What to Expect Before Surgery
After attending a free informational seminar, we encourage you to schedule an appointment with one of our bariatric surgeons. This initial visit allows us to better know you, understand your obesity and metabolic challenges, and learn your medical history.
During this first visit, your surgeon wants to learn more about your motivation for weight loss, review your weight history, and discuss your personal weight loss goals. Your surgeon also reviews your medical and surgical history, medications, and performs a physical exam. This allows him to not only evaluate your candidacy for surgery but to also assess your general risks. If deemed necessary, we also recommend additional consultation with specialists such as a cardiologist, pulmonologist, sleep disorder specialist, or gastroenterologist.
During your evaluation, we also refer you for metabolic and nutrition counseling. This allows us to assess your intake and me- tabolism and develop a medically directed weight loss plan for before and after surgery. We want to stress to you the importance of adequate protein and fluid intake, life-long vitamin supplemental therapy, and healthy food choices.
We also require consultation with a licensed clinical psychologist. The psychologist helps us to identify barriers that interfere with weight loss including untreated depression, anxiety, or eating disorders. More importantly, this helps you address emotional stressors associated with surgery and offers healthy mechanisms for coping with those stressors.
Once you complete your medical weight loss program and evaluation by a psychologist and nutritionist, we meet with you to decide on surgery. We use the data from the pre-operative program to help assess your risk for surgery and guide your choice of operation. We also review those recommendations made by our various medical specialists and obtain pre-operative laboratory and radiographic tests to determine your qualification for surgery.
Your level of motivation, realistic weight loss goals, psychological coping skills, and surgical risks help your surgeon decide on the most appropriate recommendation. We respect your personal preference for a procedure but offer guidance to mitigate risk and optimize your satisfaction.
Once this is complete, we proceed to insurance certification and typically schedule surgery within 30 days of your decision visit. We then obtain your written informed consent and schedule the preoperative testing with Anesthesiology.
History and Physical Visit (If outside 30 days from decision visit)
Once scheduled for a particular surgical procedure, we arrange a pre-operative exam to re-assess your current medical history, perform a physical exam, review further the risks and benefits of surgery, and sign the surgical consent form. We also briefly review your preoperative and initial post-operative diet, and explain what to expect during your hospital stay.
Do not drink anything after midnight the evening prior to surgery, except to take your normal medications. On your surgery day, please bring your CPAP machine (if you have sleep apnea and use CPAP), otherwise we may postpone your surgery.
Check in at the admissions desk at the hospital. The nursing staff prepares you for surgery by placing an intravenous catheter (IV), injecting you with a subcutaneous blood thinner, and interviewing you in preparation for surgery.
Your surgeon usually meets with you in the preoperative area to address any last minute questions and reiterate postoperative expectations. After induction of anesthesia, we insert a bladder catheter and, in certain cases, an arterial blood pressure monitor.
The surgery itself takes between 1.5 to 2 hours for gastric bypass and 1 hour for Lap Band.
What to Expect After Surgery
After recovery, we monitor your vital signs closely overnight. We emphasize the impor- tance of early walking to preventing blood clots in the legs (DVT) which can travel to the lungs (PE) with potentially lethal consequences. We also recommend deep breathing exer- cises which help improve oxygenation and decrease the risk of pneumonia.
On the morning after surgery, you undergo an upper GI radiology study to evaluate for leakage (for gastric bypass). When determined as normal, we advance you to a liquid diet. The nurse removes your bladder catheter (assuming your urine output is adequate) and transitions you to oral medications.
We anticipate discharge from the hospital in the morning on the second day after surgery. You advance to a liquid protein diet on the third day after surgery (usually at home).
Commonly, we reduce or discontinue diabetes or blood pressure medications. We decide this prior to discharge and adjust ac- cordingly at follow-up visits.
We cannot overstate the importance of post-operative follow-up. You routinely return for scheduled follow-up appointments at 2 weeks, 1 month, 3 months, 6 months, 12 months, 11⁄2 years, and yearly thereafter. We assess your clinical progress, weight loss, exercise, diet, medications, co-morbidities, vitamin intake, and laboratory data during the post-operative clinic appointments.
At these visits, our surgeons continually reassess for post-operative challenges and complications and provide education with regards to warning signs of long-term complications. We also strongly urge post-operative visits with the nutritionist for dietary refinement, nutritional surveillance, and diet trouble-shooting, as well as regular psychological follow-up of post-operative stressors.
Caring for yourself at home
Once discharged home, a few simple measures allow you to optimize your recovery.
Controlling your discomfort:
Take your prescribed pain medication as directed if you need it. As a less potent alternative, you may take liquid acetominophen (Tylenol) instead of your prescribed pain medication. Do not take them together due to risk of acetominophen toxicity.
Splint your abdomen with a pillow when coughing or sneezing. With lapa-roscopic gastric bypass, patients often notice increased soreness or pain at the larger abdominal incisions. This is typical and expected, especially with more movement. It can take up to 4 weeks to go away.
Understanding body changes
It is common to feel tired after surgery. Your body is adjusting to the physiologic changes and weight loss. Ironically, you may find it difficult to sleep, which is also normal. Do not sleep or nap too much during the day. You may even feel depressed for a few weeks and question your decisions to choose surgery. If you experience these feelings, you will find that after about a month’s time, you will start to feel better.
Some patients may experience nausea and/or vomiting. The most common causes of vomiting following bariatric surgery are:
Eating too fast
Eating too much
Drinking while eating
Eating foods without chewing them thoroughly
Carefully follow the diet advancement plan as outlined in the “Nutrition” section. If vomiting occurs, try the following strate- gies to better accommodate your eating style:
Eat your meals over a 30-minute period.
Avoid fluids during your meal.
Chew your food thoroughly.
Eat softer foods for a few days following the episode.
If your issues persist, please call our office. While a decreased appetite is the desired effect of the operation, you must be careful not to forget to eat. You may need to encourage yourself to eat. It is extremely important that you follow the dietary plan as directed (starving is bad).
It is common to have soft, semi-formed bowel movements following surgery. Once you advance your diet to incorporate more solid foods, your bowel movements should have regular consistency.
You may experience constipation following surgery due to the altered structure of your stomach and intestines. The prescribed pain medication and the iron supplement may also contribute to this, as can a decrease in fluid intake. If you do not have kidney problems, you may use Milk of Magnesia as directed. You may also use stool softening suppositories as directed. You may also try adding prune or pear juice to your diet. If you do, please be mindful of the sugar content. It is common to not have a bowel movement for 5 days after surgery. Conversely, some folks may have diarrhea for a few days, partly related to the UGI contrast study on the first post-operative day.
Some patients will experience hair loss following surgery. This is primarily thought to be related to the rapid weight loss during the first 9 months follow- ing surgery and will usually decrease after 9 months. If you experience this, please learn to be gentle with your hair and avoid coloring or perming your hair during this period. Use a wide-toothed comb and minimize blow drying your hair. It is also important to take your vitamins. A high fat intake in your diet is the most common cause of increased gas production following bariatric surgery. You may take anti-gas medication from your local drugstore. These medications include Beano, Gas-X and Phazyme. You might also want to try adding yogurt or acidophilus milk to your diet once your diet plan allows. These things will help change the bacterial flora in your intestines.
You or your loved ones may notice that you have bad breath following surgery. You may also notice a different taste in your mouth. A couple of things that may contribute to this are your body being in ketosis (burning excess fat) or dry mouth. This usually improves by the 6th month. In the meantime, try brushing your teeth several times daily. Maximize protein intake to the recommended level of 60-80g daily and stay well hydrated. Keep Listerine mouth strips with you. Keep your mouth moist by drinking plenty of non-sugar beverages. Sugar-free gum can also help. Keep in mind you want to avoid sugar in your diet; chewing gum with sugar can also cause bad breath to become worse. Some patients experience episodes of hypoglycemia (low blood sugar). If you experience this, try eating a protein snack such as peanut butter. The protein will help stabilize your blood sugar. If you notice that this persists, then you need to contact our office.
Some symptoms of hypoglycemia are:
Activity and Lifestyle
You will be able to take daily showers as you did prior to surgery. Wash over your incisions gently using soap and water. Try to avoid perfumed soaps from the specialty bath store (on your incisions) for the first two weeks following surgery. We recommend Dial soap. When you are fin- ished with your shower, pat the areas dry. Using a cool blow dryer can also help. You do not have to keep your incisions covered, although you may want to if you note any drainage. Please avoid taking tub baths until after your 2-week follow-up visit.
Sexual relations can be resumed as early as 2 weeks following surgery if it is comfortable. This may be longer with an open operation. The best rule is to resume when it is comfortable for you. Females, please remember to use some method of contraception to prevent pregnancy for the first 24 months following surgery.
A general rule is not to drive for 2 weeks following surgery. There are many reasons for this. However, your surgeon may let you return to driving at 1 week if you:
Are not taking narcotic pain medication
Can stomp your foot on the ground without pain (mimic pressing the brake hard) This decision will vary from surgeon to surgeon.
Return To Work
Returning to work will vary with each patient depending on the type of procedure (band vs. bypass), the approach that was used (laparoscopic vs. open), as well as the type of work you do (sedentary vs. physical). For example, it is not unusual for a person who works as a telephone operator at a desk all day to return to work following an adjustable gastric band in 1-2 weeks. On the other hand, a person who works in landscaping lifting plants/trees may need to be out 4 weeks. There are also those patients that are somewhere in between the two extremes. There are some cases in which you can go back sooner doing light duty until your surgeon clears you to go back with no restrictions. Your surgeon can give you a better idea once the two of you have decided which procedure is best for you.
Adjustable gastric band or laparoscopic gastric bypass will be out 2-4 weeks Open gastric bypass will be out 4-6 weeks
Nausea is common in the early post-operative period. It may be related to overeating/drinking, insufficient chewing, fullness, sensitivity to odors, pain medica- tion, not eating, post-nasal drip, and/or dehydration. For nausea that occurs in the first days after surgery, the nausea can usually be treated with anti-nausea medications like Phenergan or Zofran. In unusual cas- es, nausea can be so severe that it prevents intake of adequate fluid or nutrition. If this occurs, you may need some intravenous fluids.
Vomiting is often associated with eating inappropriately. It is very difficult to gauge in the beginning how little food will satisfy your hunger. Chew your food well, keep it moist and eat only half of what you anticipate eating. If there is still space, and you still feel hungry, then you can always eat a little more. Chances are that you are going to feel full with very little. A couple of teaspoons may be all that you can take in at one time.
Vomiting may be caused by:
- Eating too fast—take your time and chew your food thoroughly
- Not chewing properly
- Eating food that is too dry—remember “slow, small, moist, and easy”
- Eating too much food at once
- Eating solid foods too soon after surgery
- Drinking liquids either with meals or right after meals
- Drinking with a straw
- Lying down after a meal
- Eating foods that do not agree with youIf you begin vomiting and it continues throughout the day, stop eating solid foods and sip clear liquids. Should you have difficulty swallowing foods or keeping foods down, please call your surgeon. Vomiting may indicate that the stomach pouch is blocked. If vomiting continues for more than 24 hours, call your surgeon. Or if vomiting is associated with abdominal pain, call the surgeon.
What to Report to the Doctor’s Office
At times you may feel unsure whether or not you should call our office. You may question if something is “normal” or not.
Although the list below is not all-inclusive, please call the office if you:
- Have persistent nausea and vomiting
- Have abdominal pain not relieved by your pain medication
- Your incisions become red, swollen or have a foul smelling drainage from them
- Have a fever of 101.5 F or greater
- Have redness, warmth or pain in your lower leg(s) along with shortness of breath
- Have anything that does not seem normal to you
- Have chest pain
Symptoms of dehydration include fatigue, dark colored urine, dizziness, fainting, nausea, low back pain, and a whitish coating on the tongue. Contact our office if you believe you may be dehydrated.
Tips for preventing dehydration:
Buy a sports bottle and take it with you everywhere you go so you can sip water all day Drink at least 1-1⁄2 to 2 liters of fluids daily. Increase this amount if you are sweating Avoid beverages containing caffeine—they cause you to urinate and lose more fluid
It is unpredictable how weight loss surgery, particularly gastric bypass, will affect your bowel habits. Some people state they have loose bowel movements for a couple of weeks and others complain of dehydration. Your bowel movements may be foul smelling and associated with flatulence. Most of these changes resolve as your body adapts to its new anatomy. Call your surgeon if you have persistent diarrhea.
Keeping bowel movements regular:
Your stools may be soft until you eat more solid food.
Lactose intolerance and high fat intake are generally the culprits of loose stool and diarrhea.
Avoid all high fat foods and discontinue the use of all cow milk products if this should occur. Yogurt is okay.
Stool softeners such as Colace or mild laxatives like milk of magnesia or Dulcolax can be helpful.
All menstruating women and some men should take supplemental iron to prevent iron deficiency anemia. It is important that you follow up at the regularly scheduled appointments for laboratory testing to identify iron deficiency anemia early. Treatment with oral iron is usually sufficient; however, occasionally intravenous iron replacement is necessary.
Transient Hair Loss/Skin Changes
Hair thinning or loss is expected with rapid weight loss. It is temporary. Unfortunately, that does not make it any less disheartening. During the phase of rapid weight loss, calorie intake is markedly reduced and protein intake may be marginal.
This physical strain results in hair thinning or loss. This is a transient effect and typically resolves itself when nutrition and weight stabilize. The hair loss usually occurs anywhere from 3 to 9 months post-operatively. For the same reason, skin texture and appearance may change. It is not uncommon for patients to develop acne or dry skin after surgery. Protein, vitamins and water intake are also important for healthy skin.
Patients who may have had difficulty with irregular menses or infertility very rapidly become more fertile and have improved menstrual regularity after surgery. It is imperative that you practice birth control during the first 12 to 18 months to prevent pregnancy. Studies have shown that fetuses develop normally despite the malabsorbative component of the gastric bypass, but overall weight loss of the mother may be reduced as the body switches to a mode of weight retention rather than loss. Folate and other vitamins necessary for normal fetal development will also need to be increased in pregnancy. Patients with adjustable gastric bands will need the fluid removed should they become pregnant. You should consider mechanical means of contraception during the period of rapid weight loss (12-18 months) as absorption of birth control pills may be unpredictable.