Post op information after sleeve or gastric bypass

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 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

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).

After the surgery   The most important post op complications to watch out for are leaks, intra abdominal infections, bleeding or blood clots in the legs/lungs.   If you have any concerns please come back to the Gold Coast Private Hospital Emergency Department immediately or contact me straight away.   For follow up, please come see me in the rooms or email me. You must email me 2 weeks, 2 months and 6-12 months after surgery to update me with your post-op progress. Please make sure your GP, dietician, exercise physiologist and psychologist is willing to share the post op care.     You must keep in regular contacts via emails to make sure you update me with your progress or any surgical concerns you may have.   If you have any questions, please do not hesitate to contact me.   Email: victorliew@live.com.au or admin@gcpss.com.au     Phone: 07 5530 0770 Please do not cancel your private health fund after surgery *It is anticipated that you may need further investigations in the long term after weight loss surgery *After a sleeve, you may need a gastroscopy check if you have reflux or difficulty swallowing *You may need revision surgery if there is a hiatus hernia, Barrett’s oesophagus, gastric stricture or weight regain *After a gastric bypass, you may need a gastroscopy and dilatation if you have reflux or difficulty swallowing You may need revision surgery if there is a hiatus hernia, anastomotic stricture, internal hernia/small bowel obstruction, weight regain or other abdominal issues   You may need other surgeries in the future which may or may not be related to the initial weight loss surgery, which include gall bladder surgery, kidney stone surgery, etc

Dressings   Please remove the dressings after 5 to 7 days The laparoscopic port sites will heal up quickly The wounds may be left opened if the skin integrity is intact If you are concerned, please put a band aid over the wound   If there are redness, warmth or pain please return to see me or the GP for a course of oral antibiotics if there are any signs of wound infection   Most people can go swimming or have a bath 2 weeks after surgery   TEDS stockings The stockings may be worn for 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.

Dehydration   Please keep sipping water throughout the whole day Aim to have at least 1 to 2 litres a day in the first week after surgery   Also some hydralyte ice blocks to suck to prevent dehydration especially in the hot summer days in Queensland   Obviously avoid outdoor exposure in direct sunlight, hot kitchen environment, sauna, etc for long periods of time   If you need to come back to the Gold Coast Private Hospital for IV fluid hydration, please contact me directly   If you feel dizzy after gastric bypass, sometimes adding some extra salt to the chicken or vegetable soup or olive oil to the puree vegetables to give you more electrolytes may help to reduce the light headedness or fatigue.   Reduce alcohol consumption, patients are more likely to get drunk faster after weight loss surgery especially when consumed on an empty stomach (no food intake) Hence no driving even after 1 standard drink

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.

Diarrhoea and dumping   Symptoms may include abdominal cramps, diarrhea, palpitations, flushing, feeling dizzy and light headedness   To minimize dumping Please avoid the high GI index fluids or foods avoid sugar drinks/food (honey, fruit juice, sweet drinks, alcohol, desserts, yoghurts, smoothies) avoid starch/carbs (bread, potato, pasta, rice, corn, peas)avoid processed foods   Some people get temporary lactose intolerance please stop having milk, dairy products or the VLCD shakes   Please avoid dehydration by drinking lots of water Aim to have >1.5 to 2 litres a day You may have some hydralyte ice blocks if necessary   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

General medication use   In the early post op period, some patients will have difficulty swallowing large tablets or have difficulties with absorption Please choose the smaller tablets or capsules Choose the lower dose tablets in divided doses (2 or 3 times a day), which are less likely to get stuck Avoid the effervescent formulation to prevent burping or reflux Avoid enteric coated medications, the delayed or slow/sustained release tablets   Avoid sucrose or lactulose/sorbitol based medications may cause diarrhoea or dumping   Avoid medications that may damage the lining of the stomach or intestine, such as (NSAIDs) non steroidal anti-inflammatories, high dose aspirin or steroids that may result in gastric ulcers, bleeding or perforation   For patients on Lithium and certain other drugs with narrow therapeutic index be aware that you may reach toxicity quickly after weight loss surgery Please talk to your GP or specialist about adjusting or reducing the doses of these medications after gastric surgery

Medication on discharge   Pain medications Patients usually buy 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. Odansetron may have drug interaction with Tramadol It may cause prolonged QT interval on the ECG (an irregular heart rhythm) or serotonin syndrome Odansetron may have drug interaction with Oxycodone Serotonin syndrome is very are but watch out for symptoms (such as confusion, hallucination, seizure, fever sweating, fast heart rate, blur vision, etc)   Metochlorpramide (Maxolon) 10mg 3 times a day or Prochlorprazine (Stemetil) may be prescribed instead of Odansetron. Anti-reflux or anti-acid medication Anti acid medications are prescribed for patient who suffers from heartburn and to protect the lining of the stomach Any brand (Omeprazole, Pantoprazole, Esomeprazole) (Losec/Acimax, Somac or Nexium) may be used, usually 20-40mg once a day. The duration may be 3 to 6 months usually.   Antacids (Gaviscon, Mylanta) may also be used. This can be purchased from the supermarket or chemist. For patients who doesn’t have reflux or heartburn symptoms, you don’t need to take this medication for the long term. Absolutely no cigarette smoking and NSAIDs are prohibited to prevent gastric ulcers, bleeding or perforation/leaks

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. 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 can be prescribed Clexane injections (self administered at home) for 2 weeks, please let us know before discharge from hospital.

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. With weight loss the blood pressure tend to be easier to control Some patients may be able to weane off their medications for high blood pressure or reduce the doses significantly In the long 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 may need to reduce the insulin doses (to prevent hypoglycaemia) during the VLCD period. Stop the SGLT2i  3 days before surgery and stop metformin 24 hours before surgery (to prevent euglycaemic ketoacidosis). 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 signficantly In the long term it is preferable to avoid Insulin, Sulphonlyureas and Thiazolidinediones to prevent weight regain

Medication for anxiety/depression, mood stabilizers or anti-psychotic drugs   Please see a psychologist or psychiatrist before the surgery Please make sure they support you having weight loss surgery In the post-operative period some patients may get admitted to a psychiatric hospital/ward for in-patient care under your usual psychiatrist if this is necessary to adjust your medications   Patients on Lithium beware because you may reach toxic doses of the medications after surgery Please talk to your psychiatrist about adjusting the medication doses before weight loss surgery

Medication for contraception   Female patients are advised to avoid getting pregnant for the 12 to 18 months period after weight loss surgery.   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.   Alternatives to the oral contraceptive pill include: Mirena IUD (with progestrone hormone), this is intended to be inside for 5 yearsCopper IUD (without the hormonal side effect)Implanon (with progesterone hormone), this is intended to be inside for 3 years   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

Nutrition   You must have a pre-op blood test, which usually include FBE, ELFT, TFT, random blood glucose, fasting cholesterol/triglyceride, iron, folate, B1, B12, zinc, calcium and Vitamin D   Vitamin or mineral deficiencies need to be corrected before surgery For patients low on vitamin D, some sunlight exposure is beneficial to boost up the vitamin D levels.   Post-op blood test usually include FBE, ELFT, TFT, random blood glucose, fasting cholesterol/triglyceride, iron, folate, A, B1, B12, zinc, calcium, Vitamin D and PTH   For gastric bypass or SADI-S patients, you need lifelong blood test to monitor the above Please make sure your GP agrees to do the blood test (at least 2 to 4 times a year for the rest of your life) and to administer the oral supplements and injections (iron infusion, vitamin B12 or D) when necessary Please make sure you have a dietician who will see you for the next few years after weight loss surgery to monitor the vitamin/mineral levels and recommend that you have the adequate macro and micronutrients and anti-oxidants in your diet     Protein intake The recommended daily protein is about 1 to 1.5g protein per kg ideal body weight For a sleeve patient, the average may be about 60-70g protein a day For a gastric bypass patient, the average may be about 70-80g protein per day     Vitamin and trace minerals You are recommended to have multi-vitamin supplements, example include the BN chewable multi-vitamins. Deficiencies in calcium and vitamin D needs to be corrected to prevent secondary hyperparathyroidism, reduction in bone mineral densities, osteopenia or osteoporosis in the long term. Deficiencies in vitamin A, B1, B12 need to be corrected Deficiencies in folate (especially for pregnant mothers) needs to be corrected Deficiencies in minerals (iron, copper, magnesium, zinc, selenium, etc) need to be corrected

Duration of vitamin and mineral supplements   Unlike a gastric bypass, after a sleeve some patients only take the vitamin/mineral supplements for 3 to 6 months post op. After that if the blood tests are normal, sometimes the GP may discontinue the supplements.   Some patients may elect to remain on the supplements for longer period of time after a sleeve.   But after a gastric bypass, patients need to take multivitamin and mineral supplements for life. Blood tests need to be done at least 2 to 4 times a year and iron infusion or IM injections of vitamin B12 or D can be given if necessary.   For patients who are pregnant please seek special advice from your GP, obstetrician and dietitians.

Post bariatric surgery diet and exercise in the long term

Continue to see a dietician and an exercise physiologist in order to maximize the positive results from the surgery and lifestyle change.

Follow the examples illustrated from the bariatric food pyramid (described below). Also please have each of the following 5 food groups (protein, vegetables, grains, fruits and dairy).   Aim to have less carbs and more protein. Have more “healthy” fresh fruits and vegetables, beans, nuts, steamed fish, lean meat and avoid the “lazy” carbs, sweets, fatty/oily foods and the processed/refined food. The protein food provides more satiety and the thermogenic effect of fresh vegetables/salds will help to maintain an active metabolic rate.   Protein requirement is usually 1 to 1.5g per kg ideal body weight per day. 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.   Avoid sugars, high GI index foods (juice, fructose, soft drinks, sweets, syrups, desserts), starch (potato, white bread, flour), saturated animal or trans fat and processed foods whenever possible. Have the fresh vegetables and proteins as stated above.

Remember always to eat slowly (over 30 minutes), chew thoroughly and stop eating when feeling full. Drink fluids 30 minutes after completion of a meal. Fluids should be drunk 30 minutes after meals in order to allow more nutrients in during meal times. Avoid eating or drinking for at least 3 hours before going to bed.

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).

Having 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).

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     Please keep up the good work, continue seeing the dietician and exercise physiologist   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.