Endoscopic Sleeve Gastroscopy (ESG)

The risk of serious complications like these is small:

• Bleeding.
• Infection.
• Tears in the stomach.
• Abscess (a pocket of infection).
• Leaking of stomach contents into the chest or abdominal cavity.
• Pulmonary Embolism (a blood clot in the lung).
• Pneumothorax (collapsed lung).

Protein: try to include a protein food at every meal. Aim for 60-80g protein each day. Focus on low-fat protein sources such as chicken, fish, turkey, beans, lentils, tofu, or low-fat dairy.

Fats: limit the amount of oil, butter or margarine you use. Cooking sprays are a good alternative. Try to avoid high-fat foods such as cakes, biscuits, or crisps.

Carbohydrate: Limit carbohydrates with lots of starch. Try to have 1-2 meals per day which do not include starchy carbohydrates. Choose wholegrain options if you do eat them. Aim for less than 120g per day.

Sugars: Avoid adding any type of sugar, honey, or syrup to foods. Artificial sweeteners are ok to use. Aim to avoid eating any foods high in sugar e.g. cake, chocolate, sweets, fruit juice.

You will need to start taking a multivitamin and mineral supplementation as this diet is won’t give you all the nutrients you need. This can be either tablet or chewable/gummy. There is more information about vitamins later in this booklet.

Meal ideas

Nutrient tracking options

• Calorie Tracker & BMR Calculator to Reach Your Goals | MyFitnessPal
• Carbs & Cals | Dieting & Calorie Counting Books & App
• Top rated calorie counter website and app | Nutracheck

Where to find recipes

• Low-carb diet and meal plan | Eating with diabetes | Diabetes UK
• Low-carb meals - BBC Food
• Low calorie recipes and diet information - BBC Food
• Easy Low Calorie Meals | olivemagazine
• Books:
  • Pinch of Nom
  • Carbs and Cal: Very Low Calorie Recipes and Meal Plan
  • The Fast 800 Recipe Book

You can have low-sugar, high-protein, meal-replacement shakes to provide 800-1000 calories in total each day. Many of these shakes are low in fibre so it can be helpful to include 1-2 portions of vegetable or salad each day (fibre in these helps prevent constipation).

Look for shakes with 200-300 kcals and 20-30g protein per serving. Aim for a low sugar option - about 5g of sugar per 100g/100ml.

Some suitable options

* vegan options

If you have diabetes treated with tablet medication and/or insulin you will probably need to change these medications. Your diet before and after surgery will have very little carbohydrate and can increase your risk of hypoglycaemia.

We will help you make a plan in your pre-operative assessment appointment. You will need to monitor your diabetes control more closely during this time.

Following surgery, you will need to drink thin liquids (drinks) only for 2 days such water, squash, protein water, tea and coffee, and semi-skimmed milk.

• Have small amounts of fluid (no more than 50mls) every 10-15 minutes.
• Aim for least 2 litres of fluids each day.
• Even if you feel thirsty it is important you drink small quantities at a time
• Avoid fizzy or high sugar drinks such as juices.
• If you have stomach pain or nausea whilst drinking stop until the feeling has passed.

Aim to have high protein drinks, shakes, or soups which are smooth (with no lumps) regularly through the day. The liquids should be able to run off the back of a spoon like thin yoghurts, tinned soups, or runny custard.

• Portion sizes are approximately 100-300ml.
• Take small mouthfuls one at a time and give yourself a break in between mouthfuls so you can recognise the early signs of fullness and stop.
• If you feel pain, stop immediately.
• You will need to drink other fluids (water, tea, squash) to get your 2 litres fluids per day.
• It can be difficult to get enough nutrients while you are following a liquid diet.
• Aim to include as many liquids with lots of protein as possible. Protein is important for your general health including maintaining your muscle mass while you are losing weight. This will help your overall weight loss.
• Aim for 60g protein.

High protein liquids

• ‘Fortified milk’ - 1 pint semi-skimmed or skimmed milk with 4 tbsps of dried skimmed milk powder.
• Smoothies – fruit or vegetables blended with fortified milk, natural yoghurt or protein powder. (Avoid shop bought smoothies as these are low in protein and high in sugar).
• Smooth Soup (homemade or tinned). Add 1-2 tbsp of skimmed milk powder, protein powder or quark.
• Meritene or Complan shakes or soups – available in Supermarkets or pharmacies.
• Meal replacement shakes e.g. Slimfast, Tesco Slim, Asda Great Shape, Exante or Lighter Life.
• High protein milkshakes e.g. UFit, Arla, For Goodness Shakes, Urban Active
• Protein Water e.g. Vieve, Upbeat or +PW
• Whey, soya, or pea protein powders

Recipes

After 10 days of a liquid diet, you can progress to foods with a thicker, puree consistency. You will need to use a food blender, processor or liquidiser.

Start with 1 tsp of food at a time and check how you feel after. Each meal should have around 2- 4 tbsp. Aim to eat the protein part of the food first. It may be helpful at this stage to cook and freeze foods, as portions will be small.

See the example menu plan on the next page.

Tips:

• Eat protein food first, then vegetables and finally carbohydrates. P.V.C (Protein, Vegetable, Carbohydrate). In the early days, you may only manage the protein.
• Use high-protein milk in/with foods such as cereal, scrambled eggs etc.
• Try one new food at a time. If you feel sick, gas, or bloated, it may be the case you are not ready for this type of food, try again in a few days.
• Food can be liquidised in bulk and frozen. You can use an ice cube tray and take a few ice cubes out per meal.
• Slow cook or casserole meat in plenty of liquid to make it easier to blend.
• Adjust your portion sizes as you feel necessary. Listen to your body and stop before you feel full.

Sample meal plan

You no longer need to blend food. Gradually introduce foods which are soft in consistency, that is they fall apart easily with a fork. Foods which are naturally moist are good at this stage or add sauce/gravy to dishes.

You can also include crunchy foods in this stage such as cereal, crackers or toast. Make sure you chew these foods thoroughly. Start with a small portion e.g. 3 tablespoons as a meal and increase gradually depending on how you feel.

Tips:

• Aim to grill or air fry and use herbs/spices to flavour foods.
• If using oil, measure out a small amount (1-2 tsp).
• Try 1 tbsp (tablespoon) of a new food every 1-2 days. If you feel nauseated or bloated after eating, then you may not be ready for this food. Wait a few days before trying this food again.

Sample meal plan

You are now ready to progress onto your long-term healthy diet.

This can be challenging as you learn how much you can eat of certain foods and the importance of paying attention to your body as you eat. Continue to add new foods in slowly. Aim to eat 3 small meals per day with 1-2 snacks as necessary. Focus each meal and snack on protein-rich foods. Keep portions small by using a side plate. Aim to eat 60-80g protein per day.

Cooking tips:

• Remove fat and skin from meat before cooking.
• Use low fat cooking methods such as grilling, baking (wrap in foil to keep things moist), steaming or boiling.
• Limit oil or butter added to vegetables or salads. If you need extra flavour, add seasoning, low-calorie dressing or vinegar.
• If you need to use oil to stop food from sticking, use a spray oil.
• Add flavour using herbs, spices, seasonings, lemon juice, ginger, onions, and garlic.
• Aim to avoid adding oil or butter to carbohydrates.
• Choose high fibre (wholegrain) carbohydrate foods where possible like wholegrain bread, brown pasta, brown rice, wholegrain / seeded crackers or oatcakes and keep skins on potato.

Sample meal plan

Snack ideas - 100 calories with high protein

• Small handful nuts
• Slice of smoked salmon or ham with cucumber sticks
• Trail mix of nuts/seeds with dark choc chips
• 1 pot of high protein natural yoghurt (Icelandic or low fat Greek style)
• 1 pot Greek style Soya yoghurt
• 1 boiled or Devilled egg
• 1 oatcake or rye crispbread with 1 tbsp cottage cheese or low fat cream cheese
• 1 egg muffin
• Veg sticks with 1 tbsp of hummus or bean dip
• 2 tbsp roasted pumpkin/ sunflower seeds
• Slice smoked salmon with 1 teaspoon cream cheese
• Nice cream – frozen banana whizzed with peanut butter
• 1 pot of fruit flavoured high protein yoghurt
• 2 tbsp low fat Greek yoghurt with handful of berries
• 80g soya/edamame beans
• 80g Spicy chickpeas – try roasting with cumin and smoked paprika
• Slice of ham with low fat cheese spread* or cottage cheese
• 1 mini cheese or Babybel
• 1 stalk of celery or 2-3 slices of apple with 2 tsp of almond butter
• 1 pack of chicken bites

It is common to have constipation in the early days after these operations because you are not having much food and drink

To help manage constipation:

• Drink plenty of fluids – aim for 2 litres a day a day.
• Add in a laxative such as sodium docusate or senna.
• Add in some high fibre foods where able e.g. vegetables, wholegrain carbohydrates, beans and pulses.
• Keep as active as you can.

Please contact the Bariatric Team or the Bariatric Clinical Nurse Specialist if the above does not work.

If you have any of these, it may be because you are:

• Eating too quickly.
• Not chewing enough.
• Eating too much.
• Drinking with the meal or within half an hour after eating.
• Lying down too soon after eating.

If you suddenly feel unwell with symptoms such as shortness of breath, worsening abdominal pain, fever, limb swelling, unable to tolerate food/fluids, nausea and vomiting please go to the Emergency Department, contact Bariatric Team or GP.

It is common for people to feel tired and to have low energy levels in the early weeks after the procedure. This is usually because it is difficult to get enough calories and protein, also the fact you are losing weight.

Aim to consume at least 60g protein and 800 calories each day. If you are struggling to do this, it can be helpful to include protein shakes to help meet this target.

Tiredness can also, but less commonly, be due to a vitamin or mineral deficiency, so please do ensure you take your multivitamin and mineral supplement once a day.

In the first 6-9 months, it is common to have some hair loss. This also is usually due to not enough calories and protein. Once your weight loss has stopped, this problem usually goes away.

After your procedure you will be eating much smaller portions of food and it can be hard to get all the vitamins and minerals your body needs. Please take the following vitamins and minerals. You can buy these in most supermarkets, chemists, or online.

• 1 A-Z multivitamin tablet once a day.
• 1 vitamin D tablet once a day.

For first 6 weeks these need to be in a chewable form. Once you are on a normal textured diet you can take a tablet form.

Suitable options are:

• Chewable: Superdrug chewable, Centrum chewable
• Tablet: Tesco A-Z, Superdrug A-Z or Aldi A-Z

Dumping syndrome is a less common side effect after ESG. It happens when the lower end of the small intestine (the jejunum) fills too quickly with undigested food from the stomach. There are two types of dumping:

• Early dumping - happens during or right after a meal. Symptoms of early dumping include nausea, vomiting, bloating, cramping, diarrhoea, dizziness and fatigue
• Late dumping - happens 1-3 hours after eating and is usually due to a low blood sugar. Symptoms of late dumping include weakness, sweating and dizziness .

Managing dumping syndrome

• Early dumping syndrome: lie down as soon as you have symptoms, you are likely to feel better after around 30 minutes.
• Late dumping syndrome: have a snack that includes both carbohydrate and protein like a cracker with soft cheese. If you feel very unwell you may need a small glass of orange juice before the cracker to bring your blood sugar back to normal.

To avoid dumping symptoms:

• Avoid chocolate, biscuits, cakes, sweets, desserts, high sugar drinks, high glycaemic index (GI) carbohydrates such as white bread.
• Aim to eat at least 3 times per day (rather than 1 big meal).
• Avoid eating and drinking at the same time – wait 20 minutes.

Losing weight can increase fertility and we strongly recommend that you do not become pregnant for at least 18 months following the procedure. Weight loss can have negative effects on the pregnancy.

After this surgery your oral contraceptives (the pill) may not work. You should use alternative methods of contraception, for example, barrier methods (condoms/cups) if this is a concern.

If you become pregnant following the procedure it is important to let your GP, Obstetrician, Midwife, and Bariatric Team know as soon as possible. You may need extra monitoring during the pregnancy to make sure that you and the baby get enough nutrients to keep healthy.

• Bariatric Coordinators: 0117 414 0855/54
• Bariatric Waiting List Coordinator: 0117 414 8826
• Bariatric Surgery Senior Enhanced Practitioner: 0117 414 2085 or 0755 7312784