small risks from bleeding, early difficulty swallowing or blood clot in the legs. In the longer term there is a significant chance that the band can lead to complications. These would include migration of the band into the wrong place around the stomach, erosion of the band into the stomach, problems with the connection port and problems with the inflation valve. I would quote a 10-20% chance of a band having to be replaced or removed in the years after surgery.”

Revisional Surgery

“Some people have previously undergone bariatric surgery but the procedure that was performed did not suit them, and therefore they had disappointing weight loss results or have started to regain weight. This can happen in a small proportion of patients following either gastric band, sleeve gastrectomy or gastric bypass.”

“In patients who have previously undergone gastric band surgery, complications of the band can mean that it requires removal. These complications include the band migrating into the wrong position around the stomach, the band eroding into the stomach, problems with the connection tubing, leakage from the band, and dilation of the oesophagus above the band.”

“In these cases of failed bariatric surgery, revisional surgery may be indicated. The most common procedure would be removal of a gastric band and conversion to gastric bypass. Other common revisional surgeries include conversion of a sleeve gastrectomy to a gastric bypass and placement of a gastric band around a previous gastric bypass.”

“Revisional bariatric surgery has a higher complication rate and therefore should be considered very carefully. Choice of an experienced surgeon working in a unit dedicated to bariatric surgery, and used to the more complicated revisional surgery, will significantly decrease the risk of complications occurring.”

Golden Rules of Eating


There are six Golden Rules on how to eat following bariatric surgery. These apply to all types of surgery but are particularly applicable if the gastric band is to be effective in the long term to help reduce weight.

  • Eat whilst sitting at a table, either with company or alone. Do not eat whilst distracted, i.e. reading newspaper or watching television. Do not eat in the street. This is to ensure that the food is eaten slowly and savoured.
  • Use a small side plate to eat from. This will ensure an appropriate portion size.
  • Chew each mouthful of food 20 to 30 times. This will ensure that the food is of the right consistency to pass through the gastric band or sleeve gastrectomy without blockage.
  • Use a knife and fork and put the knife and fork back down onto the table whilst chewing your food. This will ensure that food is not eaten too fast and time is taken between mouthfuls of food.
  • Do not drink any liquid from half an hour before to half an hour after eating.
  • Have regular meals including a regular breakfast, lunch and dinner. Each small meal should have some protein content to ensure that the appetite hormones remains slightly suppressed. A small healthy snack can be taken between meals.

 

Novel Procedures

There are many novel procedures that are being offered to promote weight loss. There is a lot of interest amongst surgeons and gastroenterologists regarding these procedures. However they remain either experimental in nature or have not been proven as yet to offer patients effective, safe, cost effective, long term weight loss. Here follows a summary of these procedures:

POSE (Primary Obesity Surgery, Endoluminal)



“-This procedure is performed by endoscopy where a flexible telescope is inserted through the mouth. Therefore no cuts in the abdomen are required. The flexible endoscope has been designed to deploy staples or clips to the floppy part of the stomach. The aim of the procedure is to try and reduce the size of the stomach by folding the stomach up using these staples that are fired from the endoscope.-”

“This procedure is an adaptation of several previous procedures which have attempted to reduce the size of the stomach via an endoscope. Many of the previously attempted procedures are now not available on the market because they either did not produce effective weight loss, or they had a significant complication rate including perforation of the stomach. At present there is no significant independent evidence that the POSE procedure is a safe and effective alternative to laparoscopic bariatric surgery.”

SILS (Single Incision Laparoscopic Surgery)

“There has been great interest in SILS surgery over the last five years since the concept was introduced into the surgical scientific community. SILS surgery requires the surgeon to perform a traditional laparoscopic operation through a single port usually placed in the umbilicus. Despite the initial interest, many surgeons have tried this procedure and most would agree that the increased risk of surgery, including longer operating time and increased risk of complications, outweighs the benefit of one longer scar across the umbilical area, instead of three to five 5-10 mm scars. There has been no proven improvement in postoperative pain following SILS surgery. Most surgeons now will not offer this surgery for the reason that it confers a greater risk of complications, compared to the minimal benefits in cosmesis.”

Robotic Surgery

“The use of an articulating robot to assist a surgeon in performing laparoscopic surgery has been received with much enthusiasm by laparoscopic surgeons. The robot as an aide to surgery is now used routinely for many types of surgery, particularly gynaecological and urological surgery.”

“Some surgeons have used the robot to perform bariatric surgery such as the gastric bypass. However this has not been routinely popularised as most bariatric units are able to perform relatively fast and very effective bariatric surgery without the use of the robot. The robot has as yet not been proven to confer any advantage in safety over routine laparoscopic bariatric surgery, and in fact will lead to an increase in the operation time. In addition to this, the robot is not designed to staple or join the stomach and bowel and therefore an assistant has to be used for this, where with laparoscopic surgery the primary surgeon will perform the stapling.”

“Therefore in summary, robotic bariatric surgery does not confer any significant advantage over laparoscopic bariatric surgery and has the disadvantage of lengthening the time of the operation.”

EndoBarrier

“The EndoBarrier is a novel Endoluminal treatment to help weight loss and improve diabetic control. It involves the application of a long plastic tube from the first part of the small bowel (duodenum) to the second part of the small bowel (jejunum). It is designed to carry food through the tube but separated from digestive secretions which remain outside the tube. It therefore causes a malabsorption of foods, helping weight loss.”

“This procedure is conceptually excellent as an aide to reducing weight and improving diabetes whilst avoiding traditional laparoscopic surgery. However the initial results are not quite as promising as would be expected, and there have been some concerns raised about the safety of the mechanism that attaches the upper part of the sleeve to the duodenum, with some reports of it eroding or migrating into the duodenum requiring an emergency laparotomy or open operation. The effectiveness of the EndoBarrier in reducing weight and improving diabetic control has so far been slightly disappointing.”

“Whilst there are safety concerns for this procedure, in addition to its so far disappointing outcome, we do not currently offer the EndoBarrier as a treatment. However we are aware that with further modifications this may become a procedure that becomes more mainstream in the future. The EndoBarrier has to be removed after one year at present.”

Gastric Balloon

“The gastric balloon has been a endoscopic option to help weight loss for several years now. Our experience of the gastric balloon is that many patients have major problems with intractable vomiting following the insertion of the gastric balloon. In addition, there are reports of significant side effects from the gastric balloon including gastric perforation. The procedure is only temporary and the balloon has to be removed or replaced after six months. Once the balloon is removed a patient will invariably regain any weight that has been lost. It is for these reasons that we do not offer this therapy as we do not think that it is cost effective in long term weight loss.”