You will wake up in the operating room and will be transported in your hospital bed to the Post Anesthesia Care Unit (PACU). You will remain in the PACU for at least an hour, and then be taken to your hospital room on the surgical unit where your family/friends can meet you. If you have issues, you may need to be in the ICU or IMC. For example if you are starting CPAP, or you have shortness of breath, or complex medical conditions requiring intensive care, these require ICU or IMC admission. Sometimes we will keep patients in the PACU overnight.
You will remain drowsy for the rest of the day. Medications will be given through your IV for pain and/or nausea. You will be given oxygen through a nasal cannula. Your vital signs will be monitored frequently by the nursing staff. Compression stockings will be in place on your legs while you are in bed. You will probably have a catheter in place to keep your bladder empty. An incentive spirometry device will be demonstrated to you to help with deep breathing, which is very important after surgery to keep your lungs clear.
Depending on the details of your surgery, you may have a tube in your nose that passes in the back of your throat and into your new stomach/pouch (NG tube). A decision will be made either to leave an NG tube in place or to remove it, or to give you a liquid diet or not. See the "LIQUIDS" section below for details about acceptable liquids.
About the morning after surgery
You will be encouraged to use your incentive spirometer 10 times per hour
You will sit up in a chair and ambulate with the help of the nursing staff
Your urinary catheter will be removed
You will receive clear liquids (low-carb, non-carbonated), beginning with small sips
As you tolerate liquids, you will begin taking oral meds
A duragesic pain patch will be applied for pain control.
An abdominal binder will be provided for extra support and comfort, if needed
If you have a drain in place, it will be removed before you are discharged
If everything is going as planned, you may not need to see Dr. Elariny prior to being discharged
You may be discharged home later in the day if you are tolerating liquids, ambulating well and have adequate pain management
PLEASE NOTE : If your discharge from the hospital is delayed beyond the second day of surgery because of nausea or liquid intolerance or other gastrointestinal reasons, then you will need to be on liquids and tolerate them well for 2 days before going to the next step.
Your First Post-Operative Day: Clear Liquids
See the Clear Liquid list to determine appropriate liquids to consume. Whether you are home or in the hospital, you will be expected to walk around daily and regularly, and be up in your chair when not walking.
Days #2 - 7 Post-Operative: Full Liquids (Week 1)
If you tolerated clear liquids well, you will be advanced to a Low Carbohydrate / Full Liquid Diet. You will need to drink constantly to avoid dehydration and you will need to crush or open your medicines. You may need to supplement with protein powder for 6 weeks.
Meds: Actigall (if gallbladder not removed), Prevacid, Pain medication and other meds for chronic medical conditions.
Week Two Post-Operative: Pureed Foods
You should now be able to safely begin Pureed foods. This includes baby foods, applesauce, and pureed (blended) soft foods. You will need to drink constantly to stay hydrated. Continue to crush your meds.
Meds: Actigall (if gallbladder not removed), Pain medication, Prevacid, and other meds for chronic medical conditions. Begin taking 2 children's chewables with iron, chewed very very well, around day #7.
Week Three: Soft Foods
You should now be able to safely begin Soft foods. This includes all items listed as pureed, all allowed liquids, and items listed as soft such as baked white fish (no bones), imitation crab meat, hot dogs (well chewed) and over-cooked vegetables. This does not include New York Strip. Remember, you will still need to drink constantly to stay hydrated, and you may still need to supplement with protein powder. Continue to crush your meds.
Meds: Actigall (if gallbladder not removed), Pain medication, Prevacid, two children's chewables with iron daily and other meds for chronic medical conditions.
Weeks Four and Five: Regular food TRIAL Period
You should now be able to safely begin "Regular" foods. This includes all previously allowed items plus red meat, chicken, well-cooked vegetables and others in the list below. This is called the TRIAL period because you are expected to try only one new item at a time. Do not rush. You may also begin trying whole pills during this period (go slow).
Meds: Actigall (if gallbladder not removed, continue for 6 months post-op), Pain medication if needed (Tylenol), one adult multivitamin daily, other meds for chronic medical conditions, and after finishing the Prevacid, continue Zantac for the next 5 months.
Caloric Needs and Average Expectations
At 2 weeks: 200 Calories/day
At 3 weeks: 300 Calories/day
At 4 weeks: 350 Calories/day
At 10 weeks: 400 Calories/day
At 12 weeks: 500 Calories/day
At 6 months: 900 Calories/day
At 8 months: 1000 Calories/day
At 12 months: 1100 Calories/day
*You do not have to be exactly on target. You may be 100 to 200 calories above or below these expectations. These are expected amounts based on your new outlet size and post-op recovery. We ask that you keep a record of your daily caloric intake at least one day a week for the first year after surgery and report these to us during your follow-up visits.
You have a goal of 60 to 70 grams of protein a day . You may not be able to meet this goal through food alone. On the full liquid diet, try to eat the higher protein foods (i.e., milk, yogurt). When you begin pureed foods, you should monitor protein intake to see how much you are consuming. If you are not reaching this goal, then you may need a protein supplement. The purpose of this is to ensure that you do not have excessive protein loss that negatively affects your healing and overall health. Avoid pre-mixed drinks like Ensure or other such shakes as they tend to have a lot of carbohydrates and fats compared to pure protein powder mixed into water or skim milk. Your taste will determine the powder that is right for you.
Options for Protein Supplements: Designer Whey Protein, Isopure, Promod, others. Look for 100% protein powder. During the first six weeks if you shoot for a minimum of 60 grams of protein per day (what you eat, drink, and your powder supplement) and about 15 grams of carbohydrates and 5 grams of fat per day, that is 345 Calories. You will follow up with the dietitian after surgery to determine if you are meeting your requirements.
What are Clear Liquids?
· Fruit juices without added sugar - no citrus or tomato juice for the first 4 weeks
· Sugar-free Jello
· Crystal Light liquid or popsicles, Kool-Aid with Nutrasweet, or other sugar-free diet drinks
· Sugar-free or all-fruit popsicles
· Coffee and tea
· Broths and thin egg-drop soup (NO crunchies or solid pieces)
What are Full Liquids?
· Skim milk
· Protein mix
· Low-fat, sugar free pudding and yogurt (no fruit pieces)
· Liquids that you cannot see through
· Low fat, thin, strained cream soups such as Campbell's Cream of Mushroom Soup made with skim milk
· Remember to try to avoid carbohydrates, sugars and fats
· Skim milk shakes -- 8 oz milk with cracked ice & fruit processed in a blender. Add a scoop of sugar-free/fat-free ice cream if desired, or add protein powder for a high protein treat
How am I expected to consume Liquids (Both Clear and Full)?
Preventing dehydration is your main goal. Your fluid needs are no different after surgery than before. You must try to consume 8-10 cups of fluids a day (64-80 ounces).
· Sip as much liquid as you can tolerate slowly and constantly. Watch your urine for a dark color or strong odor. If these develop, you need to drink more until the urine is a clear light yellow. Use your thirst and your urine output as a guide .
· You may have unlimited amounts (up to 1½ gallons/day) of any liquids such as water, tea, coffee, Crystal Light, Nutrasweet Kool-Aid, Ocean Spray Lite drinks (not the regular) and chicken or beef broth. You don't need to reach this maximum amount every day. If you have a heart condition or liver disease, you may be more restricted. You will be given a urinal (MEN) or a toilet "hat" (LADIES) to measure your urine in the hospital. Take this home and be sure you are making at least 240 cc's of urine every 8 hours. (Or at least 720 cc's per day).
· Unsweetened juices--dilute them with water if they taste too sweet or if you get dumping.
· Avoid all citrus juices (orange and grapefruit) and tomato juice, especially during the first 4 weeks.
· Avoid swallowing air with liquids, which will sometimes occur when you use a straw.
· Avoid ALL foods and liquids with added sugar or if sugar is one of the first 3 ingredients listed. Sugars include any compound ending with -ose such as glucose, dextrose, sucrose, fructose, maltose, as well as corn syrup and hydrolyzed starch extract.
· If vomiting or retching occurs, you should stop eating for at least 2 hours and then start again slowly with sips of water or clear liquids.
· AVOID ALL SODAS AND CARBONATED BEVERAGES!
What are Pureed Foods?
· Non-fat cottage cheese
· Unsweetened applesauce
· Blended canned peaches in their own juice
· Overboiled Soups with NO MEAT such as Blended Healthy Choice, Healthy Request® and Progresso Lite soups
· Heavily overcooked vegetables (except corn) including potatoes cooked to a MUSH and mashed with the back of a fork
· Chopped up soft poached eggs
· Cream of Wheat®, cream of rice and grits
· Blended Soft fruits: watermelon, honeydew, cantaloupe, banana, strawberries (with the seeds removed) or ripe peaches. These can be nice to add to protein supplements.
· Non-fat, sugar-free yogurt, pudding or ice cream (no fruit pieces)
· Baby foods with no meat chunks
· Tender chicken or turkey pureed in a blender with broth added
What are Soft Foods?
· Canned peaches and pears in their own juice
· Healthy Choice, Healthy Request® and Progresso Lite soups. It will be necessary to blend any chunks or meats
· Any cooked vegetables (except corn)
· Unsweetened oatmeal or hot cereals
· Chopped up soft eggs (boiled, scrambled or as egg salad)
· Canned tuna, fresh fish filets, imitation crab or real crab meat: AVOID BONES!
· Tender chicken or turkey, not dry, chewed well
· Low fat cheese slices
· Soft fruits such as bananas, strawberries, or ripe peaches (chew thoroughly). Please be extra careful with watermelon, honeydew, cantaloupe, and the like; these are very fibrous and can cause problems if not chewed to a thin paste before swallowing.
Foods that may be difficult to digest:
Steak, Meats that are too dry, Greasy or fried foods, Peanut Butter, Shrimp, Pork chops, Breads
Ah yes at last! Regular foods include meats and salad items that have been restricted during the first four weeks. Remember to go very slowly, and try only one thing at a time. Maximum of two new things per day and spread apart by at least 6 hours. Follow the Nibble AFTER you Dribble rule to avoid the sink effect (see
Main points to remember).
**Feel free to use spices, salt and pepper, reduced-fat margarine or I Can't Believe It's Not Butter® spray, Molly McButter®, Butterbuds® garlic or onion powder, or fat-free sour cream to make your food taste better! "No sugar added" does not necessarily mean sugar-free. Artificial sweeteners are as well acceptable.
What about the Crispy and the Crunchy?
CRISPY : These are allowed after six weeks.
· Crispy becomes MUSHY when wet
· Toasted white bread
· Corn Flakes
· Rice Krispies
CRUNCHY : These are NEVER Allowed. This may seem rigid, but is in your best interest. If you must have something on this list, I recommend avoiding for at least 3 months after surgery , then if you must have it, chew into a paste before swallowing, but please try to avoid altogether .
· Crunchy is NOT allowed
· Crunchy does not melt into mush quickly so it can get stuck in your pouch and ulcerate or perforate it
· Crunchy includes uncooked veggies that crunch but don't dissolve. These fibrous items can obstruct your pouch.
· Corn chips, potato chips, tortilla chips, popcorn
· Grain and whole grain bread (pieces of incompletely ground grain)
Main points to remember
Nibble AFTER you Dribble , or DO NOT EAT AND DRINK AT THE SAME TIME! Your old stomach was very large (think of a 2 liter Coke bottle). With that size and that shape, even if you filled yourself with solid food, you could still drink a glass of water without problems. This is because a normal stomach has something called the "fast-track". Liquids can (in a normal stomach) slip down the greater curvature curving around the solid food quickly to the pylorus and empty into the duodenum without much notice except maybe whirling the food a bit. After surgery, things are different. THERE IS NO FAST-TRACK FOR LIQUIDS. So, if you eat solid food, then drink, you may experience pain or vomiting or both. The longer you wait after meals before drinking, the better for two reasons. 1) You will avoid flushing out the stomach for longer periods of time and therefore avoid rapid hunger and 2)You will avoid the stopped up sink effect. So, DRIBBLE BEFORE YOU NIBBLE and DON"T DRIBBLE WHILE YOU NIBBLE and DON"T DRIBBLE JUST AFTER YOU NIBBLE.
To avoid the Stopped-Up Sink effect, it is best to drink liquids during the hours just before you plan to eat. Imagine if you put a GLOB of pudding in your sink and then turned on the water. The water would back up and sit there in the sink before eventually going down once the pudding thinned out and decided to go down. If this were your stomach tube, that water would fill it, stretch it, back up in your throat, and cause pain discomfort, possible vomiting and other problems. Now do the opposite. Pour the water in first and then add the pudding. The water will go straight through. Walk away and wait 45-60 minutes and come back. The pudding will have gone down without all the problems associated with BACK UP. So NIBBLE AFTER you DRIBBLE to avoid the "sink effect" (Also known as the Glob effect).
RECOMMENDATION: Drink throughout the day…STOP…wait about 15 minutes before you begin eating…wait another hour after you have finished eating before you begin drinking again.
If a food item is not on the prescribed list, or does not fit the food category criteria, DO NOT EAT IT ! If you are not sure, write it down, and call the office during regular hours or email me anytime and ASK.
Eat small bites, chew very thoroughly and eat slowly . When you try a food you have not eaten since surgery, take 1 bite to see if it is comfortable for you. Be patient--you will fill up after just a few bites at first, but this is normal; your capacity will increase during the next few days to weeks. You need to eat (nibble) very small amounts (1-2 ounces) 3 times a day. Adequate fluid intake is very important. Use a dribble bottle (spout ended bottle) and drink only as much as you can comfortably tolerate.
With the adjustable gastric band, when you begin to no longer feel fullness from eating, or you are able to eat more than 3-4 ounces of regular food at a sitting, you may be ready for an adjustment, or "fill." Contact the office to make an appointment to see me.
Monitor your protein intake: If you do not get enough protein in your diet, you will become malnourished. Limit Carbohydrate, sugar and fat intake, as these will inhibit your weight loss.
Monitor your fluid intake: If you do not get 64-80 ounces of water or good fluids in a day, you may become dehydrated.
Take a multivitamin every day: It will help prevent vitamin and mineral deficiencies.
All food must be chewed very well. If it is not, it make cause an obstruction in your pouch.
DO NOT BECOME A STATISTIC!!!!
Post-operative Activity Instructions
Be as active as possible and push yourself a little more each time you walk, etc. Wear an abdominal binder while active. A good goal to aim for is to walk at least 1 mile a day by your one month office visit, taking no more than 20 minutes. You can use a treadmill (elevated a few degrees is better than flat); ride a bike; use the shallow end of a swimming pool for walking against resistance (don't soak the incisions for 2 - 3 weeks).
Avoid straining or heavy lifting for 4-6 weeks to allow your incision to heal solidly. Increase your work around the house gradually as you are able to tolerate more, but do not do ANY activity that causes you pain in your incision!
You may climb stairs one at a time, no more than a few times a day. You may ride in a car to take short trips.
You may return to work as soon as you feel up to it, again avoiding putting too much stress on your wound (s) too early.
Rest when you feel tired, but try not to sleep during the day -- it may then be more difficult to sleep at night.
Do not drive for several days and then take only short trips at first – if you are a passenger on a long car trip, get out of the car at least once an hour and walk around to exercise your leg muscles and prevent blood clots.
You may resume sexual activity as soon as you want to, but be careful not to strain your incision. Remember do not become pregnant within the first 18 months.
The bottom line for any activity is: If it hurts, DON'T do it!
Post-Operative Wound Care
You may shower or bathe -- do not let the shower stream hit directly on the tape strips and do not rub them with your washcloth or towel; just blot them dry. They'll begin to peel up at the edges in a few days; you can then trim off the peeled-up part. If you get any blisters, peel up that portion of the strip to reduce irritation. The strips will fall off by themselves when they have done their job or we will take them off for you at your first office visit.
If you have any drainage from the incision, cleanse with soap & water and put on a small dressing to protect your wound and clothing. If you have a LOT of drainage, please call me.
You may wear tight clothing if you like a snug fit or loose clothing if you prefer no pressure on your abdomen.
If you develop diarrhea (more likely if your gallbladder was just removed) for more than 24 hours, call the office for a prescription and take 3 tablets of 10meq Potassium per day until the diarrhea is gone or for three days.
On your tenth day after surgery, begin taking children's chewable multivitamins with iron - 1 in the morning, 1 in the evening, chewed thoroughly with food. That is 2 per day. Take these until the sixth week. At that point, begin taking 1 adult multivitamin a day unless otherwise instructed.
Do not ever take aspirin or aspirin-containing medicines such as Alka-Seltzer®, BC Powder®, Stan back Powder®, or Goody's Powder®. AND Avoid any and all anti-inflammatory medications – over-the-counter or prescription -- such as Ibuprofen (Motrin IB®, Advil®, Nuprin®), Naprosyn®, Anaprox®, Aleve®, Voltaren®, Feldene®, Orudis®, Daypro®, Lodine® etc.) unless you notify the office in advance. These products can easily cause ulcerations in your pouch. You should use Tylenol® instead of these products.
Use your liquid or ground pain medicine as needed.
Use over-the-counter chewable Dramamine® for mild nausea. Call for severe nausea or vomiting and a prescription for suppositories will be called in for you.
For gas pains try Gas-X®, Di-Gel®, Mylanta® (liquid or chewable form).
For diarrhea try Imodium AD® or Pepto-Bismol®.
For constipation try Benefiber, Citrucel® powder, Phillip's Milk of Magnesia®, Dulcolax® suppository, any chewable laxative, or Fleets® Oil Enema.
Follow Up and General Info
· Food Diary : You are expected to keep a record of exactly what you eat and drink and how much of it every single meal for the first 3 weeks after surgery. This is the only way we can tell if you are getting what you need and if we need to add protein to your diet.
· Follow – Up visit : You should come in for follow-up at the office 8 to 12 days after surgery. Bring your diet log with you. Follow-ups after the one week will be as follows: 1 month, 3 months (bring labs with you), 6 months and 1 year (bring labs with you). You may follow up more often if you are having issues.
· Diabetes : If you have Diabetes, we will probably have reduced or discontinued your medicines. We want you to check your sugar twice daily at different times, record, and bring with you at follow-up.
· Temperature : You are expected to check your temperature at home daily and report any temperatures > 101.0 degrees.
· Incentive Spirometer : You will use at home regularly; at least 4 times daily. This will be provided in the hospital.
· Exercise : You will exercise your calves and walk several times daily to prevent blood clots (thrombosis and pulmonary embolism).
Problems : You should report to the office if you are experiencing any excessive nausea, pain, dumping, vomiting, fever or wound drainage.
· Weight Checks : You may come in to the office once a month for the first year for a weight check. You may do this at home if your scale at home can be correlated to ours at the office. We want to know how you are doing and how you are eating. We want to know about your energy level at various times after surgery.
· Lab Values : We would like to obtain labs (Hemoglobin, Albumin, electrolyte, and vitamin levels) 3 months after surgery, sooner if you are eating poorly. You are unlikely to develop deficiencies with this type of procedure, but if symptoms develop, lab values should be checked. We would also like to see labs done for your one-year appointment.
o Protein – 60-70 grams a day
o Fluids – 64-80 ounces a day of good fluids such as water, crystal light, and low sugar juices. Sip on fluids slowly and constantly all day, but never at meals. Limit coffee and tea, and AVOID SODAS FOREVER!!
o Vitamins – it is a good idea for you to take a daily multivitamin with iron. You should take 2 a day if your intake is poor or if you have complications such as nausea.
· Support: We would like for you to attend support group meetings as much as possible. A support group meeting is held every first Tuesday of the month at Fairfax Hospital in Northern Virginia. If you do not live in the area, you can keep in touch through websites or attend a WLS support group meeting in your local area.