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 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 for pain control
- An abdominal binder will be provided for extra support and comfort, if needed (1)
- 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 & Second Post Operative Day: 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 Through Fifth Post Operative Days: Full Liquids
If you tolerated clear liquids well, you will be advanced to a Low Carbohydrate / Full Liquid Diet. You will need to crush or open your medicines. You may think you are healed, but the new connections inside are still swollen and healing. To get something stuck at the anastamosis (newly created connections) will cause a significant setback. Please follow your dietary instructions. You will need to supplement with protein powder for 6 weeks.
Meds: Actigall (if gallbladder not removed), Prevacid, Pain medication. Other meds for chronic medical conditions.
Your Sixth through Ninth Post Operative Day: Pureed Foods
You should now be able to safely begin Pureed foods. This includes baby foods, applesauce, pureed (blended) soft foods and potted meats. You will need to drink constantly to stay
Hydrated. You will need to continue to crush your meds.
Meds: Actigall (if gallbladder not removed), Pain medication, Prevacid, B12 1000 mcg sublingual daily, two children’s chewables with iron twice daily, Iron (Fergon or other) 325mg crushed daily. Other meds for chronic medical conditions.
Your 10th Day Through 20th Day: 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, including baked white fish, imitation crab meat,
hot dogs (well chewed) and canned fruits. This does not include New York Strip. You will
still need to drink constantly to stay hydrated, and you will need to supplement with protein powder for 6 weeks post-op. Continue to crush your meds.
Meds: Actigall (if gallbladder not removed), Pain medication, Prevacid, B12 1000 mcg sub-lingual daily, two children’s chewables twice daily, Iron (Fergon or other) 325mg crushed daily. Other meds for chronic medical conditions.
Three Weeks (21st Day) to Six Weeks: Regular food TRIAL Period
You should now be able to safely begin "Regular" foods. This includes all previously allowed items plus red meat and raw vegetables. This is called the TRIAL period because you are expected to try only one new item at a time. Do not rush. Add only 1 to 2 new foods per day. You may also begin taking pills whole during this period (go slow). (2)
Meds: Actigall (if gallbladder not removed, continue for 6 months), Pain medication if needed (Tylenol), B12 1000 mcg sublingual daily, Iron (Fergon or other) 325mg daily, Calcium Citrate supplement (500mg daily). Meds for chronic medical conditions. Take two children’s chewables with iron twice daily, though you may start regular multivitamins now (4 for proximal, 8 for medial RNY.)
**You will continue on Prevacid until the 4th week, then switch to Zantac for the next 5 months.
Caloric Needs and Average Expectations
Studies have shown that weight loss after gastric bypass is a result of lower caloric intake. The pattern of intake and weight loss is also known.
- 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
It is recommended that you begin drinking a protein drink regularly during the first 6 weeks post operatively. The purpose of this is to ensure that you do not have excessive protein loss that negatively affects your healing. 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, Promod, Isopure, others. Look for 100% protein powder. During the first six weeks if you shoot for a minimum of 70 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 385 Calories.
Your "normal food" intake should be enough after the first 6 weeks so that you don’t need the protein powder supplement. You may only need to continue it if you are not eating as expected. You may be required to have blood work if your intake is not up to par. 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 3 weeks
- Sugar-free Jello
- Crystal Light liquid or popsicles, Nutrasweet Kool-Aid, or other sugar-free diet drinks
- Sugar-free or all-fruit popsicles (3)
- Coffee, tea and FLAT carbonated beverages
- Broths and thin egg-drop soup (NO crunchies or solid pieces)
- AVOID ALL SODAS AND CARBONATED BEVERAGES!!
What are Full Liquids?
- Skim milk or 1% milk
- Protein mix
- Low fat, thin, strained cream soup such as Campbell’s Cream of Mushroom Soup made with skim milk
- Low-fat, sugar-free pudding, ice cream and yogurt with no fruit pieces
- Liquids that you cannot see through
- Remember to try to avoid sugars and fats
- Skim or 1% milk shakes --8 oz of milk with cracked ice & fruit processed in a blender. Add 1-2 scoops of protein powder supplement. You may also add a scoop of sugar-free/fat-free ice cream if desired.
How am I expected to consume Liquids (Both Clear and Full)?
- Preventing dehydration is very important. 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 throughout the day. 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, 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 citrus juices (orange/grapefruit) and tomato juice during the first 3 weeks.
- Try to avoid swallowing air with liquids, which will 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.
What are Pureed Foods?
- Low-fat or non-fat cottage cheese
- Unsweetened applesauce (4)
- 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 especially nice to add to protein supplements.
- Non-fat, sugar-free yogurt, pudding or ice cream
- Potted meats thinned with clear broth or baby foods with no meat chunks.
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 any meats.
- Any vegetables (except corn), including potatoes, cooked soft and mashed up
- Unsweetened oatmeal
- Chopped up soft eggs (scrambled, hard-boiled or as 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.
- Canned tuna, fresh fish filets, imitation crab or real king crab - cooked very soft & moist: ABSOLUTELY NO 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 three weeks. Remember to go very slow. Try only one thing at a time. Maximum two new foods per day and spread them apart by at least 6 hours. Follow the Nibble AFTER you Dribble rule to avoid the sink effect (see Main points to remember below).
Acceptable Additions: 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.
What about the Crispy and the Crunchy?
CRISPY: These are allowed after four weeks.
· Crispy is ALLOWED
· 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, hard taco shells, popcorn
· Nuts and Seeds
· Grain and whole grain bread (pieces of incompletely ground grain)
How am I expected to consume Pureed, Soft, or Regular Foods?
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 a lot of liquids during the hour 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. So NIBBLE AFTER you DRIBBLE to avoid the "sink effect" (Also known as the Glob effect).
· 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 using a small baby fork. 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 (1-2 ounces) 3 times a day. Do not eat and drink at the same time. Use a dribble bottle (spout ended bottle) and drink only as much as you can comfortably tolerate.
- Monitor your protein intake: If you do not get enough protein in your diet, you will become malnourished.
- 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 your vitamins every day: This will help prevent vitamin and mineral deficiencies.
- AVOID SODAS, CARBONATED BEVERAGES AND ALCOHOL!!
DO NOT BECOME A STATISTIC!!!!
Post-operative Activity Instructions
1. 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.
2. You may climb stairs or ride in a car or take a short trip
3. 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!
4. 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.
5. Rest when you feel tired, but try not to sleep during the day -- it may then be more difficult to sleep at night.
6. 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.
7. 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.
8. 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 10meq Potassium per day until the diarrhea is gone or for three days.
2. On your seventh day after surgery, begin taking children’s chewable multivitamins with iron - 2 in the AM, 2 in the PM, chewed thoroughly with food. That is 4 per day. Take these until the fourth week. At that point, begin taking adult multivitamins. Follow recommendations from the doctor based on the particular surgery you had.
3. 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.
4. Use your liquid or ground pain medicine as needed.
5. 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. (8)
6. For gas pains try Gas-X®, Di-Gel®, Mylanta® (liquid or chewable form).
7. For diarrhea try Imodium AD® or Pepto-Bismol®.
8. For constipation try Citrucel® powder, Phillip’s Milk of Magnesia®, Dulcolax® suppository, any chewable laxative, or Fleets® Oil Enema.
9. You will take 4 adult multivitamins with iron for the Proximal RNY, and 8 adult multivitamins with iron for the Medial RNY once your are four weeks post op. On top of those, you will also take a B-complex and a calcium citrate supplement regularly.
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 food diary with you. Follow up visits after your one week visit are as follows: 1 month, 3 months (bring labs with you), 6 months and 1 year (bring labs with you.)
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 the information with you to your follow-up visit.
Temperature: You are expected to check your temperature at home daily for a week 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 be able to report if you are experiencing any excessive nausea, pain, dumping, vomiting, fever or wound drainage.
Weight Checks: You should come in to the office once a month for the first year for a weight check-up at least. 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 with this type of procedure, but if symptoms develop, levels should be checked.
Support: We recommend that you attend support group meetings. Dr. Elariny’s support group meets every first Tuesday of the month at Fairfax hospital from 7pm to 9pm. Everyone is invited no matter what surgery they have had or plan to have. If you are not in the area, we recommend you find a support group in your area for weight loss surgery.