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 you will 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. Also, it may be necessary to perform an "X-ray leak test" after surgery. This is usually done on the first or second day after surgery. If so, you will be taken to the radiology department where you will be asked to sip on a clear x-ray contrast medium. The radiologist and technician will perform several x-rays while you swallow. If you have an NG tube, you will ignore it during the test and swallow around it. The x-rays will be reviewed by the radiologist and your surgeon, and 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.
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 to control pain
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
Your First Two Days of Oral Intake: Clear Liquids
When you are first allowed to eat, it will be in the form of clear liquids such as jello and cranberry juice. See the "LIQUIDS" section below for details about acceptable liquids.
Your Third & Fourth Days of Oral Intake: Full Liquids
If you tolerated clear liquids well, you may advance to a Low Carbohydrate / Full Liquid Diet. You will need to sip on liquids constantly to stay hydrated. You will have to crush
or open your meds. Meds: Actigall (if gallbladder not removed), Pain medication,
Prevacid and other meds for chronic medical conditions.
Your Fifth, Sixth and Seventh Days of Oral Intake: Pureed Foods
You should now be able to safely begin Pureed foods. This includes baby foods, apple-
sauce and pureed (blended) soft foods. You will need to drink constantly to stay hydrated. You may need to supplement with protein powder during these early days. Continue to crush your meds. Meds: Actigall (if gallbladder not removed), Pain med, Prevacid, 2 children's chewable multivitamins with Iron twice daily. Other meds for chronic medical conditions.
Your Second Week of Oral Intake: 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, 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 crush your meds.
Meds: Actigall (if gallbladder not removed), Pain medication, Prevacid, 2 children's chewable multivitamins with Iron twice daily, other meds for chronic medical conditions.
Your Third and Fourth Week: Regular food TRIAL Period:
You should now be able to safely begin "Regular" foods. This includes all previously
allowed items plus red meat, chicken, and vegetables. This is called the TRIAL period because you are expected to try only one new item at a time. Do not rush. If you add one
new regular food per day, that is 14 new items by the end of this period. You may also
begin taking pills whole during this period (go slow).
Meds: Actigall (if gallbladder not removed), Pain med, Prevacid, 2 children's chewable multivitamins with Iron twice daily, or begin regimen of adult multivitamins and
other meds for chronic medical conditions.
** You will need to take Zantac for an additional 5 months after your 1 month course of Prevacid is complete, and you will continue Actigall for 6 months after surgery.
Caloric Needs and Average Expectations:
At 2 weeks: 400 Calories/day
At 3 weeks: 500 Calories/day
At 4 weeks: 600 Calories/day
At 10 weeks: 800 Calories/day
At 12 weeks: 1000 Calories/day
At 6 months: 1100 Calories/day
At 8 months: 1300 Calories/day
At 12 months: 1500 Calories/day
Protein is priority in your food choices now
You may need protein supplements. Your "normal" food intake should contain mostly protein. Count your grams of protein from regular foods. If you are getting 70-100 grams daily then you are doing very well, and you will not need a protein supplement. If you do need extra protein in the form of supplements, make up the difference in protein intake by calculating how much protein shake you need to reach 70-100 grams per day including food intake. You should 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 tastes will determine the powder that is right for you. Options for Protein Supplement : Designer Whey Protein, Promod, Isopure, others. Look at the ingredients: We want nearly 100% protein powder. You can mix 1-2 scoops of protein powder into ½-1 cup of skim milk and mix it in a blender with ice and fruit for flavoring.
What are Clear Liquids?
· Fruit juices without added sugar - no citrus or tomato juice for the first three weeks
· Crystal Light liquid or popsicles, Nutrasweet Kool-Aid 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)
· Sugar-free Jello
· NO SODA OR CARBONATED BEVERAGES!
What are Full Liquids?
· Skim or 1% milk
· Protein mix blended with milk or water
· Low-fat, low-sugar pudding, ice cream or yogurt (without fruit pieces) (3)
· Low fat, thin cream soups (strained), such as Campbell's Cream of Mushroom Soup made with skim milk
· Liquids that you cannot see through
· Remember to avoid carbohydrates, fats and sodas
· Milk shakes --8 oz of milk with cracked ice & fruit processed in a blender. Add a scoop of sugar-free ice cream if desired and/or add a scoop or two of protein powder
How am I expected to consume Liquids (Both Clear and Full)?
Your main goal at this point is to prevent dehydration. You want to sip liquids slowly, but constantly. Your fluid needs are no different now than they were before surgery. You need to drink at least 64 to 80 ounces of good fluids a day to prevent dehydration.
· Sip as much liquid as you can tolerate slowly and constantly throughout the day. Watch your urine for a dark color or strong odor. If these develop, you need to drink more fluid until the urine is a clear light yellow.
· You may have unlimited amounts (up to 1 ½ gallons/day) of any combination of liquids such as water, Crystal Light (liquids or popsicles), Nutrasweet Kool-Aid, Ocean Spray Lite drinks (NOT the regular), and chicken or beef broth. You don't need to reach this maximum every day. If you have a heart condition or cirrhosis you may be more restricted. Use your thirst and your urine output as a guide . 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 720 cc's per day at least).
· Juices may need to be diluted with water if they taste too sweet or if you get dumping.
· Avoid all citrus juices and tomato juice during the first 3 weeks.
· Try to avoid swallowing air with liquids, which occurs 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.
· NO SODA OR CARBONATED BEVERAGES! Carbonation is hard on your new stomach. Avoid it in any form!
What are Pureed Foods?
· Cottage cheese
· Unsweetened applesauce or fruit puree
· 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. (4)
· Chopped up soft poached eggs
· Cream of Wheat®, Cream of rice and grits
· Blended Soft fruits -- banana or ripe peaches or strawberries with the seeds removed. Watermelon, honeydew and cantaloupe as long as they are blended well. These can be especially nice to add to protein supplements.
· Baby foods with no meat chunks.
· Very tender chicken or turkey blended with broth added.
What are Soft Foods?
· Canned peaches and pears in their own juice (no sweetened syrups)
· Healthy Choice, Healthy Request® and Progresso Lite soups. (chew chunks very well before swallowing)
· Any cooked vegetables (except corn) cooked soft and mashed with the back of a fork
· Oatmeal and soggy low fiber cereals
· Chopped up soft boiled or scrambled eggs or egg salad
· 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, especially early after surgery and permanently for gastric bypass or banded patients.
· Canned tuna, fresh fish fillets or imitation crab or real king crab: AVOID BONES!
· At this point, you should be avoiding nuts, seeds and high fiber foods such as bran flakes, apples and pears, fresh vegetables and tough meats such as beef. Dry, hard or chewy foods will be very hard for your new stomach to tolerate. Make sure meats are moistened with broth or mayonnaise.
Ah yes at last! Regular foods include meats and salad items that have been restricted during the first two weeks. Remember go very slow. Try only one thing at a time. Maximum 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 below).
*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 and sugar-free doesn't necessarily mean carbohydrate free!
What about the Crispy and the Crunchy?
CRISPY: These are allowed after one week.
· Crispy becomes MUSHY when wet
· Toasted white bread
· Corn Flakes
· Rice Krispies
CRUNCHY: These are not allowed for the first three weeks.
· Crunchy does not melt into mush quickly
· Crunchy can get stuck in your pouch and ulcerate or perforate it
· Uncooked veggies that crunch but don't dissolve. These fibrous items can obstruct your pouch.
· Tortilla chips and hard taco shells
· Potato chips, popcorn, corn chips and snack chips
· Nuts / seeds
· 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 food through the stomach quickly and therefore avoid rapid hunger and 2) You will avoid the stopped up sink effect. We prefer that you wait for 15-30 minutes after drinking to begin eating, then wait at least an hour after eating before you begin drinking again.
· DRIBBLE BEFORE YOU NIBBLE, DON"T DRIBBLE WHILE YOU NIBBLE and DON"T DRIBBLE JUST AFTER YOU NIBBLE. We recommend you drink through the day, stop about 15 minutes before you are to eat, then wait about one hour after you have finished eating to begin drinking again.
· 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 for a while before eventually going down once the pudding thinned out and decided to go down. If this was your stomach tube, that water would fill it, stretch it, back up in your throat, and cause pain and discomfort, possibly 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. This time without all the problems associated with BACK UP.
· 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 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 (3-5 ounces) 3 times a day. Use a spout ended bottle and drink only as much as you can comfortably tolerate. Use a small fork to take bites at first.
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 next office visit, taking no more than 15 - 20 minutes. You can use a treadmill (elevated a few degrees is better than flat); ride a regular or stationary bike; use the shallow end of a swimming pool for walking against resistance, but don't soak the incisions for 2 - 3 weeks. You may dangle your legs in the water if the shallow end is too deep and covers your incision.
Avoid any straining or heavy lifting for 3 - 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 return to work as soon as you feel up to it, again avoiding putting too much stress on your wound (s) too early.
You may climb stairs one at a time, no more than a few times a day. You may ride in a car or take a short trip.
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
1. 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.
2. 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.
3. You may wear tight clothing if you like a snug fit or loose clothing if you prefer no pressure on your abdomen.
1. 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 10 meq Potassium per day until the diarrhea is gone or for three days.
2. Do not ever take aspirin or aspirin-containing medicines such as Alka-Seltzer®, BC Powder®, Stan back Powder®, or Goody's Powder®. 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.
3. Use your liquid or ground pain medicine as needed.
4. 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.
5. For gas pains try Gas-X®, Di-Gel®, Mylanta® (liquid or chewable form).
6. For diarrhea try Imodium AD® or Pepto-Bismol® short term. If you have regular frequent loose stools, Metamucil actually helps bulk up the stool and hold things together to reduce diarrhea.
7. For constipation try Benefiber, Citrucel® powder, Phillip's Milk of Magnesia®, Dulcolax® suppository, any chewable laxative, or Fleets® Oil Enema.
8. VITAMINS: You will take specific amounts of vitamins as listed in the recommendations. We recommend you purchase Vita4Life vitamins from the office, or you may obtain them via the internet @ www.vita4life.net. You may also have a prescription of vitamins filled at the Apothecary, if you choose. We prefer that you use either of these 2 options rather than making a compilation of your own.
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 and keep a log of this. 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 and we want you to check and record your sugar twice daily at different times, and bring it 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 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-up. 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 sometimes vitamin levels) 3 months after surgery, sooner if you are eating poorly. You are unlikely to develop deficiencies if you take your vitamins, but if symptoms develop, levels should be checked. You can get a copy of the 3 month bloodwork prescription at your 1 month follow up visit. Have the labs drawn through a local lab or your PCP, and either have them faxed to our office or bring them with you to your 3 month visit.
Protein - 70-100 grams a day
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!!
Vitamins: please take them every day. When you begin taking the whole vitamins, start out slowly, 1-2 a day, and work up to the 12 or so a day you need.
· 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.