Post op information after sleeve or gastric bypass

After the surgery

If you have any questions, please do not hesitate to contact me.
Email: victorliew@live.com.au

Gold Coast Private Hospital number: (07) 5530 3000

Gold Coast Private Ward 9 number: (07) 5530 0605

Please forward this to your GP as well

Below are generic post op instructions only

Please email or make an appointment to see me, your GP or a specialist should any problems or concerns arise

Please come back to the Gold Coast Private Hospital if there are any post op surgical issues that require urgent medical attention

Symptoms after the surgery

Common symptoms after discharge: Wound, shoulder tip and rib cage pain. Oesophageal spasm (chest pain with swallowing). Acid heartburn, nausea and vomiting. Dehydration (symptoms include headache, feeling thirsty, faint, dizzy, fatigue, confusion, constipation, muscle cramps, constipation, dark urine). Early dumping (symptoms include abdominal cramps, diarrhea, feeling flushed, sweaty, palpitations, faint and dizzy and the blood sugar level may drop).   Serious warning symptoms to watch out for: Leaks (fever, sweats, chills, severe abdominal or back pain, rapid shallow breaths). Blood clots in the abdomen or legs (tenderness in the abdomen or calves). Blood clots in the lungs (sharp chest pain, shortness of breath).

Dehydration Please avoid standing outside in the hot sun, especially during summer time Please make sure you drink more than 1.5 to 2 litres water a day *Some people buy Hydralyte or sugar free Powerade or Gatorade to replace the electrolytes lost.   Dehydration will get worse with nausea, vomiting after food poisoning or viral/infective gastro-enteritis. Some people may need to return to hospital for IV fluid hydration.

Diarrhea or dumping syndrome   Some people may experience early dumping syndrome (within 30 minutes) of eating inappropriate foods, which is usually due to consuming the high GI index fluids or food   Some people may experience hypoglycaemia like symptoms (late dumping, usually 1 to 2 hours after eating), which is usually due to eating too much carbs and processed foods. *Please avoid the high GI index foods (such as honey, fruit juice, carbonated drinks, alcohol, sweets/lollies or desserts) *Please avoid starch/carbs (such as bread, potato, pasta, rice, corn, peas, pumpkins, etc).   Some people may get lactose intolerance *Please avoid the milk and other dairy products   To help reduce the watery diarrhoea you may have fiber supplements (Metamucil/Benefiber), codeine, Immodium or Lomotil but this is often not necessary If you are really dehydrated, I will ask you to come back to the hospital for IV fluids

Reflux symptoms   After the sleeve gastrectomy or gastric bypass, some people may get acid reflux or regurgitation of gastric contents. The symptoms are heartburn, waterbrash sensation and discomfort in the lower chest with lying down. *Please remember to eat small portions, slowly over 30 minutes *Then wait 30 minutes after you drink any fluids *Stop before you feel too full *Please avoid eating foods that may get stuck in the oesophagus (such as bread, rice, canned fish, dry meat)   Please avoid eating/drinking 3 to 4 hours before going to bed to prevent reflux at night *Some people sleep with the head of the bed elevated or on 3 pillows *If you experience night time reflux, please sit up or walk around the house   You may buy over the counter antacids (Gaviscon, Mylanta) from the chemist. Please have some anti acid medications (Losec, Acimax, Somac, Pariet or Nexium)   Avoid eating food that makes heartburn worse (such as caffeine, chocolates, carbonated drinks, alcohol, acidic/spicy foods)   Avoid food that cause gas bloating, avoid starch (bread, potato, pasta, rice), sweets (fruit juice, desserts) or fatty meals.   If you have irritable bowel syndrome (IBS) please try the low FODMAP diet.   If the reflux symptoms persist, let me know and I will organize a gastroscopy check

After discharge   Please make sure you drink at least 1.5 to 2 litres of water a day to prevent dehydration *You may add the protein powder supplements to the chicken or vegetable soups *Add some salt to your soups *You may have the VLCD shakes or other fluids in the first month or two   Add olive oil to your puree vegetables or salads *Have some vegemite if needed, they are a good source of vitamin B   Please continue to see your dietician and exercise physiologist, remember you have 12 months to lose the weight *Hence please put the effort in to change your lifestyle and lose as much weight as possible in the first 12 months   There will be weight regain after 2 to 3 years *This is common and will occur with time, don’t be too concerned *Remember the most important goal of metabolic bariatric surgery is to help patients make positive lifestyle changes, to ensure patients are eating well (good food portion size, good food choices, good eating habits) as well as having regular simple and fun exercises *It is not about the scales or body weight   Also with building lean muscle mass, the kilograms will increase *This is a desirable outcome, please don’t worry if there is weight gain in the future.

Post op instructions after the surgery

Dressings The water proof dressings usually stay for a week. Please peel off the dressings after 1 week *The wounds should be healed by then *If not, you may put a bandaid over it   Please wait 2 weeks after surgery before going back to swimming in a pool.     TEDS stockings The stockings may be worn for 1 to 2 weeks after discharge to prevent blood clots in the legs, especially during long trips home.   Please ensure the stockings are properly fitted, sometimes a poor TEDS stocking that cuts off the blood return is more dangerous than not wearing one.   For patients at high risk to develop blood clots, sometimes they are discharged home on Enoxaparin (Clexane) injections or aspirin tablets.

Pain medications   Patients may purchase paracetamol (Panadol or Heron) from the supermarket or chemist. *Have one to two tablets (500mg to 1000mg) 4 times a day if necessary *Not more than 8 tablets (4000mg) a day.   Buprenorphine (Temgesic) 200mcg, under the tongue 4 times a day.   Oxycodone (Endone) 5mg, one tablet 4 times a day.   Tramadol 50-100mg 4 times a day or   Oxycodone/Naloxone (Targin) may also be prescribed depending on physician preference or patient request.

Nausea medications Odansetron wafers (4mg) 3 times a day is usually prescribed for nausea or vomiting. *This is placed under the tongue, not swallowed. *Hence it is easier to tolerate without having to swallow a big tablet but it is more expensive.   Metochlorpramide (Maxolon) 10mg 3 times a day or   Prochlorprazine (Stemetil) may be prescribed instead of Odansetron.

Reflux medications Anti acid medications are prescribed for patient who suffers from heartburn and to protect the lining of the stomach, especially after gastric bypass. *Any brand (Omeprazole, Pantoprazole, Esomeprazole) (Losec/Acimax, Somac or Nexium) may be used, usually 20-40mg once a day *After a gastric bypass the duration may be for 6 months or more   Antacids (Gaviscon, Mylanta) may also be used. *This can be purchased from the supermarket or chemist without a script   For patients who doesn’t have reflux or heartburn symptoms, you don’t need to take this medication for the long term Cigarette smoking, vaping and NSAIDs are prohibited to prevent gastric ulcers, bleeding or perforation/leaks especially after a gastric bypass.

Anti-coagulations   If you take any anticoagulants (blood thinners), please stop them prior to your surgery. *Please stop Warfarin, Xarelto, Pradaxa or Eliquis for at least 3 to 4 days prior to surgery *Please stop Plavix, Ticlid or any anti platelet for at least 7 days prior to surgery *Please stop krill/fish oil, garlic and glucosamine tablets for at least 7 days prior to surgery You may continue to take Aspirin.   After surgery you may recommence the above medications on discharge if there are no post op issues   Straight away after surgery you will be given Clexane injections in hospital Patient at high risk for blood clots may be prescribed Clexane injections (self administered at home) for 2 weeks, please let us know before discharge from hospital.

Fiber supplements and laxatives   For constipation: Please buy fiber supplements (Metamucil or Benefiber) from the chemist *Have it 2 to 3 times a day   Together with the fiber supplements please have plenty of water to drink, aim to have >1.5 to 2 litres a day   Sometimes stool softeners (Movicol or Coloxyl) may be necessary after taking the fiber supplements     Constipation During the first month after bariatric surgery constipation is common because patients are only on oral fluids or puree. Please buy bulking agents such as Metamucil (Psyllium) or Benefiber (Wheat Dextrin) or Cocolax (Coconut fiber). For patients with wheat or gluten intolerance, please buy Metamucil or Cocolax. Patients may have the supplemental fibers (1 or 2 teaspoons), 2 or 3 times a day. Please drink plenty of water together with the bulking agents, > 1.5 to 2 litres a day. Patients may buy stool softeners/laxatives such as Coloxyl (Sodium Docusate) or Movicol. Please drink plenty of water when having the fiber and laxatives. Senna is a herbal extract, which can be used as well. However please avoid using it long term as warnings include intestinal irritation, intestinal cramps and dehydration.

Oral contraceptive pills   Female patients are advised against getting pregnant 12 to 18 months after bariatric surgery, to allow maximal weight loss and reduction of medical co-morbidities. Also with adequate weight loss, many of the risk of pregnancy may be reduced.   Please discuss with the GP regarding the best pill or other contraceptive measures (eg. Mirena) Alternatives to the oral contraceptive pill include: *Mirena IUD (with progestrone hormone), this is intended to be inside for 5 years *Copper IUD (without the hormonal side effect) *Implanon (with progesterone hormone), this is intended to be inside for 3 years   Generally young girls are recommended to have a laparoscopic sleeve gastrectomy and to avoid a gastric bypass if they are planning to start a family after weight loss surgery, to avoid nutrition problems or bowel obstruction during pregnancy. *They may also require revision bariatric surgery for long term weight regain after multiple pregnancies. *Young girls are advised to discussed with their GP or gynaecologist before the weight loss surgery regarding appropriate contraception.

Eating after the surgery

Please follow the bariatric food pyramid example Please look into the Mediterranean diet and the CSIRO diet for fiber and nutrition Also please have a balanced meal from each of the following 5 food groups (protein, vegetables, grains, fruits and dairy) *Generally aim to have less carbs and more protein     In the long term please have more “healthy” fresh fruits and vegetables, beans, nuts, steamed fish, lean meat and avoid the “lazy” carbs, sweets, soft drinks/alcohol, fatty/oily foods and the processed/refined food *The protein food provides nutrition and satiety *Protein requirement is usually 1 to 1.5g per kg ideal body weight per day *The thermogenic effect of fresh vegetables/salads will help to maintain an active metabolic rate.   Avoid sugars, high GI index foods (juice, fructose, soft drinks, sweets, syrups, desserts), reduce the starch (potato, white bread, flour, pasta, rice, corn, peas, pumpkins/squash), saturated animal or trans fat and processed foods whenever possible   Have more fresh vegetables and proteins instead of processed/refined meat   Having adequate vitamins and minerals is also important in order to avoid micronutrient deficiencies (especially iron, calcium, vitamin D). A blood test can be done to monitor vitamin levels.   With time you will learn to develop and sustain a healthy lifestyle, achieve the right balance between eating healthy meals (good food choices), in proper quantity (good portions) and to eat slowly to avoid compulsive or binge eating behaviour (good eating habits). Have a consistent level of aerobic exercise and resistance training is recommended. *Regular exercise or physical training is important to preserve lean body muscle mass, uphold a consistent basal metabolic rate, which in turn will assist in further weight loss (truncal fat loss), improve core strength and helps with body contour (reduce the unsightly excess skin folds).

Eat less food that stimulate hunger or cravings 2 hours later (for reduction in calorie content and to avoid the reactive hypoglycaemia effects)   Reduce the total amount of carbohydrate in the diet Aim for low glycemic index food (unrefined natural carbs) rather than the high GI foods (highly processed/refined foods) *Avoid eating foods that cause rapid glucose/insulin spike followed by reactive hypoglycaemia *Avoid eating late at night

Eat more foods that increase GLP-1 incretin levels   1. Eat more fiber or resistant starch *Non digestible fiber acts on the stretch receptors in the stomach, giving a satiety sensation *The non digestible reaches the colon and get fermented by the gut microbiome into short chain fatty acids (acetate, butyrate, propionate) which helps increase GLP-1 secretion   2. Eat more leafy green vegetables *Eat more bitter foods (bitter melon, gourd) stimulate the bitter taste buds in the tongue, increase GLP-1   3. Eat more protein (lean meat, steamed fish, boiled/grilled chicken, eggs) *Aim to have 30% instead of 10% protein in the diet, have better satiety and nutrition value *Have more dairy foods which contain branched chain amino acids, which helps increase incretin release   4. Eat more dietary fats (olive oil, avocado oil)   5. Eat more curcumin (turmeric, curry), these spice help to increase GLP-1 levels

Medical conditions after surgery

Medication for hypertension   With successful weight loss the blood pressure will be easier to control *After surgery please monitor your blood pressure, if you feel dizzy please see your GP to reduce the blood pressure medications *Some patients may be able to weane off their medications for high blood pressure or reduce the doses significantly In the short to medium term it is preferable to avoid diuretics to prevent dehydration or electrolyte disturbances   Please note some medications called ACEI or ARB are prescribed for Type 2 diabetic patients to protect the kidney and the heart, please talk to your GP before changing your medications

Medication for diabetes   For diabetics (especially those on insulin, SGLT2i drugs or metformin), you will need to monitor your blood sugar levels carefully during the pre-op, intra-op and post-operative phase   You will need to reduce the insulin doses (to prevent hypoglycaemia) during the VLCD period *Stop the GLP-1 RA injections 4 weeks before surgery (to prevent reflux or aspiration) *Stop the SGLT2i  3 days before surgery (to prevent euglycaemic ketoacidosis) *Stop metformin 24 hours before surgery Please talk to your GP or endocrinologist if you are unsure what to do.   After surgery please monitor your blood sugar at home With weight loss the blood sugar tend to be easier to control *Some patients may be able to weane off their tablets for diabetes *Some patient may be able to cease the insulin use or reduce the dose significantly In the long term it is preferable to avoid/reduce the doses of Insulin, Sulphonlyureas and Thiazolidinediones to prevent weight regain

Pregnancy after weight loss surgery   You must see your GP, obstetrician and dietician Antenatal blood test and adequate vitamin supplements is necessary *Higher dose folic acid (4-5g a day) may be necessary to prevent neural tube defects *Higher dose of vitamin D (>50nmol/L) may be necessary *Iron and vitamin B12 replacement may be necessary           *Calcium supplement may be necessary   *Vitamin A may need to be avoided to prevent harmful effects to the fetus       Screening for gestation diabetes is vital Most patients won’t be able to have the oral glucose tolerance test after sleeve or gastric bypass, it causes severe dumping or diarrhoea                    Other blood test such as HbA1C will be needed   The obstetrician often recommends routine ultrasound scan to monitor the fetal growth rate at 28, 32 and 36 weeks

Summary

General advice for the long term   Most importantly bear in mind that at the end of the day, the weight loss lost alone is not the only focus What is important is a healthy lifestyle change, the bariatric surgery is done to improve your health and quality of life, to reduce the cardio vascular risk and early/premature cardio-vascular mortality, this is not a cosmetic surgery   If you have reduced your medical problems, improved your quality of life, spending good quality time with your family, achieving success at work/sports, then that is true success of bariatric surgery   The focus is about changing your lifestyle, to make sure you are eating well (good portion size, good food choices, good food choices) balanced with regular physical activities & exercises     Remember surgery is only a tool, only a small part of the weight loss journey, you maintain it with all the above     Almost everyone will regain some weight in the long term   The sleeved stomach or the gastric bypass pouch will stretch with time *You will be able to eat more after a year, you will almost certainly regain weight after 2 to 5 years post op   *Don’t be concerned, this is normal Please focus on making positive lifestyle changes, not just focus on the weight or scales.   Please engage the services of a good dietitian, exercise physiologist, life coach or a bariatric psychologist if necessary.